OPINIONS OF THE PRESS 

ON 

WATSON'S PRACTICE OF PHYSIC. 



The Publishers have great pleasure in submitting the following letter from 
Professor Chapman, as well as a few of the notices of the medical press, with 
which this work has been honoured, 
# 

Philadelphia, September 27th, 1844. 
Watson's Practice of Physic, in my opinion, is among the most comprehen- 
sive works on the subject extant, replete with curious and important matter, and 
written with great perspicuity and feli^y of manner. As calculated to do much 
good, I cordially recommend it to th^ portion of the profession in this country 
who may be influenced by my judgment. 

N. CHAPMAN, M.D. 

Professor of the Practice and Theory of Medicine 
In the University of Pennsylvania. 



"We know of no work better calculated for being placed in the hands of the student, and 
for a text book, and as such we are sure it will be very extensively adopted. On every import- 
ant point the author seems to have posted up his knowledge to the day." — American Medical 
Journal. 

"In the Lectures of. Dr. Watson, now republished here in a large and closely printed volume, 
we have a body of doctrine and practice of medicine well calculated, by its intrinsic soundness 
and correctness of style, to instruct the student and younger practitioner, and improve members 
of the profession of every age." — Bulletin of Medical Science. 

" We regard these lectures as the best exposition of their subjects of any we remember to 
have read. The author is assuredly master of his art. His has been a life of observation and 
study, and in this work he has given us the matured results of these mental efforts." — New Or- 
leans Medical Journal. 

" We know not, indeed, of any work of the same size that contains a greater amount of inte- 
resting and useful matter. The author is evidently well acquainted with everything appertaining 
to the principles and practice of medicine, and has incorporated the stores of his well-stocked 
mind, in the work before us, so ably and agreeably, that it is impossible for the interest of the 
reader to flag for a moment. That they-are well adapted for such a purpose, all must admit; 
but their sphere of usefulness may extend much beyond this. We are satisfied, indeed, that no 
physician, well read and observant as he may be, can rise from their perusal without having added 
largely to his stock of valuable information." — Medical Examiner. 

"In this volume of the ' Principles and Practice of Medicine,' we have before us a mass of 
information which is rarely to be found within the boards of a single volume. This is the age ot 
condensation. Here is brought together mature views of the present state of the science, by a 
lecturer, acknowledged by all to be of the first order, and that which was spread over 1700 pages 
of the London edition, we have in about 1100, (of course large pages,) and so cheap that no me- 
dical reader will hesitate a moment to transfer it from the bookseller's counter to his own table 
where it should he constantly before him." — U. S. Gazette. 

" We know of no systematic work on the Practice of Medicine equal to this. To extensive 
erudition and natural cleverness, the discrimination and tact of a practical man, personally fami- 
liar with all he treats of, is added. Besides showing himself a sound pathologist in these pages, 
he proves that he is an admirable therapeutist. A vein of practical good sense distinguishes 
every page. The time and patience of the reader are not consumed by idle disquisitions on 
iiiooted points of no real utility. The style is agreeable, and we may even say fascinating. To 
the medical student we consider the work as invaluable, and there are few practitioners, old or 
young, who, on reading it, will not be willing to acknowledge their obligations to it." — Saturday 
Post. 

" The medical literature of this country has been enriched by a work of standard excellence, 
which we can proudly hold up to our brethren of other countries as a representative of the natu 
ral state of British medicine, as professed and practised by our most enlightened physicians. 
And, for our own parts, we are not only willing that our characters as scientific physicians and 
skilful practitioners may be deduced from the doctrines contained in this book, but we hesitate 

CI) 



2 NOTICES OF Watson's practice. 

not to declare our belief, that for sound, trustworthy principles, and substantial good practice, it j 
cannot be paralleled by any similar production in any other country. * * * * We would [ 
advise no one to set himself down in practice, unprovided with a copy." — British and Foreign ; 
Medical Review. _ | 

" We cannot refrain from calling the attention of our younger brethren, as soon as possible, to ! 
Dr. Watson's Lectures, if they want a safe and comprehensive guide to the study of practical 
medicine. _ j 

"In fact, to any of our more advanced brethren, who wish to possess a commodious book of j 
reference on any of the topics usually treated of in a course of lectures on the practice of physic, 
or who wish to have a simple enunciation of any facts or doctrines, which, from their novelty or | 
their difficulty, the busy practitioner may not have made himself master of amidst the all-absorb- 
ing toils of his professional career, we can recommend these lectures most cordially. Here we 
meet with none of those brilliant theories which are so seductive to young men, because they 
are made to explain every phenomenon, and save all the trouble of observation and reflection ; 
here are no exclusive doctrines ; none of those 

•Bubbles that glitter as they rise and break, 
On vain Philosophy's all babbling spring.' 

But we have the sterling production of a liberal, well-stored, and truly honest mind, possessed 
of all that is currently known and established of professional knowledge, and capable of pro- j 
nouncing a trustworthy and impartial judgment on those numerous points in which Truth is yet ' 
obscured with false facts, or false hypotheses." — Provincial Medical Journal. j 

" We find that, from the great length we have gone in our analysis of this work, we must I 
close our notice of it here for the present, not, however, without expressing our unqualified 
approbation of the manner in which the author has performed his task. But it is as a book of ele- ' 
mentary instruction that we admire Dr. Watson's fprk." — Medico- Chirurgical Review. _ : 

" One of the most practically useful books that ever was presented to the student — indeed a j 
more admirable summary of general and special pathology, and of the application of therapeutics 
to diseases, we are free to say, has not appeared for very many years. The lecturer proceeds \ 
through the whole classification of human ills, a capite ad calcem, showing at every step an ex- 
tensive knowledge of his subject, with the ability of communicating his precise ideas, in a style j 
remarkable for its clearness and simplicity." — N. Y. Journal of Medicine, ^c. _ _ 

" The style is correct and pleasing, and the matter worth the attention of all practitioners, j 
young and old." — Western Lancet. _ _ j 

" We are free to state that a careful examination of this volume has satisfied us that it merits , 
all the commendation bestowed on it in this country and at home. It is a work adapted to the | 
wants of young practitioners, combining, as it does, sound principles and substantial practice, i 
It is not too much to say, that it is a representative of the actual state of medicine as taught and 
practised by the most eminent physicians of the present day, and as such we would advise every ' 
one about embarking in the practice of physic to provide himself with a copy of it.''— Western ; 
Journal of Medicine and Surgery. _ j 

" It is an admirable digest of general pathology and therapeutics. As a text book for medical j 
schools, it cannot be surpassed, and in no other treatise can practitioners find so concise, and at ; 
the same time so complete a summary of the present state of the science of medicine." — Balti- \ 
more Patriot. j 

" It is the production of a physician of undoubted talent and great learning, and whose indus- i 
try in performing the most laborious duties of this profession has been well known for a long 
series of years. * * * Let us not forget to add that the style and general character of the i 
work are peculiarly practical ; and the cases which Dr. Watson has from time to time introduced 
to illustrate his views, are highly appropriate and interesting, and add much to the value of the 
work ; and this certainly must be admitted to be one of the great advantages of casting this 
work in the shape of lectures, in which these ca;ses assuredly appear more fitly, and in which 
they are introduced more easily and naturally than they could have been had the form of the .1 
work been different. I 

"Lastly, we are well pleased to observe that a strong vein of common sense, as well as good 
taste, runs through the whole treatise, and sustains both the interest and the confidence of the i 
reader throughout." — Edinburgh Medical and Surgical Journal. j 

" In calling the attention of the profession to the elegant volume recently published by Lea & 
Blanchard — the lectures delivered at King's College, London, by Dr. Watson — we do not suppose j 
any one at all conversant with the medical literature of the day to be unacquainted with its gene- \ 
ral character. Dr. W. delivered these now celebrated lectures during the medical session of ' 
1836-7. They have been revised by the author, and those who now study these erudite pro- j 
ductions will have them divested of any objectionable matter that might have formerly crept in 
through inadvertence. There are ninety lectures, fully written, embracing the whole domain of | 
human maladies, with their treatment, besides an appendix particularly remarkable for its rich- I 
ness in important practical information. We could not give even a tolerable synopsis of the sub- ' 
jects discussed in this great undertaking without materially entrenching on the limits assigned to j 
other matter. * * * Open this huge well-finished volume wherever we may, the eye imme- ; 
diately rests on something that carries value on its front. We are impressed at once with the [ 
strength and depth of the lecturer's views ; he gains on our admiration in proportion to the extent ■; 
of our acquaintance with his profound researches. Whoever owns this book will have an acknow- 
ledged treasure if the combined wisdom of the highest authorities is appreciated." — Boston] 
Medical and Surgical Journal. \< 



LECTUE 

ON THE 

PRINCIPLES AND 



ES 

PRACTICE 



PHYSIC; 



DELIVERED AT KING'S COLLEGE, LONDON, 



ET 



THOMAS WATSON, M.D., 



FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; LATE PHYSICIAN TO THE MIDDLESEX HOSPITAL; 
AND FORMERLY FELLOW OF ST. JOHn's COLLEGE, CAMBRIDGE. 



THIRD AMBRICAIsr, FROM THE LAST LONDON EDITION. 

REVISED, WITH ADDITIONS, 

BY 

D. FEANCIS CONDIE, M.D., 

SECRETARY OF THE COLLEGE OF PHYSICIANS; AUTHOR OF A TREATISE ON DISEASES 
OF CHILDREN, ETC. ETC. 




PHILADELPHIA: 
LEA AND BLANCHARD. 
1847. 



^^^^ 



Entered, according to the Act of Congress, in the year 1845, by 
LEA AND BLANCHARD, 
in the clerk's office of the District Court for the' Eastern District of Pennsylvania. 



PRINTED BY T. K. AND P. G. COLLIi^S. 



(4) 



LC Control Number 




tmp96 029102 



MAY 9 1919 



TOE 



The very full and accurate exposition presented by Dr. Watson of the 
present state of pathology and therapeutics, in reference to nearly all of 
the diseases embraced in these Lectures, has rendered it unnecessary to 
augment materially the size of the work by the addition of frequent and 
extended notes. In regard, however, to a few of the forms of disease 
more particularly interesting to the American physician, the account 
given by the Author will be found somewhat defective, while he has omitted 
to notice one or two affections endemic in the United States, his lectures 
being chiefly confined to a consideration of the diseases most prevalent in 
Great Britain. It is to remedy these deficiencies that the Editor, in pre- 
paring the present edition, has mainly directed his attention. In the notes 
he has added to ^Dpj. Watson's lectures on diarrhoea and dysentery, he has 
endeavoured to fill up the very brief sketch presented in the text, of the 
chronijs forms of those diseases ; he has attempted, also, to supply, in part, 
the omissions of the Author, by his notes on the history, pathology and 
treatment of %phoid pneumonia, remittent fever, &c. 

The intrinsic merits of Dr. Watson's Lectures are sufficient to ensure 
for them a favourable reception. If, by the few notes he has been induced 
to append to the present edition, the Editor has succeeded in adding in 
some sHght degree to their value, he will be amply repaid for his labour. 

Philadelphia, SepUmher^ 1845. 



In passing through the press a new edition of Dr. Watson's Lectures, the 
Editor has only to remark that he has corrected some few errors which 
escaped attention in the last, while he has added some additional notes 
where the subject appeared to require them. 

Philadelphia^ August, 1847. 

a8 (5) 

^- ! ' 'RARY, 



'N, D. C. 



AUTHOR'S ADVERTISEMENT 

TO 

THE SECOND EDITION. 



The unexpected exhaustion of the former edition of these Lectures 
within the space of a twelvemonth, has left but little (Opportunity to the 
Author, whose leisure is small, for such revision as might render them 
more worthy of the encouragement they have received. Some errors 
have been corrected, but in substance, as well as in form, the Lectures 
are nearly the same as before. ^ 



(6) 



ADVERTISEMENT 

TO 

THE FIRST EDITION. 



The following Lectures were put together, with unavoidable haste, dur- 
ing the Medical Session of 1836 — 37, in which they were first delivered. 
They were repeated, with slight variations, for four successive years ; the 
Author always meditating, but never finding time to accomplish, their 
thorough reconstruction and revision. They were afterwards printed, to 
fulfil a rash promise, in the pages of the Medical Gazette : and they are 
now published, in a collected form, at the request, formally conveyed to 
him in writing, of many who had heard or read them, including several 
of his colleagues at King's College. 

Writing for mere beginners, and without any thought of future publica- 
tion, the Author took no pains to note authorities as he went along. He 
may often, therefore, have used, without acknowledgment, not only the 
facts and reasonings, but sometimes, perhaps, the very words of others. 
This omission he regrets, but is now unable to supply. Neither has he 
leisure to correct, if that were desirable, the colloquial and familiar style 
in which the Lectures were originally composed. 

Should they attract the notice of any who are no longer in statu pupil- 
lari, he would request such readers to bear in mind for whom these les- 
sons were intended. They do not profess to present a formal and complete 
treatise on the Practice of Physic, much less to exhaust the various subjects 
upon which they touch. His chief hope is that they may prove useful as 
a text-book for students. 

As they are passing through the press, such additions and alterations 
have been introduced as the Author would have made had he continued to 
deliver the Lectures orally. 

Henrietta Street, Cavendish Square, 
September, 1843. 

(7) 



i 



i 



I 



I 



I 
I 



CONTENTS. 



LECTURE I. 

InTBODUCTOHY .PAGE 17 

LECTURE IL 

Pathology — meaning of the term. Pathology, general and special. Morbid alterations of 
the solid parts of the body. Alterations in bulk. Hypertrophy — law of its production — 
its effects. Atrophy — its causes and consequences. Changes in form. Alterations in 
consistence. Induration — its various kinds 25 

LECTURE III. 

Softening ; its causes and varieties. Transformations of Tissue ; Changes of situation— 4^ 
the Chest, of the Lung, of the Heart — in the Abdomen and Pelvis, Hernia, Intussuscep- 
tion, Prolapsus 33 

\ LECTURE IV. 

Morbid alterations of the Fluids, especially of the Blood. Changes in its quantity and distri- 
bution. General and Local Plethora. Poverty of Blood. Active Congestion — its Phe- 
nomena — state of the Vessels, as seen by the Microscope. Mechanical Congestion. Pas- 
sive Congestion. Relations of these forms of Congestion to Inflammations — to Hemorrhages 
— to Dropsies 39 

LECTURE V. 

Different modes of Dying. Pathology of Sudden Death. Death by Anaemia ; its Course, 
Phenomena, and Anatomical Characters. Death by Asthenia ; its Course, Phenomena, 
and Anatomical Characters. Syncope. Death by Inanition. Death by Apnoea: Death 
by Coma : their Course and Phenomena, and the Anatomical Characters common to both. 
Application of the Principles obtained from the investigation of the Phenomena of Sudden 
death, in elucidating the Symptoms and Tendencies of Disease 48 

LECTURE VI. 

Causes of Disease: distinction between predisposing and exciting causes. ^ Enumeration of 
causes, as connected with the Atmosphere — Food and Drink — Poisons — Exercise — Sleep 
— Mental and Moral Conditions — Hereditary Tendencies — Malformations. Temperature. 
Effects of Heat and of Cold 57 

LECTURE VIL 

Causes of Disease, continued. Laws by which the operation of Cold upon the Bodily Health 
is regulated. Circumstances that favour its injurious Effects, and respect, first, the Body 
itself ; secondly, the manner in which the Cold is applied. Modifying influence of certain 
states of the Mind — of Sleep — of Habit. Means of protection. Influence of the different 
Seasons. Impurity of the Air, Its influence in the production of Disease [note]. Heredi- 
tary tendencies to Disease 68 

LECTURE Vm. 

Symptoms. Their Uses in relation to the Diagnosis, the Prognosis and the Treatment of 
Diseases. Signs, as distinguished from Symptoms. Pathognomonic, Commemorative, 
Direct and Indirect Symptoms. Examples of Symptoms as they consist of uneasy Sensa- 
tions, disordered Functions, or changes of Sensible Qualities 79 

LECTURE IX. 

Inflammation. Its Morbid and its Salutary Effects. Sketch of the Local and Constitutional 
Phenomena of Inflammation as it occurs in External Parts, Examination of the Symp- 
toms of Inflammation ; Pain ; Heat ; Redness ; Swelling. State of the Capillary Blood- 
vessels and of the Blood inote] in a part inflamed . .^..^ 92 

(9) 



10 



CONTENTS. 



LECTURE X. 

Inflammation, continued. BufFy Coat of the Blood. Terminations or Events of Inflamma- 
tion. Resolution — Delitescence — Metastasis. Effusion of Serum. Effusion of Coagulable 
Lymph, or Fibrin. Organization of this Lymph. Suppuration. Ulceration 103 

LECTURE XL 

Mortification, as an event of Inflammation, Inflammatory Fever. Hectic Fever. Typhoid 
Fever. Modification of Inflammation by diflferences of Tissue ; Areolar Tissue ; substance 
of Glands and Solid Viscera ; Serous Membranes ; Synovial Membranes ; Tegumentary 
Membranes — Skin — Mucous Membranes; Muscular Tissue 5 Arteries; Veins; substance 
of the Brain 112 

LECTURE XIL 

Varieties of Inflammation : Acute and Chronic ; Latent ; Specific. Scrofulous Inflammation. 
Tubercles. Forms of Tubercles [wo^e]. Relative frequency of Scrofulous Disease in 
different Organs. Signs of the Strumous Diathesis 124 

^ ^ LECTURE XIII. 

Cancer ; its Species or Varieties. Scirrhus ; Encephaloid Cancer ; Colloid Cancer. Its 

mode of Growth and dissemination. Habitudes of the several Varieties. 
Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting 136 

LECTURE XIV. 

Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. Mercury. 

Antimony. Digitalis. Colchicum. Opium. 
Local Remedies. External Cold. External Warmth. Countep-Irritation 149 

LECTURE XV. 

Hemorrhage : — most commonly by Exhalation. Habitual Hemorrhages. Vicarious Hemor- 
rhages. Idiopathic Hemorrhages. Active and Passive. Symptomatic Hemorrhages. 
Usual Situations of Hemorrhage. Symptoms and Diagnosis. Principles of Treatment. . 159 

LECTURE XVL 

Dropsy : its General Pathology. Passive Dropsy ; Cardiac and Renal. Active, Acute, or 



Febrile Dropsy. Prognosis; and General Principles of Treatment in Dropsies 168 

LECTURE XVIL 

Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults 180 

LECTURE XVIIL 

Purulent Ophthalmia, continued. Gonorrhoea! Ophthalmia. Purulent Ophthalmia of Infants. 
Strumous Ophthalmia ; 190 

LECTURE XIX. 

Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Ophthalmia. 
General Remarks on Conjunctival Inflammations. Iritis : its Symptoms and Treatment. 
Causes of Iritis >. 199 

LECTURE XX. 

Iritis concluded. Rheumatic Ophthalmia. Amaurosis 209 

LECTURE XXL 

Diseases of the Brain and Nervous System. Difficulties of the subject. Short Review of 
some points in the Physiology of the Brain and Nerves. Peculiarity of the Cerebral Cir- 
culation. Pressure '. 220 

LECTURE XXII. 

Symptoms of Cerebral Diseases. Inflammation of the Dura Maier and Arachnoid, from 



CONTENTS. 11 

external injury ; from Disease of the Bones of the Ear, and of the Nose. Inflammation 

of the Pia Mater 229 

LECTURE XXIII. 

Acute and general Inflammation of the Encephalon. Period of Excitement. Modes in"" 
which the disease may commence. Period of Collapse. Treatment. Delirium tremens. 249 

LECTURE XXIV. 

Delirium Tremens, concluded; treatment [noie]. Chronic Inflammation of the Brain. 
Softening, Suppuration, Abscess, Induration, Tumours in the Brain 247 

LECTURE XXV. 

Hypertrophy of the Brain [note] ; Atrophy. Acute Hydrocephalus ; Premonitory Signs ; 
Different Modes of Attack ; Stages of the Disease ; Anatomical Characters ; Causes . . . 259 



LECTURE XXVI. 

Acute Hydrocephalus, continued. Prognosis and Mortality of the Disease. Treatment ; 
Blood-letting ; Purgatives ; Cold ; Mercury ; Blisters. Prophylaxis. Spurious Hydroce- 
phalus. Chronic Hydrocephalus, or Dropsy of the Brain. Shape of the Head and Face. 
Anatomical Conditions. Symptoms > 271 

LECTURE XXVIL 

Treai^ment of Chronic Hydrocephalus ; Internal Remedies : Mechanical Expedients ; Band- 
ages, Tapping. Meningitis Encephalica [no^e]. Symptoms of Spinal Disease. Inflam- 
matory conditions of the Spinal Marrow. Cerebro Spinal Meningitis [noiej 282 

LECTURE XXVIIL 

Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment. * 
Apoplexy. Its General Symptoms and Diagnosis. Different forms of the attacks. Predis- 
position to Apoplexy — Natural, and accidental. Precursory Symptoms 298 

LECTURE XXIX. 

Apoplexy continued. Symptoms characterizing the Apoplectic State. Pressure the ordinary 
Physical cause. Hemiplegia. Affection of Involuntary Muscles. Anatomical Characters. 
Situation of the Clot of Blood. Disease of the Cerebral Blood- Vessels 307 

LECTURE XXX. 

Apoplexy continued. Relations between the Symptfms and the Appearances found in the 
brain after death. Exciting Causes. Prognosis. Treatment 321 



LECTURE XXXL 

Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Anaesthesia ; their Symptoms, 
Prognosis, and Treatment. Other Forms of Local Paralysis, and Local Anaesthesia .... 332 

LECTURE XXXIL 



Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology. Treatment : 
Opium ; Blood-letting; the Warm Bath; the Cold Bath 345 

LECTURE XXXIII. 

Treatment of Tetanus continued. Wine ; Mercury ; Purgatives ; Digitalis ; Tobacco ; Musk ; 
Prussic Acid ; Belladonna ; Carbonate of Iron ; Oil of Turpentine ; Strychnia ; Surgical 
Expedients; General Rules. Hydrophobia 355 

LECTURE XXXIV. 

Hydrophobia concluded. Various Questions considered respecting the Disease as it appears 
in the Human Subject, and respecting Rabies in the Dog. Pathology of the Disorder. 
Treatment. Preventive Measures 368 



12 CONTENTS. 

LECTURE XXXV. 

Epilepsy. Its Symptoms and varieties ; duration and recurrence of the paroxysms ; periods 
of life at which they commence ; warnings. Effects of the paroxysms, immediate and 
ultimate. Pathology. Anatomical characters 379 

LECTURE XXXVL 

Epilepsy continued. Recapitulation. Exciting causes. Simulated epilepsy. Diagnosis. 
Prognosis. Treatment : during the fit ; during the Intervals ; during the Warnings .... 388 

LECTURE XXXVIL 

Chorea. Symptoms ; Pathology ; Comphcations ; Causes ; Treatment. Chronic Chorea. 
Other Nervous Disorders to which the same name has been applied 399 

LECTURE XXXVIIL 

Paralysis Agitans. Mercurial Tremor. Hysteria ; Two Forms of Hysteric Paroxysm ; 
Diagnosis from Epilepsy; Class of persons most liable to Hysteria ; Diseases apt to be 
simulated by Hysteria ; Treatment ; Prevention. Salaam Convulsions [note] 410 

LECTURE XXXIX. 

Catalepsy. Ecstasy. Neuralgia ; Tic Douloureux ; Sciatica ; Hemicranigf 424 

LECTURE XL. 

Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of Intermittent^ 

Predisposing causes. Exciting cause. Malaria : known only by its effects ; places which 
it chiefly infests ; conditions of its production ; its effects upon the human body ; influence 
of soils in evolving it 435 

LECTURE XLL 

Ague, continued. Speculations respecting its periodicity. Habits and properties of the 
malaria ; most noxious at night ; lies near the ground ; is carried along by winds ; cannot 
pass across water ; attaches itself to trees ; is diminished by the increase of cultivation and 
of population. Ultimate effects of the poison on the body. Ague formerly thought salu- 
tary. Prognosis. Propriety of stopping the disease ^ . . 447 

LECTURE XLIL 

Treatment of Intermittent Fever ; during the paroxysm ; during the intermissions. Prophy- 
laxis 457 

LEteTURE XLin. 

Epistaxis. Bronchocele ; Cretinism ; their Phenomena and probable Causes. Medical and 
Surgical Treatment of Bronchocele 467 

LECTURE XLIV. 

Cynanche Parotidsea. Spontaneous Salivation. Aphthae ; pathology of [note], Cynanche 
Tonsillaris 479 

LECTURE XLV. 

Acute Laryngitis. Symptoms. Treatment ; Blood-letting. Tracheotomy, Mercury, Anti- 
mony. Anatomical Characters of the Disease. Causes. Secondary Laryngitis. CEdema 
of the Glottis. Chronic affections of the Larynx 491 

LECTURE XL VI. 

Cynanche Trachealis : Symptoms ; Pathology ; Prognosis ; Treatment. Tracheotomy [note]. 
Child-crowing, or Spurious Croup. Spasmodic Laryngitis [no^e]. Nocturnal periodic 
Cough [note] .- 602 

LECTURE XLVIL 

Piseases of the Thorax. General observations. Dyspncea. Cough. Methods of exploring 
the physical conditions of the Chest, by the senses of sight, touch and hearing ......... 617 



CONTENTS. 



13 



LECTURE XL VIII. 

Catarrh ; its varieties. "Acute Bronchitis. Dry sounds attending the Respiration ; Rhonchus 
and Sibilus ; Moist sounds ; Large and Small Crepitation : how these are produced, and 
what they denote. Treatment of Acute Bronchitis. Peripneumonia Notha. Sudden 
Infraction of a large Bronchus • 528 

LECTURE XLIX. 

Influenza. Symptoms and progress. Conjecture as to its Cause. Treatment. Hay Asthma. ^ 
Chronic Bronchitis. Its varieties. Morbid Anatomy of these affections 53y 

LECTURE L. 

Hooping-cough : symptoms ; duration ; complications ; pathology; treatment. Pneumonia ; 
its stages and morbid anatomy; auscultatory signs 553 

LECTURE LL 

Pneumonia, continued ; its general symptoms ; pain, dyspnoea, cough, expectoration. Course 
of the disease. Prognosis. Treatment. Pneumonia in Children [note] 564 

LECTURE LII. 

Pleurisy. Its anatomical characters ; false membranes ; liquid effusion ; effects of these upon 
the shape and contents of the Chest, and upon its healthy sounds. Symptoms of Pleurisy 579 

LECTURE LTIL 

Pleurisy, continued. Recapitulation of symptoms ; of diagnostic signs. Causes of Pleurisy. 
Pneumothorax ; its condition, and signs. Treatment of Pleurisy. Empyema. Paracen- 
tesis Thoracis. Typhoid Pneumonia [nofej 590 

LECTURE LIV. 

Pulmonary Hemorrhage ; its varieties ; its connection with pulmonary consumption, and 
with disease of the heart. Pulmonary Apoplexy. Prognosis in Haemoptysis. Symptoms 
Treatment 608 

LECTURE LV. 

Pulmonary Emphysema ; vesicular and interlobular. Anatomical characters of vesicular 
Emphysema ; physical signs; general symptoms; causes; treatment. Interlobular Em- 
physema ; its anatomical characters, symptoms, cause, and cure. GEdema of the Lungs. 
Phthisis Pulmonalis 618 

LECTURE LVL 

Phthisis, continued. Voraicse ; adhesions of the pleurse ; ulceration of the larynx and trachea 
— of the intestines ; fatty liver ; auscultatory signs of a vomica ; gurgling ; cavernous 
respiration, pectoriloquy. General Symptoms of Phthisis ; cough, expectoration, dyspnoea, 
pain, hectic fever, diarrhoea, wasting, oedema, aphthse 629 

LECTURE LVIL 

Phthisis, continued. Diagnosis. Forms and varieties of Phthisis. Ordinary duration. Age 
at which it is most frequently fatal. Influence of sex, and of occupation. Question of 
contagion. Treatment. Curability of [note] 641 

LECTURE LVm. 

Melanosis of the Lung ; true, and spurious. Accidental intrusion ot solid substances info 

the air-passas:es 652 

B 



J4 



CONTENTS. 



LECTURE LIX. 



Diseases of the Heart ; usually partial. Changes in its muscular texture. Mechanism of 
those changes. Natural dimensions of the Heart. Natural sounds. Modifications of 
these by disease. Review of the physical and general signs that accompany Cardiac 
Disease 660 

LECTURE LX. 

Diseases affecting the muscular texture of the Heart, and their treatment. Changes to which 
the valves of the Heart are subject. Effects and diagnosis of those changes. Angina 
Pectoris « 671 



LECTURE LXL 

Pericarditis ; its frequent connection with Acute Articular Rheumatism. Rheumatic Car- 
ditis. Anatomical characters of acute inflammation of the pericardium ; of the Endocar- 
dium. General symptoms. Auscultatory signs. Relations of Carditis with Rheumatic 
Fever 682 

LECTURE LXn. 

Treatment of Acute Pericarditis and Endocarditis : blood-letting ; mercury; blisters. Chro- 
nic and partial inflammation of the pericardium. Disease of the Aorta. Thoracic Aneu- 
risms ; their various situations and symptoms ; plan of treatment 697 

LECTURE LXin. 

Diseases of the Veins. Phlebitis ; adhesive and suppurative ; consecutive scattered Abscesses. 
Treatment of Inflammation of Veins. Effects of the gradual obstruction of large Venous 
Trunks ^ 707 

LECTURE LXIV. 

Asthma : its nature ; complications ; exciting causes ; and treatment. Diseases of the 
CEsophagus ; Inflammation of Infants [wo/e] ; Stricture; Spasm: Dilatation 716 

LECTURE LXV. 

Diseases of the Abdomen ; sometimes difficult to identify. Method of investigating these 
diseases ; by the eye, the hand, the ear. Inflammation of the Peritoneum : its symptoms ; 
and causes. Puerperal Peritonitis. Peritonitis from Perforation .-.^ 727 

LECTURE LXVL 

^ Treatment of Acute Peritonitis ; Bleeding, Mercury, Opium. Chronic Peritonitis ; Granular 
Peritoneum. Ascites; Ovarian Dropsy; Diagnosis of these diseases. Other forms of 
Abdominal Dropsy 736 

LECTURE LXVIL 

Pathology of Chronic Ascites ; of Ovarian Dropsy. Treatment of these two disorders. In- 
ternal remedies ; Extirpation of the ovarian sac ; Paracentesis Abdominis , 744 

LECTURE LXVIIL " 

Acute Gastritis ; symptoms ; anatomical characters ; treatment. Acute Gastritis of Infants 
[note]. Chronic Inflammation of the Stomach ; thickening of the Mucous Membrane ; 
Ulceration : symptoms and treatment of the disorder. Cancer of the Stomach 753 

LECTURE LXIX. 

Hemorrhage from the Stomach : sometimes from a large vessel, usually by exhalation. 
Idiopathic Haematemesis. Vicarious Haematemesis. Haeraatemesis from gastric disease 
for injury: from disease in other organs. Meiaena. Haematemesis from a morbid state 
of the blood. General phenomena of H^matemesis. Diagnosis. Treatment 766 



CONTENTS. 



15 



LECTURE LXX. 

Dyspepsia. Physiology of Digestion. Symptoms of Dyspepsia. Treatment and Prevention, 
Dietetic and Medicinal 774 

LECTURE LXXL 

Enteritis : its symptoms ? causes ; treatment. Mechanical occlusion of the Intestinal Tube. 
Colic. Colica Pictonum 5 its symptoms, complications, treatment, and prevention 784 

LECTURE LXXIL 

Diarrhoea. Chronic Diarrhoea [note]. Sporadic Cholera. Epidemic Cholera. Cholera 
Infantum [note] '^^^ 

LECTURE LXXni. 

Dysentery: Morbid Anatomy [note] ; Chronic [note]. Diarrhcea Adiposa. Intestinal Con- 
cretions. Worms 

LECTURE LXXIV. 

Entozoa, continued. Hydatids. Trichina Spiralis. The Guinea Worm. Strongulus Gigas. 
Origin of Entozoa. Question of Spontaneous Generation. General Symptoms of the 
presence of Intestinal Worms. Particular symptoms, and remedies, of the common Round 
Worm, of Thread Worms, of Tape Worms 829 

LECTURE LXXV. 

Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and Treatment 
of Acute Hepatitis. Chronic Hepatitis. Jaundice. Its symptoms, causes, species, and. 
pathology [note] 841 

LECTURE LXXVL ^ 

Treatment of the various species of Jaundice. Diseases of the Gall-bladder ; of the Spleen ; 
of the Pancreas. Diseases of the Kidneys. Nephritis and Nephralgia. Phenomena 
constituting a *'fit of the Gravel." Different kinds of Gravel. Diseased states of the 
Urine. Description and Remedies of the Lithic, Phosphatic, and Oxalic Diathesis 854 

LECTURE LXXVIL 

Suppression of Urine. Diabetes : Qualities of the Urine ? symptoms ; anatomical appear- 
ances ; general pathology of the disease ; treatment. Diuresis 866 

LECTURE LXXVIIL 

Albuminous Urine. Means of detecting the Albumen. What it imports. Anatomical 
characters of Bright's Kidney. Symptoms to which this renal disease gives rise. Nature 
of the Affection .... 877 

LECTURE LXXIX. 

Anasarca ; its consideration resumed. Distinction of Chronic General Dropsy into Cardiac 
and Renal. Characters and signs of each of these varieties. Treatment 887 

LECTURE LXXX. 

Chylous Urine. Haematuria ; its diagnosis, general and particular ; Local Disorders of the 
Urinary Organs on which it depends 5 treatment. Abdominal Tumours 897 

LECTURE LXXXL 

Acute Rheumatism ; symptoms ; varieties ; treatment. Chronic Rheumatism ; phenomena ; 
plan of cure. 

Gout : description of a paroxysm ; progress of the disease ; general state of the health in 
gouty persons ; causes of the disease j diagnosis between Gout and Rheuma^sm 906 



16 



CONTENTS. 



LECTURE LXXXII. 

Pathology of Gout. Prognosis. Prejudices respecting the disease. Treatment : during the 
paroxysms ; during the intervals. Cutaneous diseasSs 917 

LECTURE LXXXIIL 

Exanthemata. They are contagious ; sometimes epidemic. Period of the eruption ; period 
of incubation. Theory of contagious Febrile Diseases. Continued Fever 925 

LECTURE LXXXIV. 

Continued Fever, continued. Phenomena of the second week : Delirium, an Eruption, 
Diarrhoea : of the third week ; Recovery, or death in the way of Coma, of Apncea, of 
Asthenia. Symptoms that usher in those modes of death ; morbid changes found after 
them 937 

LECTURE LXXXV. 

Varieties of Continued Fever. Its causes, exciting and predisposing. Prophylaxis 946 

LECTURE LXXXVL 

Continued Fever, concluded. Treatment. Bilious Remittent Fever \note]. Small-pox. 
Its essential symptoms. Distinction into discrete and confluent. Periods and modes in 
which it proves fatal 957 

LECTURE LXXXVn. 

Small-pox, continued. Inoculation. Vaccination. Their comparative advantages. Treat- 
ment of Small-pox 978 

*r LECTURE LXXXVIIL 
Chicken-pox. Measles. Scarlet Fever 991 

LECTURE LXXXIX. 

The Plague. Erysipelas. Erysipelas in Infants [note]. Erythema Nodosum. Urticaria. 
Prurigo. Scabies 1004 

LECTURE XC. 

Herpes ; Eczema ; Pompholix ; Lepra ; Psoriasis ; Impetigo ; Boils ; Carbuncle ; Purpura; 

Scurvy. Conclusion of the Course 1017 

Index , 1031 



LECTURES 



our THE 



PEINCIPLES AND PKACTICE OF PHYSIC. 



INTRODUCTORY LECTURE. 

Gentlemen : — In approaching any new course of systematic inquiry, there are 
certain points concerning which the inquirer shouJd always be careful to satisfy 
himself. He should comprehend, distinctly, what it is that he proposes to learn ; 
its subject-matter, and its objects : he should consider whether he is about to adopt 
the most easy, direct, and effectual means for obtaining his purpose ; and whether 
he is qualified, by the possession of the requisite preliminary information, for pursu- 
ing his inquiries with intelligence and profit. To these points, and to some others, 
as they are connected with the duties with which I have been entrusted in this col- 
lege, I wish briefly to direct your attention on the present occasion. It will be my 
endeavour to furnish you, at the outset, with clear notions of the nature and the ends 
of that branch of study upon v/hich you are now about to enter; to explain why it 
^is taught, and how far it may be taught, by oral discourses ; to point out to you what 
may reasonably be expected from me, and what, to render my attempts prosperous, 
will be required on your parts. Something also it is expedient you should know 
beforehand respecting the general order and arrangement of the course ; and a short 
explanatory comment upon some of the terms that we shall constantly be employing, 
will clear the way for the succeeding lectures, which forming, more strictly than the 
present, a part of the series, will also be more strictly didactic in their character. 

The subject of our study is that wonderful thing, the anireial body — and more par- 
ticularly the human body ; its construction and qualities ; its actions and its suffer- 
ings ; its derangements ; its decay. 

In this study, which affects the mind with a strong feeling of curiosity, not un- 
mixed with av/e, you have already advanced a certain way : for you have observed 
the outward form and configuration of the body ; examined its internal composition 
and structure ; and learned what is known of its various endowments, the working 
and the uses of its several parts. 

This amount of knowledge was indispensable to j^our further progress. But it 
forms a portion only of what you assemble here to learn : or rather it is the neces- 
sary preparation for that ulterior knowledge which it is your main purpose to acquire. 
The sublimer speculations springing naturally from the researches in which you 
have as yet been engaged, have not, I trust, been unregarded. You cannot have 
looked into the mechanism of that intricate but perfect work, — you cannot have con- 
templated its fullness of exquisite contrivance, its endless examples of means adjusted 
to ends ; its prospective expedient^ against future needs, its compensations for inevi- 
table disadvantages, its direct provisions for happiness and enjoyment, — without 
receiving the profoundest conviction of the being and the attributes of its Maker. It 
is upon human anatomy that Paley, in his unrivalled argument for Natural Theology, 
"takes his stand;" and sixteen centuries before him, Galen had felt that, in writing 
2 b2 (17) 



18 



INTRODUCTORY LECTURE. 



his anatomical treatises, he was composing a hymn to the Deity; that a declaration 
so plain of the wisdom, the power, and the goodness of God, was an act of piety 
and praise. But beyond, though not above, these higher objects of a diligent inves- 
tigation of man's bodily fabric, we have another and still a nobler end ; and it is my 
business to take you one step nearer to that end. Hitherto you have been told of 
structure and of function. Henceforward our theme must be of health and of dis- 
ease. Of health, that we may understand disease; of disease, that we may, under 
Providence, restore health. Our objects are to preserve the one; to prevent, remove, 
or mitigate the other. 

What then do these contrasted terms denote ? 

Health we regard as a standard condition of the hving body. But it is not easy 
to express that condition in a few words, nor is it necessary. My wish is to be 
intelhgible rather than scholastic; and I should probably puzzle myself as well as 
you, were I to attempt to lay down a strict and scientific definition of the term health. 
It is sufficient for our purpose to say, that it implies freedom from pain and sick- 
ness ; freedom also from all those changes in the structure of the body that endanger 
life, or impede the easy and effective exercise of the vital functions. 

It is plain that health does not signify any fixed and immutable condition of the 
body. The standard of heakh varies, in different persons, according to age, sex, 
and original constitution ; and in the same person even, from week to week, or from 
day to day, within certain limits it may shift and oscillate. 

Neither does health necessarily imply the integrity of all the bodily organs : it is 
not incompatible with great and permanent akerations, nor even with the loss, of 
parts that are not vital ; as of an arm, a leg, or an eye. 

If we can form and fix in our minds a clear conception of the state of heakh, we 
shall have no difficulty in comprehending what is meant by disease, which consists 
in some deviation from that state : some uneasy or unnatural sensation of which the 
patient is aware ; some embarrassment of function perceptible by himself, or by 
others; or some unsafe, though hidden condition, of which he may be quite uncon- 
scious : some mode, in short, of being, or of action, or of feeling, different from those 
which are proper to health. 

I use the word disease generically. Various terms in our language bear nearly 
the same meaning, and endeavours have been made to appropriate some of these 
more distinctively. Thus the word disorder has sometimes been apphed to simple 
derangements of function, where no alteration of structure is seen, or can reasonably 
be inferred to exist ; while the term disease has been restricted to maladies, which 
are attended with appreciable change of texture, or which run a short and definite 
course. I see no great utihty, but, on the contrary, some risk of confusion, in tying 
ourselves rigidly down to such distinctions : indeed, we cannot always make them. 
During hfe it is often no easy thing to determine whether the parts, of which the 
functions are disturbed, preserve their integrity of structure or not: and even when 
the peccant organ is placed before our eyes after death, and the most careful scrutiny 
fails to discover in it any faultiness of texture, there may still be ground for suspect- 
ing that some material change, too subtle for detection by our senses, may have been 
wrought in its finer and more delicate organization. I shall take care to point out 
to you, as we go along, the cases in which we can trace organic change, and the 
cases in which we cannot ; but, for the sake of simphcity, I shall call all deviations 
from the healthy standard, whether of function or of structure, by the generic term 
disease ; and to avoid the perpetual and tiresome recurrence of the same word, I 
shall not scruple to employ the several terms disorder, complaint, malady, distemper, 
illness, as its synonyms. 

The number of these deviations from the standard of health, (in other words, the 
whole number of diseases,) if we include all their differences in kind and in degree, 
is scarcely calculable ; and the first thing requisite towards investigating the laws 
that govern their phenomena, is, that we should break them into groups, and dispose 
them according to some principle of order. 

Now, there are various methods in which this fi-rst broad classification of diseases 
might be framed. 



INTRODUCTORY LECTURE. 



19 



The most cursory examination of the animal economy suffices to show that it is 
made up, not merely of separate parts, but of several distinct systems. There is 
one set of organs for the mechanical circulation of the blood ; there is an apparatus 
expressly designed for the repeated exposure of the blood to the air; a system for 
regulating the movements and the feelings of the body; another for receiving, pre- 
paring, and appropriating its nourishment ; another for the elaboration of matters 
that are useful or essential to its functions ; another for carrying off its impurities, 
and for removing its superfluous or effete materials ; and another for the continuance 
of the species. 

Now each of these systems is hable to changes of structure and interruptions of 
function^ peculiar to itself; and these peculiarities must be taken into account, what- 
ever may be the order adopted in treating of diseases in detail. But I shall not 
divide the subject, as some have done, into diseases of the circulating system — dis- 
eases of the respiratory system — diseases of the nervous system — and so on ; for 
this, among other reasons, that there are many forms of disorder that effect all these 
systems in common, or simultaneously, and comparatively few that are strictly con- 
fined to any one of them. 

Neither, in the lectures which I am about to commence, shall I classify diseases 
according to the several tissues of which the animal frame is composed. In speak- 
ing of diseases in general, it will, indeed, be both proper and necessary to explain in 
what manner the same morbid process may be modified by the nature of the special 
tissue affected. But as the entire body is more or less penetrated and pervaded by 
the intermixture of several of these tissues, so no useful nor lucid arrangement of 
diseases could be founded on this basis. 

Nor shall I attempt to construct a nosological system by grouping together certain 
sets of symptoms, and calling each set, in its collective form, a disease. 

To say the truth, I shall consider convenience and usefulness, in framing my 
plan, rather than an appearance of scientific precision ; and if I make one principle 
of arrangement more prominent than another, it will be that which relates to the 
anatomy of regions, — the place and situation of organs. At the same time, I shall 
not omit to borrow in part from some of those other methods to which I have just 
been referring. 

Before, however, we treat of the nature of particular diseases, it will be requisite 
to give some general account of the different ways in which the various parts of the 
body are liable to be altered in structure, or disordered in function ; and before we 
speak of the signs of particular diseases, it wiU be proper to take a general view of 
symptoms, and of their ascertained relations with the several forms of altered struc- 
ture : for doubtless you are aware that, although diseases are not constituted by 
symptoms, they are, in the living body, disclosed by symptoms. Sometimes the 
symptoms are outw^ard signals which alone reach our senses, and through which 
internal changes declare themselves ; and we then have to decipher and to interpret 
those signals. Sometimes we see the morbid changes themselves on the surface of 
the body, or in parts within our ken. Some internal changes we can appreciate as 
surely by the touch, or by the sense of hearing ; and of some we infer the existence 
from alterations in the chemical or in the sensible qualities of the natural excretions. 

After death, diseases are often to be traced by visible changes of structure in the 
internal parts of the body. These changes are extremely interesting, as illustrative 
of morbid processes : they throw light upon what is past ; they afford some guidance 
for the time to come. But, for obvious reasons, those signs which reveal diseases 
during life are, practically, of chief moment. In truth, the great object of our art 
is to prevent or postpone the disclosure of the others. The instruction afforded by 
the dead body comes too late to be of use in that particular Case. 

I have ahead}' intimated that the morbid phj^sical conditions from which the symp- 
toms flow, are not always to be detected, either before or after dissolution. Neither, 
when they are detected, is their connection with the symptoms always evident. 

Besides inquiring into the modes in which the various organs and textures of the 
body may be spoiled, and into the signals or symptoms b}^ which the presence of 
disease may be ascertained, it will be expedient to premise something, in a general 



20 



INTRODUCTORY LECTURE. 



manner, of the causes of disease, both with a view to its cure, and, what is much 
better, to its prevention. We shall also find it very useful to institute a short inquiry 
into the different ways in which death may take place — the different processes of 
dying. 

There is one morbid condition or process, to which all parts of the body are 
liable, and which contributes so largely and so frequently to alterations both of tex- 
ture and function, that it claims our especial attention when discussing the more 
general facts and doctrines of pathology : I allude to that change, or series of 
changes, which we comprehend under the term inflammation. 

It will be necessary, therefore, in the preliminary part of the course, to give a 
general account of inflammation ; and this account must chiefly be drawn from those 
of its phenomena which are most familiar to us — which we can see and handle; 
those which we witness when the disorder is seated in or near the surface, in the 
skin, in some of the mucous membranes, or in the subjacent areolar tissue. Then 
we shall pursue the examination of its peculiar phenomena as they are presented in 
the other tissues of the body — the mucous,' serous, fibrous, parenchymatous, muscu- 
lar, and nervous tissues ; and here the general principles of treatment apphcable to 
inflammation may be laid down, with the modifications required according to the 
tissues interested. 

In this part of the course may also be conveniently discussed the modifications of 
inflammation, and of morbid conditions generally, by the influence of certain diathe- 
ses, or peculiar dispositions of the body. Some constitutional morbific tendencies 
we shall find to be innate or hereditary ; such are the scrofulous and the cancerous 
dispositions : others, again, are plainly acquired, as that in which the whole system 
is tainted for a longer or shorter period by the venereal poison. 

Hemorrhages, also, and serous accumulations, or dropsies, as they are liable to 
occur in all parts of the body, require to be treated of generally, before they pass 
under our notice in the fist of particular maladies. There are certain facts and rea- 
sonings common to all inflammations, to all hemorrhages, to all dropsies. By com- 
bining these " generahties" into one comprehensive statement, we help the memory, 
avoid needless repetitions, and find room for the exposition of principles. 

Diseases themselves, in the mass, are sometimes distinguished according as they 
are local, or general. 

Taking these epithets in their popular sense, we should say that local diseases are 
those which occupy a definite portion only of the body; general diseases, those 
which pervade the whole body. 

But let us endeavour to obtain clear notions upon these points. 

Certainly there are many diseases which, occupying a definite portion only of the 
body, leave all the remaining parts, and the system at large, healthy both in texture 
and in function. Such diseases we have no hesitation in calling local. 

Again, there are many other diseases which, occupying a definite portion only of 
the body, yet occasion a manifest and serious disturbance in the functions of various 
other parts, and (it may perhaps be said) of the whole system. Inflammation of a 
small portion of the frame may give rise to much secondary or symptomatic fever ; 
but here also we properly speak of the disease as being local ; the secondary general 
disorder resulting from the local and primary, following it in point of time, and sub- 
siding upon its cessation. 

But there are still other forms of disease which show themselves, not like inflam- 
mation now in this and now in that part, but in many or most parts of the body at 
the same time. I will take the complaint called purpura, characterized by the uni- 
versal appearance of purple spots, as an example of what I mean. It is in truth a 
hemorrhage affecting many or all the tissues of the body simultaneously. For this 
reason it is commonly regarded as a general disease. 

But if we look somewhat closer into the matter, we shall, I think, perceive that 
most, if not all, of those which have been thus reputed general, are, in fact, reduci- 
ble to the class of local diseases. The fluids are as much parts of the body as the 
solids ; and if it be true, as I believe it is, that the essential and primary change in 
purpura is a change in the blood, its characteristic phenomena will be apt to present 



INTRODUCTORY LECTURE. 



21 



themselves wherever there is blood circulating — that is, throughout the whole sys- 
tem. The disease is local, inasmuch as its original seat is in that particular fluid, 
the blood : it appears to be general, because the morbid blood is everywhere present. 

The same observations apply to a large class of febrile contagious diseases ; to 
that state of the general system which is sometimes called anasmia ; also to certain, 
spasmodic aflections, where the seat of the actual disorder is in the whole nervous 
system. 

What are called general diseases, therefore, are those in which the whole of some 
one system that pervades the entire body happens to be similarly deranged. Whe- 
ther diseases can ever be truly called general in any more strict or absolute sense 
than this, is much to be doubted. 

I have mentioned dropsy as a malady which, like hemorrhage or inflammation, 
may occur in various parts of the body separately. It may also extend at once to 
all parts capable of receiving and retaining serous effusions : i. e., besides filhng the 
large serous cavities, the effused fluid may occupy the universal areolar tissue. 
But even this apparently general dropsy will be found, upon careful investigation, 
to resolve itself, in most cases at least, into local disease within the thorax, or the 
abdomen. 

The diseases which, in the sense now explained, may be called general, I shall 
arrange among the diseases of those parts of the system from which they have been 
ascertained^ or may be presumed, to arise. 

The first part, then, of the course will embrace an outhne of general pathology, 
with an especial reference to those morbid conditions which fall to the care of the 
physician. In its relations to surgery and to midwifery, pathology will be more 
particularly taught by the respective professors of those distinct though kindred 
departments of medicine. Do not, however, imagine that I take no interest in 
these, or that there can be any thing different in the principles upon which the 
several branches of pathological knowledge are founded. The truth is, that you 
cannot, if you would, separate the one from the other. You can neither understand 
what may be called medical, without learning much which as strictly belongs to 
surgical pathology ; nor can you be ignorant of either, without being in many 
important respects deficient in the other also. But the open field of pathology is of 
wide extent, and although we may, and must, survey the whole, yet its artificial 
divisions, its enclosures and allotments, will be cultivated best, and most improved, 
by a division of labour. 

Afterwards, separate diseases are to be described and considered ; all such, at least, 
as admit of being individuahzed, or presented under a definite shape. And here, I 
repeat, I shall chiefly pursue an anatomical order, as being comprehensive and inar- 
tificial, and as tending to facilitate diagnosis. The diseases of parts which lie near 
each other are the most liable to be confounded. 

I shall begin, therefore, with the diseases of the parts that appertain to the head 
and spinal cord, and then proceed in succession to those of the parts belonging to 
the neck, the thorax, and the abdomen ; to those of the joints, the muscles, and the 
skin. I shall not hesitate, however, to deviate from this order, whenever, by doing 
so, I can promote your convenience or advantage. 

With that portion of the course w^hich relates to particular diseases, I shall also 
interweave certain pathological considerations, applicable not so much to the whole 
body as to the several great systems of which it is made up. Thus, when I come 
to the brain, I shall speak of the functions pecuhar to the nervous system, and of 
the obstructions and disturbances to which those functions are obnoxious, by way of 
preface to a detailed examination of the various affections of the several parts of 
that system. Before discussing the diseases of the chest, I shall bring before yon, 
in a general view, the manner in which the great functions of respiration and of 
circulation are liable to be impeded, or otherwise disordered. As preparatory to 
the consideration of the diseases of the abdomen, I shall treat, in the same way, of 
the function of nutrition; and of waste, which imphes an interruption of those 
functions. 

^ Still there would remain certain diseases, which would not necessarily find a 



22 



INTRODUCTORY LECTURE. 



place m this arrangement, inasmuch as their seat is uncertain or only guessed at. 
Ague is one of these. Cholera, perhaps, another. It is quite -unimportant where- 
abouts in the course such maladies are considered. I feel no concern about any 
imputations of imperfect or clumsy arrangement with which the plan that I propose 
to adopt may appear chargeable. I had rather not be cramped and hampered by 
attempting what abler heads than mine have failed to achieve, and what, in truth, 
I believe, in the present state of our science, to be impossible, a complete methodical 
system of nosology. My object will be to furnish as much instruction and informa- 
tion as I can, in the w^ay that seems most hkely to be practically useful to you. 

Ague I shall take leave to include among the disorders of the nervous system ; 
and with it, the^ important subject of malaria will necessarily engage much of our 
attention. 

The great question of contagion I shall consider in connection with continued 
fever, which I rank among that remarkable class of diseases, the contagious exan- 
themata of Cullen. 

Of sympathetic and of hectic fever, I must speak when upon the subject of 
inflammation. 

This, then, is a sketch of the method I propose to follow. In the earher lectures, 
with the general pathology, I shall endeavour to lay down principles. To these 
principles I shall continually refer, as occasions offer, both in those prefatory remarks 
with which I purpose to introduce the diseases belonging to the several great sys- 
tems that contribute to form the body ; and also in what I shall subsequently have 
to say concerning those diseases themselves in detail. In this way I hope to com- 
bine the advantage of repetition, which was the peculiar advantage of two short 
courses in a season, with that of greater completeness, which forms the recom- 
mendation of a single extended course. The same great advantage of repetition — 
or I should rather say of recapitulation — will be further aimed at in the stated exa- 
minations of the class. 

Such being a summary of the topics to be embraced in the ensuing series of 
lectures, and of the order in which I hope to take up those topics, it seems proper 
that I should now say a few words in explanation of the scope and objects of the 
course. The prospectus informs you that it will comprehend the Principles and 
Practice of Physic. What are the true import and promise of these words ? 

By the principles of medicine are meant those general truths and doctrines which 
have been ascertained and estabhshed, slowly, indeed, and irregularly, but still 
with considerable precision, by the continued observation of attentive minds through- 
out the entire progress of medicine as a science. These principles I profess to teach 
you. The practice of medicine, or the particular application of those general facts 
and doctrines I shall describe to you ; but I cannot profess to teach it in this room : 
nor can you learn it, except in a very imperfect sense, from my description of it. 
Tt is the science that I shall here endeavour to unfold. Skill and facihty in turning 
that science to useful purposes I am unable to impart. These are qualities that do 
not admit of being communicated from one mind to another. The practice of 
hysic, like every other practical art, is to be learned by its repeated exercise ; by 
abit ; by carrying its various acts into direct effect again and again ; or, if they 
happen to require no manual dexterity, by looking on, and seeing them done again 
and again. There is this capital difference, however, between the art of healing 
and some other arts : that the blunders of early attempts may be both grievous and 
irremediable — may hurt or spoil the goodly and precious machine they are intended 
to repair. There is this also peculiar to our art — that it proceeds upon observations 
made at the very time Avhen its exercise is wanted ; and that it requires skill in ob- 
serving as well as skill in acting. You will find what, perhaps, previously to 
positive trial, you might not suspect, that the senses — the eye, the ear, the touch — 
however sharp or delicate they may naturally be, require a special course of training 
and education before their evidence can be trusted in the investigation of disease. I 
do not know that these views are capable of being rendered plainer by illustration ; 
for you must have observed a similar distinction between the science and the art in 



INTRODUCTORY LECTURE. 



23 



various other branches of human knowledge. The principles of navigation may- 
be thoroughly comprehended by a person who scarcely knows a rudder from a cable, 
and who would not be trusted, nay, who would not trust himself, with the conduct 
of the simplest boat. A man may master the beautiful science of astronomy— may- 
acquire the power of working upon paper its subiimest and most abstruse problems 
— and yet remain in complete ignorance of the method of adjusting and using a 
telescope, and unable to ascertain for himself the position or the movements of a 
single star. But place such a person night after night in an observatory — let him 
notice and imitate the proceedings of some one already skilled in examining the phe- 
nomena of the heavens — and he will soon acquire the requisite tact and facility him- 
self. Just so it is with that branch of knowledge wnth which we are concerned. It 
is in the wards of a hospital, or in the domestic chamber — it is among the sick and 
the dying — and there alone — that you can either thoroughly or safely learn to prac- 
tise physic. 

In what, then, you may fairly ask, consists the value or the use of lectures on the 
practice of physic, if the practice of physic cannot be taught by lectures? 

The main object of systematic lectures, explanatory of the principles, and descrip- 
tive of the practice of medicine, is to prepare the hearer for observing, to the best 
advantage, the actual phenomena of disease, and the power of remedies over it. 
They are intended to fit him for seeing with intelligence — to enable him to read, and 
understand; and interpret, the book of nature when it is laid open before him — in 
short, to quahfy hinl for clinical study. One man shall travel into a foreign land, 
knowing nothing beforehand of its scenery or its climate, of its natural productions, 
its manufactures, or its works of art, and ignorant alike of the manners, customs, 
history, laws, and language of its inhabitants ; another shall visit it after having fur- 
nished his mind with information on these subjects by reading, and by conversing 
with men who have already passed over the same ground. Supposing the visit to 
be limited in each case to a certain, but not long period of time, and I need not ask 
your opinion as to which of these travellers will reap the greatest harvest of enjoy- 
ment and of profitable knowledge from his journey. Not less striking is the dif- 
ference, in point of instruction and of interest, perceived by different students, upon 
their admission to the bedsides of the sick, according as they have been well or ill 
prepared for the multiform spectacle of bodily sufTering then first displayed before 
them. There are persons, indeed, who seriously, and I make no doubt in perfect 
good faith, warn the student against bringing to the contemplation of disease any pre- 
conceived opinions ; who tell him that he must come with a free and unprejudiced 
mind, and see, and note, and judge of all things for himself. I also would have him 
exercise, and ultimately abide by, his own judgment ; but surely if every man were 
to depend upon his own unassisted observation for his knowledge of disease, every 
man would be marvellously ignorant, and the science of medicine would stand still, 
or cease to be. " If no use be made (says Dr. Samuel Johnson) of the labours of 
past ages, the world must remain always in the infancy of knowledge." In truth, a 
person who, without any previous information concerning diseases, should betake 
himself to a hospital with the design of impartially and resolutely investigating their 
phenomena, such a person, however clear and strong his intellect might be, would 
find himself, for a long time, more puzzled than instructed by what he saw around 
him. He would be perplexed by the shifting and seemingly contradictory characters 
presented by the same malady in different patients ; or in the same patient at dif- 
ferent times ; and not less so b)^ the outward resemblance of disorders essentially un- 
like. He could not but be confused by the multitude of symptoms that crowded 
upon his attention on every side ; and at a loss to distinguish important facts from 
those which, for the chief ends of his pursuit, were trivial, or useless. 

The business, therefore, of a lecturer upon the Principles and Practice of Medi- 
cine^ or, as it is sometimes worded, the Nature and Treatment of Diseases, is first 
to fix upon some order in which to treat of the various subjects comprised in his 
course, The simpler and less artificial his arrangement, the better. The chief use 
of this classification is to facilitate the recollection of particular facts ; and I have 
already told you that if I can distribute and connect the multifarious forms of disease 



24 



INTRODUCTORY LECTURE. 



in such a manner as that they shall appear plain to your understanding, and take a 
secure hold upon 3'^our memory, I shall not trouble myself nor you with a vain search 
after that phantom — a perfect methodical nosology. " In all such classifications," 
writes Lord Brougham, " we should be guided by views of convenience rather than 
by an}^ desire to attain perfect sym.metry ; and that arrangement may be best suited 
to a particular purpose which plants the same things in one order, and separates 
them and unites them in one way, when an arrangement which should dispose those 
things differently might be preferable, if we had another purpose to serve." 

Having settled this framework of his discourses, the next aim of the lecturer must 
be to collect and arrange from the voluminous and bewildering records of medicine, 
and fromx the necessarily more slender stores of his personal experience, w^hatever it 
may seem of consequence that his hearers should know concerning each distinct 
form of disease, as it comes before them for consideration : to state all the facts which 
are well ascertained, and which tend to explain its symptoms, to elucidate its origin, 
to identifjr its nature, to direct its treatment, to accompHsh its prevention : to sift the 
true facts from the false, the important from the trivial, the essential from the acci- 
dental : to analyze the relations of these facts, and ascending from particulars to 
generals, to point out those great principles and precepts which constitute the keys 
both to the knowledge and to the management of all diseases of the same kind. It 
may even sometimes be his duty to notice and discuss mere theoretical opinions ; to 
express his own sentiments upon disputed or undecided questions ; and to admonish 
his audience against the danger of being led away by ingenious refinements, by the 
speciousness of novelty, or the boldness of speculation, from the more secure and 
settled results of careful observation improved by patient thought. 

These duties of a lecturer on medicine are metaphorically, but aptly, expressed in 
the following passage from Lord Bacon : — 

" Formica colligit, et utitur, ut faciunt empirici ; aranea ex se fila educit, neque 
a particularibus materiam petit, ita faciunt medic speculativi acmere sophistici ; apis 
denique cjsteris se meHus gerit. HaBC indigesti e floribus mella cohigit, deinde in 
viscerum cellulis concocta niaturat, iisdem tamdiu insudat, donee ad integram perfec- 
tionem perduxerit." 

I may venture to paraphrase it thus : — 

The lecturer must not be the ant, collecting all things indiscriminately from all 
quarters, as provender for his discourses ; 

Nor the spider, seeking no materials abroad, but spinning his web of speculative 
doctrine from within himself ; 

But rather the bee, extracting crude honey from various flowers, storing it up in 
the recesses of his brain, and submitting it to the operation of his internal faculties, 
until it be matured, and ready for use. 

Such, gentlemen, are the main objects which I shall endeavour to keep steadily 
in view during the series of lectures I am about to commence ; and I should ill 
deserve the chair I have the honour to occupy, if I did not feel the great responsi- 
hihty under which I speak to you. The subjects Avith which we have to deal are 
not matters of mere speculative curiosity or intellectual amusement — to be taken up 
to-day and dismissed perhaps with unconcern to-morrow — but they involve ques- 
tions of life and death. The opinions you are now to form or to embrace, are for 
the most part the opinions upon which in after fife you will confidently and con- 
stantly be acting. The comfort or the misery of many famihes may probably hang 
upon the notions, that each of you will carry from this place. Therefore it is that I 
feel mj^self to be engaged in a very serious undertaking. Doctrines and maxims, 
good or bad, flow abroad from a public teacher as from a fountain, and his faulty 
lessons may become the indirect source of incalculable mischief and suffering to 
hundreds who have never even heard his name. These reflections fill my mind 
with an almost painful sense of the obhgation imposed upon me, by my present 
office, of closely sifting the facts, and of carefully examining the principles to be 
derived from those facts, which I propose to employ for your instruction and 
guidance. 



PATHOLOGY. 



25 



But amid all the responsibilities, gentlemen, both of teacher and of learner, the 
profession which you and I have chosen, or which circumstances have prescribed to 
us, is a noble profession, and worthy the devotion of a lifetime. If you fit your- 
selves now for its high functions, and pursue it hereafter in earnestness and trath, it 
will probably conduct you to an honourable competence, and it will assuredly prove 
a salutary school of mental and of moral discipline. Trials, no doubt, belong to it, 
and difficulties ; but it has also privileges and immunities peculiar to itself. Afford- 
ing ample scope and exercise for the intellect, it is conversant with objects that tend 
to elevate the thoughts, to chastise the feehngs, and to touch the heart. I have 
* already reminded you how it brings beneath our minute and daily notice that most 
remarkable portion of matter, which is destined for a season to be the tabernacle of 
the human spirit, and which, apart from that singularly interesting thought, excites 
increasing wonder and admiration the more closely we investigate its marvellous 
construction. The sad varieties of human pain and weakness with which our daily 
vocation is famihar, should rebuke our pride, while they quicken* our charity. To 
ns are entrusted, in more than ordinary measure, opportunities of doing good to our 
afflicted fellow-creatures — of showing love towards our neighbour. Let us beware 
how we idly neglect, or selfishly abuse, a stewardship so precious, yet so weighty. 
The profession of medicine, having for its end the common good of mankind, knows 
nothing of national enmities, of pohtical strife, of 'sectarian dissensions. Disease 
and pain the sole conditions of its ministry, it is disquieted by no misgivings con- 
cerning the justice and honesty of its client's cause ; but dispenses its pecuhar 
benefits, without stint or scruple, to men of every country, and party, and rank, and 
religion, and to men of no religion at all. And hke the quality of mercy, of which 
it is the favourite handmaid, "it blesseth him that gives and him that takes;" read- 
ing continually to our own hearts and understandings the most impressive lessons, 
the most solemn warnings. It is ours to know in how many instances, forming 
indeed a vast majority of the whole, bodily suffering and sickness are the natural 
, fruits of evil courses ; of the sins of our fathers, of our own unbridled passions, of 
the malevolent spirit of others. We see, too, the uses of these judgments, which 
are mercifully designed to recall men from the strong allurements of vice, and the 
skmber of temporal prosperity; teaching that it is good for us to be sometimes 
afflicted. Familiar with death in its manifold shapes, witnessing from day to day 
its sudden stroke, its slow but open siege, its secret and insidious approaches, we are 
not permitted to be unmindful that our own stay also is brief and uncertain, our 
opportunity precarious, and our time, even when longest, very short, if measured by 
our moral wants, and intellectual cravings. 

Surely, gentlemen, you will not dare, without adequate and earnest preparation, 
to embark in a calling hke this ; so capable of good if rightly used, so full of peril 
to yourselves and to society if administered ignorantly or unfaithfully. And even 
when you have made it, as you may, the means of continual self-improvement, 
and the channel of health and ease to those around you, let not the influence you 
will thus obtain beget an unbecoming spirit of presumption ; but remember that, in 
your most successful efforts, you are but the honoured instruments of a superior 
power — that, after all, " It is God who healeth our diseases, and redeemeth our life 
from destruction." 



LECTURE IIJ 

Pathology — meaning of the term. Pathology, general and special Morbid 
alterations of the solid parts of the body, derations in bidk. Hypertrophy 
— law of its production — its effects. Atrophy — its causes and consequences. 
Changes in form. Alterations in consistence. Induration — its various kinds, 

I PROPOSE to devote several lectures, in the commencement of the course, to 
pathology, as it relates to medicine. 

o 



26 



ALTERATIONS OF SOLIDS. 



And I must first of all explain to you what I mean by the word Pathology. 

Many persons speak of pathology as if it were the same thing with morbid 
anatomy. That is not the sense in which I purpose to use the term. Pathology is 
morbid anatomy, but it is something more. 

A knowledge of pathology (in the full and proper acceptation of the word) 
implies indeed a knowledge of altered structures and of diseased conditions; — but 
it implies also an explanation of these — a knowledge of what precedes them, and a 
knowledge of what results from them. 

It comprehends, therefore, the following particulars: — 1. A knowledge of the 
material changes to which the several parts of the living body are subject : 2. A 
knowledge of the processes or actions whereby these changes may be wrought : 8. 
A knowledge of the causes which may set these processes on foot : and 4. A 
knowledge of the consequences of the same changes, or of the symptoms they 
occasion. 

On some of thes'e points our actual knowledge is still scanty and imperfect. Yet 
a good deal of valuable information concerning each of them has been collected ; 
and this I shall endeavour to place before you as distinctly, and at the same time in 
as small a compass, as I can. 

Pathology is general or special. General pathology treats of the morbid condi- 
tions which are common to the entire system, or to the whole of each of the several 
tissues that pervade and compose the system. Special pathology contemplates par- 
ticular diseases. An acquaintance with general pathology prepares us for, and con- 
ducts us to, that which is special ; and when I say that the earlier lectures of the 
course will be given to a consideration of the leading facts and doctrines of patho- 
logy, you will of course understand me to speak of general pathology. 

I shall begin by inquiring what are the changes to which the com.ponent parts 
of the hving frame are hable : and I speak chiefly of sensible changes ; leaving 
unnoticed for the present those conditions which are perceptible only through the 
microscope. 

There are, then, various ways, capable of intelligible description, in which the 
different parts of the body may be sensibly altered by disease. 

Th6 solid parts may be altered in hulk; in form; in consistence ; in their inti- 
mate texture, i. e., in the qualities and arrangement of their component particles ; 
and in situation. 

The fluid parts may also be altered in quantity; in quality; and m place, 
I" And many of these alterations may exist in combination with each other. 
[ Let us first consider the solids. 

They may be simply altered in bulk without any change of texture ; and that in 
two ways. They may become larger than natural, or smaller than natural. In the 
one case the change is called hypertrophy, in the other atrophy. 

We find the best illustrations of hypertrophy in the muscular system. The 
huge fleshy masses visibly prominent in the arm of a blacksmith or a pugiUst, 
and in the leg of an opera dancer, afford familiar examples of it. In these cases 
the increased bulk, although it may be unsightly, as being out of proportion to other 
parts, is not disease, and does not interfere with the most perfect health. By con- 
stant exercise the muscles acquire preternatural volume, and weight, and power. 
It seems to be a law which prevails extensively in the animal economy, that increase 
of function should lead to augmentation of bulk. The function of the muscular 
system is contraction, and more frequent and energetic contraction begets an ad- 
dition of substance. But the same principle obtains in various other parts and 
tissues. It is especially noticeable in some of the organs that are double. If one 
kidney wastes, or is spoiled by disease, an increase of function is thrown upon the 
other, and by a beautiful law of compensation, the sound organ, without any alter- 
ation of its peculiar fabric, enlarges. The same is observed to be the case with the 
lungs. The law resembles, somewhat, one that is familiar to political economists, 
and is expressed by them in the maxim — that the supply of a marketable com- 
modity is regulated by the demand for it. If, in respect to a muscle, increase of 
force be habitually needed, the necessity generates the requisite addition of bulk, 



ALTERATIONS OF SOLIDS. 



27 



whicli implies an augmentation of force. One kidney becoming inefficient, it is 
necessary that the other should secrete a larger quantity of urine ; and this faculty is 
obtained by the enlargement of the secreting organ. 

I say this law is of extensive operation in the living body : but it is not universal. 
It does not hold, for instance, in respect to the organs of the special senses. One 
eye does not become hypertrophic when the other is Wind ; nor one ear grow larger 
or longer because the other is deaf. And we see at once why the law in question 
does not apply in such cases. These organs differ from such as I mentioned before 
' — from muscular and glandular parts — in this : that increase of their size would not 
further or facilitate the purpose they are designed to serve. A muscular arm will 
strike a harder blow and lift a heavier weight, in proportion to the greater bulk of 
its muscles : but we should gain nothing in distance or distinctness of vision by the 
enlargement of an eye ; nor should we hear more acutely or more clearly if our ears 
were of twice the ordinary magnitude. 

Hypertrophy of this unmixed kind — unattended by any change of texture — (and 
it is to this that the term should as much as possible be restricted) — is beheved to 
depend upon more active nutrition of the part [vTtsp tpo^yj,) More materials are laid 
down in the part by the blood, and assimilated, than are received back from the part 
into the blood to be taken out of the body. The nutritive process preponderates over 
the .re-absorbent. That hypertrophy does thus result from an excess in the process 
by which parts are nourished and built up, and not from a defect in the process by 
which they are continually unmade and removed, is rendered probable by the fact 
that an increased quantity of nutrient blood is sent to the hypertrophied part ; its 
arteries grow larger : this we perceive by comparing these vessels with others where 
no accession of bulk has occurred. This opinion is further strengthened by the 
converse effect produced upon an hypertrophied part (the thyreoid gland, for in- 
stance), by tying its principal nutrient artery. The magnitude of the bronchocele 
diminishes. It is curious that no such alteration of size has been noticed in the 
nerves supplying the hypertrophied parts. 

Now these examples of hypertrophy clearly have not the nature of disease. But 
hypertrophy is often plainly connected with disease, while still it is not itself a 
morbid process. Thus we have it in the hollow contractile organs, the office of 
which is to propel fluids : — in the heart when the progress of the blood suffers some 
mechanical impediment : in the bladder w^hen the urine, and in the intestinal canal 
when its contents are somehow hindered in their natural course ; or when, from 
some undue stimulus or irritation, these parts respectively are urged for a long time 
together to excessive, or too frequent action. I show you preserved specimens of 
each of these changes. You will find that muscular tissue may become apparent, 
under the influence of disease, where very shght traces of it, or none at all, were 
visible before. We sometimes observe this in the air-tubes, the trachea and bronchi, 
when the respiratory functions have been long embarrassed ; and in the gall-blad- 
der, when the exit of the bile has been chronically obstructed. And it is worth 
remarking that this new, or greatly exaggerated appearance of muscular tissue, 
which is the consequence of disease in the human body, is a part of the natural and 
healthy structure in the corresponding organ of some of the inferior animals. 

The several instances of hypertrophy that I have now been mentioning, if they 
are to be looked upon as morbid, are morbid in a particular and limited sense — 
morbid, merely as being associated with disease, but not so either in their own pro- 
cesses or in their tendencies. Many, indeed, of the writers who notice them, speak 
of the hypertrophy as constituting a source of disease, and a cause of danger to the 
patient. But I shall have occasion to show you hereafter that in most cases it is 
really a compensatory change, and conservative of life ; — a resource of nature by 
which impending danger is postponed, and existence prolonged. 

It may be said of hypertrophy, that its relation to disease depends very much 
upon its seat. As regards the muscular system — in the voluntary muscles it is 
generally innocent, in the involuntary it is generally connected with disease ; 
sometimes as a cause, much oftener as a consequence, sometimes as both cause 
and consequence. One way in which hypertrophy may manifestly be a cause of 



28 



HYPERTROPHY. 



disease is by the pressure of an enlarged organ upon the parts in its neighbour- 
hood, and a consequent interference with the functions or the sensations of those 
parts. 

I am not sure, whether to those among you who are beginners, I make myself 
understood. An example or two will render my meaning obvious. 

It often happens that the aortic orifice of the left ventricle of the heart becomes 
narrow and constricted, in consequence of disease in the semilunar valves there 
situate. Under these circumstances it is requisite, for the due propulsion of the 
obstructed blood, that the ventricle should contract with increased force : and its 
walls become, accordingly, thicker and stronger. Here the hypertrophy of the left 
chamber is evidently a consequence or effect of the disease that previously existed 
at its outlet. 

On the other hand, when the thyreoid gland is enlarged, it sometimes presses so 
much upon the parts that lie behind it, as to impede the breathing, or the swallow- 
ing. In this case the hypertrophy is the cause of consecutive disease. 

Hypertrophy is exceedingly common in other tissues as well as in the mus- 
cular. Of its affecting the glandular system we have good examples in what I 
have just mentioned, the true bronchocele ; in certain forms of enlarged prostate ; 
in the thymus gland not unfrequently. Of a state of the brain which is considered 
to constitute hypertrophy, I shall speak more particularly when we tiome to the 
morbid conditions of that organ. Hypertrophy is also said (I am not certain with 
how much propriety always) to occur in the cutaneous, mucous, and vascular 
systems, in the bronchial, mesenteric, and mammary glands, in the hver, spleen, 
and pancreas. Of these parts I suspect that the enlargements to which the term 
hypertrophy has been sometimes applied, most frequently combine some alter- 
ation of texture with the increase of size, and therefore are not strict examples of 
hypertrophy. 

You ought to be aware that hypertrophy of one or more of the component tissues 
of an organ may exist, while the others either remain unaltered, or are changed in 
some other way. It frequently happens that when one component part is thus over- 
nourished, it is so at the expense (as it would seem) of another which becomes atro- 
phied. There are parts of the heart upon which a certain quantity of fat is usually 
deposited. It is not uncommon to meet with this fat in excess, and at the same time 
to find the muscular texture of that organ pale, flabby, soft, and wasted. What has 
been deemed hypertrophy of the female breast consists, almost always, I believe, in 
excessive development of its adipose tissue, without any enlargement of the gland 
itself — or even with its diminution. 

Hypertrophy of the adipose tissue is often general throughout the body, producing 
obesity ; and this may become so extreme as to amount to disease, when it is called 
by noso legists polysarcia. I have seen one fatal instance of this kind. The mother 
of a large family, whom I long knew as a slender aad elegant woman, began sud- 
denly to grow fat; and in about fifteen months, without any other discoverable 
malady, she gradually enlarged into a corpulent unwieldy monster. At length her 
legs and thighs became osdematous as well as fat, her hps blue, her breath was 
short, and her pulse feeble. One night she was found dead in her bed. The body 
was not examined ; but her death was mainly owing, as I believe, to fat collected 
upon the heart, oppressing its movements, and at last stopping them altogether. 

[n the majority of cases the size of an hypertrophied organ is augmented ; it has 
a larger superficies than is natural : and therefore I have introduced hypertrophy to 
your notice among the alterations to which parts are liable in bulk. 

But it is not always so. There may be hypertrophy of an organ without enlarge- 
ment — in at least three different ways : — 

1st. In hollow organs, where the additional substance is deposited centrically, and 
the hypertrophy takes place at the expense of the cavity : 

2diy. In any organ, whereof the hypertrophy is confined to one or more tissues, 
while the others are proportionably wasted ; and, 

3dly. Hypertrophy may even be consistent with no alteration of shape, or increase 
of bulii in any direction, the organ occupying exactly the same space, and preserving 



HYPERTROPHY. 



29 



the same absolute dimensions as before, but becoming more full of component par 
tides, more compact, heavier. This state is well exemplified in certain cases of 
hypertrophy of bone : the spongy or cancelous texture of the bone disappears ; its 
specific gravity is increased ; it becomes hard, firm, and Hke ivory. The structure 
appears, to the eje, to be changed, yet remains the same, except in respect of its 
density. 

I have told you that hypertrophy is usually a conservative and salutary change. * 
We shall meet with many illustrations of this as we proceed. But I may take the 
present occasion for pointing out to you some of the beneficial tendencies of this 
change when it takes place in bone. For, since the diseases of the bones do not 
belong to my province, I shall have no other opportunity. 

You probably know that in the disorder called rickets, occurring principally during 
childhood, the bones are soft and deficient in their more sohd ingredient ; so that 
they bend under the weight of the body, or the contraction of the muscles attached 
to them. After a certain period this disproportion in the constituent particles of the 
osseous tissue ceases ; but the bones are permanently distorted, and, therefore, less 
adapted to their office, and less strong, than if they had remained straight. Now the 
natural remedy that ensues is very striking and beautiful. The bent bones become 
hypertrophied in certain places ; they grow thicker, denser, harder, and consequently 
strong, at the very concave part where the stress of the pressure is the greatest. 

The following experiment showed the same thing in a somewhat different man- 
ner. An inch of the middle part of the fibula of a quadruped was cut out. A long 
time afterwards the animal was killed. The tibia was then found to have become 
considerably larger exactly in that part of it which corresponded to the defect in the 
fibula.* 

The same principle appears still more conspicuously in a case of disease related 
by Cruveilhier. He saw in the hospital at Limoges a young man who had lost 
(from necrosis with suppuration) the middle third of his tibia ; of the larger of the 
two bones of the leg. The lost bone had not been reproduced, but the fibula, the 
naturally slender bone, had become thick and strong enough to support the whole 
weight of his body. 

I was explaining to you that hypertrophy may exist without enlargement. On 
the other hand there may be enlargement without any change of structure, and yet 
no hji^pertrophy. The liver and spleen are apt to acqui're a considerable increase of 
bulk from mere congestion and distension of their vessels by blood. An immense 
spleen will shrink into its proper size in a few hours, after hemorrhage from the sto- 
mach, whereby the gorged venous system of the abdomen has been relieved. Dr. 
Townshend mentions a remarkable example of the same kind respecting the liver. 
The inferior cava has been compressed by an aneurismal tumour, so that the pas- 
sage of blood from the liver was greatly impeded. Under these circumstances the 
fiver became so large as nearly to reach the crest of the ilium. Suddenly the aneur- 
ism burst, the pressure was taken from the cava, the hepatic veins were allowed to 
empty themselves, and before the body was opened for inspection, the liver had 
nearly resumed its natural situation and dimensions. 

Of the causes of hypertrophy little more is known than I have already told you. 
The most important circumstance for you to remember is, that increase of function 
produces increase of nutrition. This is nearly a general fact ; but whether the con- 
verse proposition be as generally true — whether hypertrophy of a part always de- 
notes increased activity in its function — is much less certain. If that were ascer- 
tained, we might hope to discover the actual office of certain parts of the body, the 
uses of which we do not yet understand (of the thyreoid gland, for example), by 
investigating the circumstances under which they become subject to hypertrophy. 
In Mr. Mayo's Outlines of Human Pathology, a case is related of hypertrophy of 
the tongue, in a young child, treated by Mr. Hodgson, of Birmingham. It would 
seem to be impossible to account for this by any increased energy in the known 
functions of that member. 



* Mr, Stanley's Lectures, Coll. Surg. 



30 



ATROPHY. 



A few isolated facts, bearing upon some points connected with this inquiry, hav3 
been made out. 

In the first place, certain localities appear to be influential in the production of 
certain forms of h3^pertrophy. Thus bronchocele is very frequent among the inha- 
bitants of certain districts ; especially in close or marshy valleys at the feet of high 
mountains. Its real cause is to be sought in some condition, hitherto undetermined, 
of the air in those places, or of the water, or of both. 

2dly. Certain congenital or acquired conditions of the body tend to produce local 
hypertrophy. In that peculiar diathesis which we call the strumous — and of which 
I shall have much to say hereafter — certain parts of the body, as the upper lip, and 
the extremities of the long bones, undergo a kind and degree of enlargement that 
seem properly to fall within the definition of hypertrophy. 

3dly. Certain habits of life have a distinct effect in promoting certain forms of 
hypertrophy. Full diet, with bodily inactivity, leads to hypertrophy of the adipose 
tissue. So general is this tendency, that we confidently act upon it in the fattening 
of animals. Shut a healthy pig up in a small sty, and give him as much food as 
he is wilhng to eat, and you insure his rapid pinguescence. If you cannot so cer- 
tainly attain the same result by similar means in the human animal, it is chiefly, I 
believe, because moral causes, and especially mental anxiety, will effectually coun- 
teract those means. A healthy man, with a quiet mind, using habitually a full nu- 
tritious diet, and leading a sedentary life, wih fatten, I apprehend, as unfaihngly as 
a calf, or a turkey. Sometimes, indeed, fat accumulates to an enormous extent, in 
spite of abstinent habits, and very active exercise. 

4thly. It is a curious fact that the removal of certain parts of the body, as the 
testicles from male animals, and the ovaries from females, increases the disposition 
to accumulate fat. The same tendency appears to be given, for a time, by the 
extirpation of the spleen. 

Of the curative methods that hypertrophy may require it would be premature to 
speak at present. 

The bulk of parts m^ay be also augmented in various other ways. The hollow 
organs may be inordinately distended by an undue accumulation of their natural 
contents : or by matters that do not enter them in health. The sohd organs may 
have their size increased by the presence of matter foreign to their natural composi- 
tion, collected in their interior, or distributed through the insterstices of their proper 
tissues, or deposited upon their surface : and in either case the functions of the part 
itself may be disturbed or suspended; or the functions of parts immediately con- 
tiguous to it may sustain damage from its pressure ; or the functions of distant parts 
connected with it by dependency of office may be disordered ; or all these conse- 
quences may exist together. Numerous examples of them all will hereafter be 
brought under your notice. 

Let us next attend to that condition which is the opposite of hypertrophy — to 
atrophy, namely, in which parts become notably smaller than natural, without other 
akeration of texture. 

The two conditions contrast strongly with each other in their nature and origin, as 
well as in their physical character. 

Hypertrophy depends essentially upon an increase — atrophy upon a diminution 
or defect, of the nutritive functions. You will find that atrophy plays an important 
part in altering the bodily organs, both in health and in disease. 

Of the effect of atrophy in causing alterations consistent M'ith health, T shall merely 
remind you of some instances, that you may the better comprehend its morbid 
operation. 

There are parts of the body, as you well know, destined for a temporary purpose 
only. Upon the cessation of their especial function they dwindle, or disappear. We 
have examples of this in the thymus gland, in the supra-renal capsules, and in those 
parts of the mechanism of the circulation which are pecuHar to the fostal state. The 
atrophy here begins as soon as the child is born, and is not only consistent with, but 
necessary to, its perfect heakh. As life advances, we see the same principle at 



ATROPHY. 



31 



work, remodelling from time to time those structures of which the office has only a 
limited duration. After the child-bearing period in women is over, when the func- 
tions of the ovaries expire, these organs shrink, through atrophy. It is so with the 
testes of old men. Indeed, atrophj^ to a certain extent, pervades all parts of the 
system in old age ; the muscles diminish in size, the whole body is less plump, the 
bones lose a portion of their substance, and become brittle. 

Even in the period of foetal life this process, by which parts are starved and 
stunted, sometimes displays itself. But here it is no longer compatible with the 
integrity and well-being of the system. The arrest or retardation of the nutritive 
function produces changes of great interest, and gives rise to various kinds of mon- 
strosity. Harehp — fissure of the palate — certain malformations of the heart— are 
famihar examples of the consequences of intra-uterine atrophy. 

Atrophy, considered as a morbid change, is conspicuous, no less than hypertrophy, 
in the muscular system. We see it in the voluntary muscles, whenever a limb 
remains long in a state of inaction — whether from palsy depending upon disease in 
the brain or spinal cord ; or from pain connected with disease of a joint ; or from 
perversion of the will, as in the self-infliicted penance of the Fakir. The same law, 
therefore, obtains here, which was previously announced ; the development of a part 
is proportioned to the activity of Its function. In most cases, I believe, the atrophy 
will be found to resolve itself into a deficient supply of healthy arterial blood. Build- 
ing materials are not provided, or are provided inadequately. Mere inaction will 
produce atrophy ; but it is probable that the inaction operates simply by abridging 
the flow of arterial blood to the muscle. If (as some suppose) what is called a 
change in the innervation of a part tends sometimes to occasion its atrophy ; if, for 
example, the akered state of the nervous influence has some share, beyond the inac- 
tion which it produces, in causing the atrophy of a paralyzed limb — it stiJl acts, I 
conceive, indirectly, and by reducing somehow the supply of healthy arterial blood. 
The nerves belonging to palsied and atrophied muscles are said not to diminish in 
size. It is with the arterial circulation, certainly, that atrophy is most concerned. It 
is upon a diminution of the number of the smaller, and perhaps also of the capacity 
of the larger arteries, that senile atrophy depends. We find atrophy of the brain 
accompanying certain diseased conditions of its main arteries. So the testicles 
wither when the spermatic artery is tied for the cure of varicocele. 

Pressure of any kind, exercised either upon the large arterial trunks, or upon the 
capillary vessels, so as to lessen without completely preventing the supply of blood, 
will be found to give rise to atrophy, whenever the due quantity of blood is not fur- 
nished by the establishment of a collateral circulation. Chronic injiammation is 
sometimes attended by the wasting of the part w^hich it occupies. It acts, in all 
probability, by unfitting the capillary arteries for transmitting the requisite quantity 
of blood. Various diseases, by which the supply of nutriment to ail parts of the 
body is checked at its source in the digestive organs, or by which some unnatural 
drain upon the system is kept up — by which, in short, the quantity of the nutrient 
fluid is diminished, or its quality impaired — produce a greater or less degree of 
^•mera/ atrophy ; but to this universal wasting we usually apply the term emaciation. 

Atrophy, then, such at least as is morbid in its nature, may be the consequence of 
inaction, of compression, of chronic inflammation, and of various diseases ; but in all 
cases the defect of nutrition which constitutes the atrophy seems to be resolvable into 
a diminished supply of healthy blood through the arteries. 

As in hypertrophy, so hkevvise in atrophy, the change may be hmited to some 
one or more of the component tissues of a part ; and by these altered proportions of 
its constituent tissues the appearance of the part may be remarkably modified. 

So, also, as hypertrophy may exist without any increase of absolute size, atrophy 
may occur without any decrease : as in the heart, when the cavities are dilated in 
the exact degree in which their walls become thinner. Bones, externally sound in 
appearance, have had their specific gravity so greatly reduced by internal atrophy, 
that they would float upon water like a cork. 

It is a curious fact — which I mentioned in other terms before — that an atrophied 
part is sometimes plentifully encompassed by fat. But this is by no means a neces- 



32 



INDURATION. 



sary accompaniment. Why it happens in one case, and not in another — whether 
the adipose hypertrophy is ever the cause of the atrophy associated with it, or the 
atrophy the cause of the hypertrophy : — these are questions which, in the present 
state of the science of medicine, do not admit of any positive solution. 

It is scarcely necessary to observe that the changes of bulk which we have been 
considering, imply often, though not always, changes of form also. You will have 
one or two of the chambers of the heart greatly enlarged, while the others remain of 
their natural size. Of course this altered proportion modifies the shape of the organ. 

Signal changes of form are produced also by inflammation, by pressure, and in 
various other ways. But, after all, modifications of figure are rather to be consi- 
dered as accidents of disease than among its important elements : and I pass on to 
other alterations. 

Various parts of the body are liable to be changed in consistence. They may 
# become harder and firmer than before : or they may become softer. To the state 
of increased or unnatural hardness the term induration has been apphed : the same 
word is used also to express the process of hardening. To the state of diminished 
consistence we give the name of softening. The French pathologists, who first 
noticed this condition as an element of disease, calPit ramoUissement. 

You are already aware — those of you who have attended the lectures of the pro- 
fessors of midwifery and of anatomy — that a slow process of natural and healthy 
induration is going on throughout the body from the earliest period of uterine fife to 
extreme old age. 

There are several ways in which imnatural induration may take place. 

Induration of an organ may happen, without any other alteration of its proper 
tissue, in consequence of inordinate fullness of its blood- vessels* This is apt to occur 
in the lungs, or liver, whenever the free exit of blood from these organs is in any 
way impeded. They become stretched, tense, resisting, hard. 

In hke manner induration of the hollow organs, or of cellular parts, will arise 
(without any change of their texture) from an undue accumulation of fluids within 
them ; — of bile, for example, in the gall-bladder ; of urine, in its receptacle ; of gases 
in the stomach and intestines ; of serosity in the cellular tissue. 

In either of these kinds of induration the unnatural hardness may be temporary 
only, or it may be the permanent accompaniment of other disease. It is necessary 
that you should be aware of its occurrence, and of its nature. I say of its nature, 
because this is not always understood. In the induration arising from the last cir- 
cumstance I mentioned, viz., from infiltration of the cellular tissue with the serous 
or albuminous parts of the blood — from oedema, in short — the hardness has some- 
times been erroneously ascribed to some other morbid condition. Dr. Carswell has 
shown that in the curious disease of new-born children who are said to be skin-hound, 
the hardness of the surface is the consequence of simple oedema of the subcutaneous 
cellular tissue. The same phenomenon is remarkable in cedema of the tongue. I 
beheve the induration belonging to (Edema will be found to be the greater, in propor- 
tion as the effusion is recent, and has taken place rapidly. 

Again, induration may accompany, and be a consequence of, simple hypertrophy. 
Of this I have already shown you examples ; especially in the eburnation (as it has 
been called) of hypertrophied bone. 

Induration of an organ may also result from the compression of its fluid, and the 
compression of its soUd parts. We see this extremely well in the lung, when it has 
been thrust and flattened against the vertebral column by fluid effused into the pleura ; 
or when it is still more tightly bound down by an investing layer of plastic lymph. 
In this way, therefore, induration may be consistent with atrophy. That the natural 
structure of the hardened lung is not always lost in these cases we know, because 
we can restore, to a certain extent at least, its bulk and spongy feel, by forcibly 
mflating it. The spleen sometimes exhibits the same kind of induration, under the 
constrictive force of an investing false membrane. I am mentioning samples only 
of these changes. 

More frequently induration depends upon the presence, in the internal texture of 



SOFTENING. 



33 



parts, in the little spaces left between their competent tissues, of fluid or solid matters 
which are not found there in the healthy state. Bony or earthy particles are some- 
times laid down, and the part thus changed is said to be ossified. There are few 
parts of the body in which this kind of induration does not .occasionally take place. 
It is especially common in the coats of arteries, and in the subserous tissues. Blood, 
or fluids separated from the blood, may fill and obliterate the natural interstices, and 
concreting, tend to sohdify and harden the part which they occupy. What is called 
hepatization of the lung is a good instance. I need not tell you that the healthy 
lung is spongy and crepitant under pressure : in this altered state it no longer crackles 
between the fingers ; its spongy character is lost ; it resembles hver in its compact- 
ness and colour, and it is therefore said to be " hepatized." This is a consequence 
of inflammation ; and induration of this kind is a very common consequence (as we 
shall see) of the same morbid process in various other parts and organs. Another 
instance of induration of the pulmonary substance we have in what is badly called 
pulmonary apoplexy. This is independent of inflammation. Blood is collected and 
coagulates in a part of the lung which should contain air — in the vesicle of one or 
more of its lobules ; the lobules thus gorged with blood become even harder and 
firmer than when hepatized ; but by a different process. 

In the instances last mentioned, fluids after escaping from their proper vessels, 
i. e., in technical phrase, after being extravasated, pass into the solid form, and thereby 
render the parts which they pervade harder and more firm. But fluids may con- 
crete and harden within their proper vessels, and so lead to another form of indu- 
ration. Thus the blood, under certain circumstances, coagulates in the living veins 
— nay, sometimes even in the heart itself: and we may hereafter have to consider 
the conditions under which this coagulation is liable to occur, and the serious conse- 
quences which it involves. The bile, again, as you probably know, sometimes 
concretes, by a rude kind of crystalHzation, into what are called gall stones : and 
the passage of these calculi through the narrow ducts that connect the gall bladder 
with the bowel, is apt to be attended with pain the most intense. The formation of 
urinary calculi is not exactly of the same kind. 

Numerous specimens of all the changes I have been describing are on the table 
before you. You may examine them at leisure after lecture, or in the museum. 
, I have yet to notice another source of unnatural induration, in the deposition or 
growth of irregular masses of matter within the body, differing remarkably from any 
of the soKds or fluids that enter into its heakhy composition. These unnatural for- 
mations vary considerably in their nature and appearance, and in their consistence, 
at different periods. Sometimes they exist in distinct and separate masses, and 
whether hard or soft in themselves, cause induration by their pressure upon surround- 
ing textures : sometimes they are diffused through or among the natural tissues of a 
part, which thus they indurate. All the varieties of tubercle, and of cancer, and 
other forms of disease which have been styled mahgnant, fall under this head. 

These new and morbid products play a fearful part in disorganizing the bodily 
frame, and in embittering and shortening life. They will necessarily occupy much 
of our attention in the progress of the course. At present I merely point them out 
as illustrations of the manner in which the consistence of parts may be increased. 



LECTURE III. 

Softening ^ its causes and varieties. Transformation of Tissue; Changes of 
situation — in the Chesty of the Lung, of the Heart — in the Abdomen and Pelvis, 
Hernia, Intussusception, Prolapsus. 
# 

We were occupied with that branch of pathological inquiry which relates to the 
Tarious ways in which the several parts and organs of the living body are liable to 
be sensibly akered by disease. 



34 



SOFTENING. 



We considered the changes to which the solid parts are subject in hulk and form ; 
and that alteration of their consistence which constitutes hardening or induration. 

The opposite condition to this is softening, diminished consistence, a less degree 
of cohesion of parts and tissues than is natural. 

This is also a state of which it is important that you should comprehend the 
nature, and causes, and varieties ; and the share that it often has in breaking down 
the structure of organs, and in destroying life. * 

There is scarcely any tissue of the living body in which softening may not take 
place. I shall here, however, as before, mention a few illustrations only of its occur- 
rence, taking those instances in which the phenomenon is most evident, or is best 
understood. 

Softening is perhaps never more strikingly obvious to our senses than when it 
affects the brain or spinal cord. We find portions of these organs manifestly softer 
than the rest. You are famihar with the usual consistence of the adult brain : you 
will find it sometimes reduced, in places, to the consistence of cream : a gentle stream 
of water suffered to fall upon the softened pulp suffices to wash it away, and a cavity 
is left in its place. 

The cellular tissue — or rather let us call it, with Professor Todd, the areolar tissue, 
since minute anatomists now affirm that all the tissues in their embryonic state are 
cellular — the areolar tissue is another part in which softening is exceedingly com- 
mon, although the change is not so readily perceived. This is the great connecting 
tissue of the body ; and we are made sensible of its diminished consistence when 
parts which it unites become separable with unusual ease. Thus you may some- 
times, by exerting a very slight degree of force, strip off a serous membrane from 
the parts which it invests, or a mucous membrane from the surface hned by it. This 
ready separation is a consequence of the diminished consistence of the subserous, 
or the submucous, areolar tissue. The membranes themselves, in such cases, may 
be in a perfectly natural state. 

Muscles, again, are often palpably softer than they should be : the fleshy substance 
of the heart, for example. Here the muscular fibre may itself have undergone a 
change of consistence ; or the muscle may simply appear to be softened, in conse- 
quence of the softening of the threads of areolar tissue by which its fibres are tied 
together. 

The mucous membranes very frequently present the phenomenon of softening. 
This is more commonly seen in the stomach than elsewhere. Instead of being 
raised from the subjacent tissues in large flakes, the mucous membrane, when seized 
between the forceps, breaks off in small fragments ; or it may be crushed and mashed 
by the pressure of the finger, or washed away in shapeless pulp by a httle current 
of w^ater. This condition of its lining membrane is usually hmited to parts of the 
stomach ; but occasionally it is general. 

Even the bones are liable to this change of consistence. There is a disease called 
molliiies ossium, in which the bones even of adults become soft and phant, and 
capable of bending in any direction. There is a deficiency in their earthy consti- 
tuents ; atrophy of that particular tissue. Indeed, softening is often a concomitant 
or a result of atrophy. 

The accidental products to which I adverted when speaking of induration — espe- 
cially some of the varieties of cancer — are sometimes remarkably soft, resembling 
brain in consistence and appearance, or cream, or jelly. But in these cases vi^e can 
scarcely consider the change as an example of softening of the textures of the 
body ; it rather consists in the addition of parts that are themselves soft and half fluid. 

Now softening may occur under very different circumstances. One very general 
cause of softening is inflammation. Every part, I believe, that is inflamed, under- 
goes, in the first instance, a diminution of its consistence. This appears to be almost 
the necessary consequence of stagnation of the blood, the effusion of serosity, and 
the suspension of healthy nutrition. These are circumstances to which I shall 
recur. I cannot avoid alluding occasionally to things with which you are supposed 
to be as yet but little acquainted, and which will engage our particular attention as 
the course advances. 



TRANSFORMATION OP TISSUE. 



It would be a great mistake, however, to suppose that all softening results from 
previous inflammation. Doubtless it often proceeds directly and simply from defi- 
ciency of nutrition, and is then closely aUied, as I said before, to atrophy. Thus 
softening of the brain is, sometimes, due to inflammation : we meet with it where 
the inflammation has been unequivocal, and was caused by external injury ; but 
sometimes also it is quite independent of inflammation, and is owing to disease of 
the cerebral arteries, whereby the brain, or a portion of it, is deprived of its full 
supply of arterial blood, and ceases to be properly renovated : hence a loosening of 
its texture, a separation of its component particles, an approach to the fluid state. I 
shall, of course, hereafter endeavour to point out to you more particularly the means 
we possess of distinguishing these two forms of cerebral softening ; they constitute 
morbid conditions of the highest interest. 

I may observe, that we have an illustration of the principle now laid down, in that 
general softness, flaccidity, and shght cohesion of parts, noticeable in children, and 
others, who are imperfectly nourished. We find this general absence of the natural 
firmness coincident with paleness, and a thin watery condition of the blood. Ma- 
gendie kept animals upon food unsuitable to them, containing no azote, and incapa- 
ble of supplying sufficient nourishment ; and one curious consequence that followed, 
was a loss of substance in the cornea, which melted down and disappeared. 

There is another source of softening which requires to be mentioned — I mean the 
gastric juice, which has the power of dissolving not only food that is submitted to its 
action, but the mucous membrane of the stomach itself, and even all its tissues and 
coats. This cause of softening operates, however, in the dead body only ; but its 
effects have often been mistaken for the consequences of disease ; and therefore it 
will be necessary for me hereafter to call your attention to the circumstances under 
which they may be expected, and to the means we possess of discriminating them 
from similar changes, which are more properly called morbid. 

Upon the whole, it may be said that every form and kind of softening in the living 
body — whether it proceed from inflammation, from disease of the arteries, from 
insufficient sustenance, or from altered quahties of the blood — may ultimately (like 
atrophy) be resolved into suspended or defective nutrition. 

Furthermore, as there is a hardness of parts resulting from repletion and disten- 
sion, so there is a softness rather than a softeniyig, from their emptiness and flac- 
cidity : as of the breast immediately after the child has sucked ; of the abdomen 
soon after delivery ; of the integuments in those who, having been fat, have wasted, 
either from disease or from advancing age ; and so on. 

On former occasions, I thought it right to lay before you the views of M. Andral 
f which appear to have been adopted also by Dr. Carswell) respecting what has been 
called the transformation of tissues. " In the proper place of one natural tissue 
(1 remarked) we sometimes find another, which last is thus mnatural in regard to 
its situation, but natural in all other respects. The new tissue is such as we meet 
with elsewhere in the body, but it is not such as properly belongs to the place it 
occupies. Either the original tissue has been gradually converted into the new, or 
the original tissue has disappeared, and the new tissue has been substituted for it : 
that, for example, which should be cartilage we sometimes find to be bone." 

" In most cases the tissue that has been changed or displaced is in one of the two 
following predicaments : 

" Either its natural function has been for a long time suspended ; 

" Or, it has been accidentally called upon to fulfil a purpose for which it was not 
originally designed. 

" In the former case it gradually approximates towards areolar tissue, which at 
length is all that remains. 

" In the latter, it assumes the characters of that other tissue of which it has taken, 
up the office." 

Now the analogy which M. Andral thought he could perceive between changes 
of this kind, and those changes which occur during the growth and progressive 
developement of the human body, does not in reality obtain. More recent and more 



36 



TRANSFORMATION OF TISSUE. 



exact microscopical researches have shown that the several tissues do not commence 
by being areolar tissue — which is the sense in which M. Andral uses the Avord 
cellular — and therefore, that in the dwindhng of any given tissue into the areolar, 
there is no return, as he had supposed, towards the primitive state of the tissue so 
wasting. A muscle remaining for a long time in complete inaction, loses bulk, but 
does not pass from the condition of muscular into that of areolar tissue : when wasted 
to the utmost, it still retains its proper anatomical elements. The areolar tissue is 
quite as complex and advanced a tissue as the muscular. There is no true conver- 
sion of the one tissue into the other. It is commonly stated, indeed, that when a 
muscle comes accidentally to invest a dislocated joint, the dislocation remaining unre- 
duced, it assumes by degrees the characters, together with the uses, of those tissues 
which naturally inclose the joint, and is converted from muscular into fibrous or 
ligamentous tissue — ^just as in the vegetable kingdom, the cut branch of a willow 
tree, planted in the earth, takes up the office, and gradually acquires the form and 
properties of a root. But here again the analogy is more fanciful than real. The 
formation of a false joint implies no actual conversion of tissues. The muscular 
fibres shrink and disappear, while the areolar tissue augments, and is transformed 
only into the fibrous ; these two, the fibrous and the areolar, being essentially and 
primarily the same tissue. 

The change from cartilage to bone approaches more nearly than any other to 
actual transmutation; but even this resolves itself into a simple increase of one of 
the natural constituents of both the tissues concerned ; phosphate of lime, which 
-exists in healthy cartilage. 

A curious and common change is the so-called transformation of other tissues into 
adipose tissue. The fat, however, does not take the place of the natural elements 
of the tissue. It is deposited among them, and wastes them, yet they still remain, 
and are easily distinguishable. If you examine a fat heart — such as is not unfre- 
quently met with in very fat persons — you will generally find a combination of 
hypertrophy of the adipose tissue with atrophy of the muscular, rather than any 
conversion of the one into the other. The fat is deposited around and between the 
attenuated muscular fibres, and the two may usually be separated from each other. 
It would seem that here the converse of one of the propositions which I lately men- 
tioned holds good — of the proposition, namely, that suspension of the function of a 
tissue leads to its degeneration into adipose or areolar tissue. In the instance before 
us, the increase of adipose tissue tends to lessen, and at length to destroy, the function 
of the part. What is called the fatty liver affords another instance of this morbid 
accumulation. The altered liver is of a light tawny colour, of diminished specific 
gravity, retains the impression of one's finger, is tender, and tears easily ; it greases 
the knife that cuts it, or bibulous paper in which it is wrapped. By boiling it you 
may obtain a concrete oil, which has all the characters of fat. The change is 
wrought by an enormous augmentation in quantity of the fat which is a natural 
constituent of the texture of the liver, and which thus comes to predominate immea- 
surably over all its other elements. 

What is very curious in respect to this morbid condition of the liver is, that we 
can produce it, at will, in some at least of the lower animals. You know that the 
"ybze gras " procured from certain birds, is an article of great luxury among epi- 
cures. It is obtained by a very cruel process. Geese or ducks are confined in 
baskets just large enough to contain them, but not large enough to allow them any 
motion ; they are kept continually in the dark also ; sometimes even, I am afraid, 
their eyes are put out, but this I should imagine to be a useless and superfluous 
piece of cruelty, it being the absence of light, and not the absence of the power of 
vision, which helps to bring about the desired effect. At the same time the birds 
are sedulously crammed with food. Under this disciphne their livers acquire the 
requisite size, and greasiness, and the true flavour. 

An ingenious theory has been constructed, in reference to the modus operandi of 
this process. The excessive supply of nutriment tends, no doubt, of itself, as it 
always does, to the production of fat; the constrained state of inaction interferes 
probably with the right and healthful formation of blood, a matter in which the liver 



TRANSFORMATION OF TISSUE. 



37 



is belie-^ed to be a good deal concerned ; then we know, by experience, that the 
privation of light has the effect of blanching animals as well as vegetables, and thus 
further interferes with the due renovation of the blood. In this way, the trans- 
formation of the liver into a fatty mass has been sometimes attempted to be explained. 
To what extent the explanation is correct, I will not pretend to say : but it is worth 
remarking that the fatty liver is very frequently met with in persons who die of con- 
sumption ; and in that disease there are various causes in operation tending to 
modify the constitution of the blood. 

The history of these unfortunate fowls is not barren of instruction in respect to 
the more limited bad effects of full diet, want of exercise, and a short allowance of 
da3^-light, upon the " featherless biped" man. 

These accumulations of fat are morbid changes. The transformations that are 
effected in false joints are evidently methods of accommodation and repair. The 
same may be said of the transformation — -which is not conversion— of areolar tissue 
into synovial membrane. Synovial membrane consists chiefly of condensed areolar 
tissue. Sir B. Brodie, in his book on Diseases of the Joints, gives instances of 
synovial membranes being formed, where none before existed. " In a young lady 
who had attained the age of ten or twelve years, labouring under the inconvenience 
of a club-foot, a large bursa was distinctly to be fek on that part of the instep which 
came in contact with the ground in walking. In another young lady, who had 
apparently recovered of a caries of the spine, attended with a considerable angular 
curvature, a bursa appeared to have been formed between the projecting spinous 
process and the skin." 

In like manner we find that sinuses, fistulous openings and tubes, in various parts, 
become lined, through the intervention of the areolar tissue, with a surface which in 
its appearance and in its properties resembles the mucous membranes. Like them 
it is with difficulty made to take on adhesive inflammation : and therefore it is that 
sinuses of this kind, and chronic abscesses, are often so troublesome to the surgeon, 
and require to be laid open before they can be abolished. 

On the other hand, the mucous membranes, under peculiar circumstances, 
approximate to the skin in their physical aspect and qualities. When, for instance, 
a portion of the mucous lining of the rectum, or of the vagina, protrudes externally, 
is permanently exposed to the air, and subject to the friction of clothes or of neigh- 
bouring parts — -that is to say, when it is placed under the same conditions as the 
skin — it assumes somevv^hat the characters of the skin: it gradually loses its red 
colour and approaches the tint of the skin, ceases to pour forth mucus, becomes dry, 
obtains even a sort of permanent cuticle, acquires firmness and density, and is less 
sensible to the contact and pressure of foreign substances. It is impossible not to 
perceive the beneficial nature of this transformation. 

The greater number, then, of those interesting changes in the living body which 
have been classed under the head of transformations of tissue, have a restorative 
tendency. They exempHfy the working of what the older pathologists discerned, 
and called the vis inedicatrix naturse. This is a phrase that has been much sneered 
at; but (as I conceive) very unjustly, and sometimes ignorantly. It is simply a 
short formulary expressive of a great general truth, viz., that the animal frame is so 
constituted as to contain within itself the elements of repair, and of conservative adap- 
tation. To a certain extent it is a self-mending machine. Surely this is an admirable 
provision, and clearly indicative both of wise contrivance and of beneficent design. 

The intimate texture of parts may be further altered — not simply by some modi- 
fication or reconstruction of the ordinary tissues, but — by an absolute disappearance 
or confusion of all regular structure. This is usually a consequence either of the 
effusion, in the natural interstices of the parts, of fluids, which afterwards pass into 
the solid state, or it is a consequence of the growth of solids which do not belong to 
the healthy body. In this sketch of general pathology I must content myself with 
thus briefly alluding to this source of morbid change. 

I may as well observe here, that the alterations with which we have hitherto been 
occupied, of the solids of the body, fall, almost all of them, under the head of 
lesions of nutrition, as the French pathologists speak. That is to say, they coni- 



38 



LESTOx\S OF NUTRITION. 



mence, and have their primitive seat, in that process and place where the blood, 
having reached the capillary system of vessels, performs its special purposes. It is 
in or through the capillaries that the fluids and soKds accomplish their vital union. 
Each solid receives from the blood, and assimilates with its proper substance, ma- 
terial particles, identical in their nature with those of which it already consists. 
£ach solid gives up also to the blood, and so dismisses other particles, which before 
formed a portion of itself, but which have become unfit or superfluous. Now any 
departure from this continual building up and pulling down — any excess or defect 
of the particles added, or of the particles subtracted — any irregularity in the manner 
in which they are deposited — any variation from their right consistence, or in their 
kind and quality — in short any deviation from the regular process, as I have briefly 
described it — is called a lesion of nutrition. 

The few changes already spoken of, and not included among the lesions of nu- 
trition, are : — 

The distension of the hollow organs by an undue accumulation of fluids within 
them ; 

The coagulation of the fluids in their proper vessels, excluding, however, the 
capillaries ; 

The escape of the fluids, as such, out of and beyond their containing vessels ; and 
The solution of tissues, after death, by the chemical agency of the gastric juice. 
None of these, properly speaking, constitute lesions of nutrition, although they 
sometimes lead to them. 

Lastly, let us take a glance at the changes of situation to which the solid parts of 
the body are liable. They are sometimes of very serious import. 

These changes of place — sometimes the consequence of disease, sometimes its 
cause, and not unfrequently the cause of death — respect chiefly the viscera ; and 
most especially the viscera of the chest, abdomen, and pelvis. I omit dislocations of 
joints, as belonging exclusively to surgery. 

In the chest, a whole lung may be displaced, and compressed against the ver- 
tebral column, by blood, or serum, or air, efliised into the cavity of the pleura. An 
alteration of this kind, whereby one half of the respiratory apparatus is rendered 
incapable of its peculiar function, cannot be otherwise than full of peril. 

The very same causes operating on the left side of the thorax will dislocate the 
heart, thrust it over to the right of the sternum, where it may be felt, and heard, and 
seen, to pulsate. This again cannot happen without greatly disturbing the vital 
function of circulation, and putting life in jeopardy. 

Yet neither of these serious displacements is necessarily fatal. Both admit, 
under certain circumstances, of remedial treatment : as I hope to prove to you 
hereafter. 

In the abdomen and pelvis, the various forms of hernia may be adduced as 
involving very dangerous changes in the place and relative position of parts. 
Portions of the intestinal tube are apt to pass through accidental openings in the 
diaphragm — or between the edges of the linea alba surrounding the navel — or out 
at the abdominal ring — or through some other natural or accidental aperture. I 
need not tell you how fearfully life is compromised when, in consequence of such 
faulty position, the bowel becomes constricted — when its contents can no longer 
pass onwards, and inflammation, or gangrene, is present or impending. Even 
when there is no strangulation, the mere displacements to which the escape of 
the contents of the abdomen and pelvis from their natural limits gives rise, maj^ be 
productive of much discomfort, deformity and hazard. Of this the historian Gib- 
bon presented a remarkable example. He had an immense scrotal hernia ; so 
large it was, that it hung down very nearly as low as his knees. After his death it 
was found that almost the whole of the omentum, and the greater part of the colon, 
had descended into the scrotum, and had dragged the stomach after them ; so that 
its pyloric orifice lay close to the abdominal ring. 

Akin to hernia is that partial displacement of the bowel in which a portion of it 
passes, not through any natural or accidental opening, but into the bowel itself; 



CHANGES IN THE BLOOD. 



39 



just tis one portion of the finger of a glove is sometimes pulled into the remaining 
part, by the withdrawal of one's hand. The container/ portion of intestine is liable 
to be nipped and strangulated by the containw^ portion — and all the peril of hernia 
results, with much less chance of relief by art. This state of things is called intus- 
susception. 

Exactly of the same nature, though less alarming, is prolapsus of the rectum, or 
of the vagina. Here, also, a portion of the tube passes into the contiguous portion ; 
but being near the extremity of the canal, the inverted part protrudes externally, and 
becomes, in most cases, a source of distress and suffering, rather than of danger. 
Inversion of the uterus is another example. 

Thus much, then, of the changes to which the solid parts of the body are subject, 
in hulk, in form, in consistence, in texture, in situation. 

You cannot fail to perceive the injurious effects which many of these changes in 
the various solids are calculated to produce upon the movements and working of the 
living machine ; how some of them must impede or derange its natural action ; 
some stop that action altogether. 

Now, the fluid parts of the body are liable also to alterations, which, if they 
are not always so obvious as those of the solids, are certainly not of less moment. 

You are probably aware that for many centuries, the fluids were supposed to be 
the primary agents in every form of disease ; that all maladies were attributed to 
some acrimony or peccant state of the humours ; and that, however else the the- 
ories of medicine might vary and fluctuate, the humoral pathology, till a compara- 
tively recent period, ran through almost all of them. At length, the absurdity of 
the hypotheses, and still more the dangerous practice, which this doctrine gene- 
rated, began to be manifest, and led to its total abandonment. Rather more than a 
century and a half ago, the foundation of the opposite doctrine appears to have been 
laid, by the writings of Glisson in this country, and by those of Baglivi in Italy ; and 
presently the notion came to prevail throughout the schools, that all the morbid con- 
ditions of the body had their exclusive origin in the sohds. The pendulum of 
opinion swung at once, as is usual, into the opposite extreme of error. It promises, 
in our time, to settle at the proper medium. The old extravagances of the humoral 
doctrine still, indeed, find favour among the ignorant, and are commonly adopted by 
the quack : circumstances which illustrate the fact that the mischievous influence of 
unsound theories survives the duration of the theories themselves. The scientific 
physician of the present day can only wonder how exclusive solidism, or exclusive 
humoralism, should ever have found advocates. 



LECTUEE IV. 

'Morbid Jllterafions of the Fluids, especially of the Blood. Changes in its quan- 
tity and distribution. General and Local Plethora. Poverty of Blood. Active 
Congestion — its Phenomena — State of the Vessels, as seen by the Microscope. 
Meclianical Congestion. Passive Congestion. Relations of these forms of 
Congestion to Inflammation — to Hemorrhages — to Dropsies. 

After running over the principal alterations to which the solid parts of the body 
are liable, we were beginning to inquire into those no less important morbid changes 
which are apt to take place in its fluid constituents. I reminded you that, respect- 
ing the whole of this subject, pathologists had passed from one extreme of opinion to 
another : that, for a very long period, the humoral pathology prevailed in the 
schools, and that in times not very remote from our own, it was entirely superseded 
by the opposite doctrine of exclusive solidism. It is strange that either miscon- 
ception should have so long maintained its ground. 

If we consider the definite relation subsisting between the solids and the fluids of 



40 



CHANGES IN THE BLOOD. 



the body, and the unceasing agencies which the.^r mutually exercise on each other — 
how, for instance, on the one hand, all the solids are originally built up, and are 
afterwards perpetually nourished and sustained by materials furnished from the 
blood — how again, on the other hand, some of the sohds are continually employed 
in the reciprocal ofBce of feeding and renewing the blood, while others are as con- 
stantly at work in decompounding it by the various secretions — we cannot avoid 
perceiving that distinctions of the kind I have mentioned, founded upon mere diffei- 
ences of consistence, are futile. Flesh and blood are almost convertible terms : their 
composition, the chemists tell us, is identically the same. To use the strong expres- 
sion of Bordeu, Le. sang est de la chair coulante. You may be certain that no 
notable alteration can take place in the sohds of the body which will not soon affect, 
in some way, its fluids ; and that every important change in its fluids must lead to, 
or proceed from, a corresponding and proportionate modification of its sohds. The 
long dispute between the solidists and the humoralists was altogether baseless and 
unprofitable. 

The animal fluids are — the blood, the fluids that enter the blood, and the fluids 
that proceed from the blood. 

The fluids that enter the blood are of two kinds. 

1. Those by which it is renew^ed and enriched. 

2. Those which enter it in order that they may be conveyed out of the body. 

. Now, although we cannot doubt that any considerable modification or defect of the 
fluids that feed and renovate the blood, and particularly of the chyle, must have a 
direct influence upon its composition and quality, we really know but little about 
them, except in their effects. We seldom have any means of procuring these, the 
first products of nutrition, so as to examine them, or to test their qualities ; yet we 
can perceive causes that are iikely to deteriorate or deprave those fluids (unfit ali- 
ment, impure air), and we know that, under the continued operation of such causes, 
the blood, replenished by these fluids, is actually and sensibly modified. 

Again, we cannot doubt that some of the matters derived from the body itself, and 
taken into the blood in order to be conveyed away, may, and often do, directly alter 
and contaminate the blood, and act as poisons upon the system : matters, for in- 
stance, absorbed from the parts of the body that are diseased, or dead and putrefying ; 
in this way, doubtless, disorders which were at first strictly local, may come to affect 
the whole economiy : — matters, again, w^hich, though harmless while merely transi- 
tory, and in minute quantity, become noxious when retained and accumulated in the 
blood, in consequence of faulty or deficient action of the organs destined to eliminate 
them from the circulating fluid. The injurious effects of some of the substances 
which thus become deleterious, — as urea, of which the blood, during health, is con- 
tinually purified by the kidneys; and bile, which is naturally separated therefrom 
by the fiver ; and carbonic acid, which it is the office of the lungs to excrete — will 
furnish topics of interesting inquiry hereafter. 

The fluids that leave the blood maj^ be considered under a threefold division. 

1. Those which are directly expended in the growth or maintenance of parts, 
some of them becoming fixed and solid, and others retaining their fluid condition. 
Of these, the principal alterations have been briefly pointed out among the lesions 
of nutrition. 

2. Those that are em^ployed in aid of some definite function of the body : as the 
saliva, the gastric juice, the bile, the pancreatic secretion, the tears, the synovia of 
the joints, and so on. Now these ma]/ be secreted in excessive abundance, or in too 
scanty quantity, or of imperfect quality, or not at all; and all, or any, of these 
deviations from tlie healthy standard, may be the result of very serious disease, or 
may cause very serious disease ; and they w-ill be spoken of hereafter when the dis- 
orders of the parts or functions connected with each shall be discussed. 

3. Those which are separated from the blood merely to be excreted, as the urine, 
certain secretions from the bowels, and from the bronchi and skin. Some of these 
are extremely worthy of study, as furnishing, in their altered quahties, indications 
of disease ; but they require no particular consideration in this part of the course. 

Dismissing, therefore, for the present; all further account, as well of the fluids that 



PLETHORA. 



41 



concur to form the blood, as of the fluids that issue from the blood, let us inquire 
what morbid changes the blood itself is hable to undergo. 

The blood, then, is subject, first, to remarkal^le variations in its qiianiity, both in 
respect to the whole system, and in respect to particular organs and tissues. 

2. Closely connected with these differences of quantity is the variety which is 
observable in regard to the proportions between the several proximate constituents 
of the blood. The changes that occur of this kind are sometimes strikingly evident 
to our senses. For example, we not unfrequently perceive that the blood drawn 
from a vein is thinner, manifestly more watery, less rich in fibrin, and in colouring 
matter, than blood of the standard quality. 

3. Again, independently of mere alterations in the relative proportions of its 
proximate constituent parts, the blood is liable to great change in its chemical com- 
position, and, therefore, in its physical quality. This appears to be the case in sea- 
scurvy, and in the analogous disease called purpura, and it is doubtless so in many 
other complaints. 

The composition of the blood cannot fail to be affected by a deficient supply of the 
elements of nutrition from without ; by diseases of the digestive organs, interfering 
with the process of chyhfication ; by diseases of the organs of respiration, interfering 
with its change from venous to arterial ; by diseases of other channels of excretion— 
the bowels, the biliary apparatus, the skin — interfering (as I have already hinted) 
wdth its appointed purification ; by foreign contaminating matters, finding entrance 
(as they may when in solution, or in a gaseous form) through artery, vein, or any 
membranous substance, such as bladder and intestine : lastly, the composition of the 
blood may be altered, there is good reason to beheve, by certain states of the nervous 
system. 

But contenting myself with having indicated these latter changes, or sources of 
change, I shall defer giving a more particular account of any except those that relate 
to the quantity and the distribution of the blood. 

I say the blood may undergo important alterations in its quantity. It may exist 
in too great abundance throughout the body ; and it may exist in too great abun- 
dance in certain parts only of the body. These states have been recognized for 
ages. Sometimes they are called respectively general and partial plethora: some- 
times general and local congestions of blood ; people speak also of irregular deter- 
minations of blood to difierent organs ; and, of late, the term hypersemia, first 
invented by M. Andral, in France, has been imported into this country, and much 
adopted here. All these words and phrases mean, in truth, the same thing ; and 
their frequent recurrence in medical works, is, of itself, sufficient evidence of the 
frequency and importance of the conditions which they express. 

if we comprehend rightly this subject of plethora or congestion, we shall be pre- 
pared to understand some most important morbid states, of which it seems to be in 
many, if not in all cases, the earliest approach — the initial step. Inflammation, 
hemorrhage, dropsy, all acknowledge and imply a previous condition of congestion. 
" There is probably," says Dr. Ahson, " no kind of diseased action of which any 
part of the living body is susceptible, which is not connected, sooner or later, with 
increased afflux of blood towards that part, either as its cause or its effect ; and the 
immediate object of all our most powerful remedies is to act on these irregularities 
of the circulation." 

That the blood may be differently distributed in the capillaries at different times, 
we know by the variable colour of the surface, which depends upon the varying 
degrees of fulness of the cutaneous blood-vessels. The phenomenon of blushing, the 
red cheek of anger, the heightened colour of the skin under brisk exercise, are fami- 
liar facts illustrative of partial plethora of the capillaries, consistent with health. 

There are reasons (which I shall hereafter lay before you) for believing that a 
similar sudden accumulation of blood, taking place in internal parts, may sensibly 
disturb their functions ; causing transient fits of giddiness, insensibility, and some- 
times death itself, when the congestion affects the cerebral blood-vessels; and attaclts 

d2 



42 



GENERAL PLETHORA. 



of difficult breathing when the capillaries of the pulmonary tissue are concerned ; 
and even these attacks, for aught that I know, may end fatally. 

It often happens that when certain portions of the surface, as the cheeks, are 
visibly redder and fuller of blood than usual, or when such symptoms as I have just 
referred to denote the probabihty of some internal congestion, other parts of the sur- 
face, as in the extremities, are visibly paler : and there are, at the same time, cor- 
responding and palpable differences of temperature. 

Perhaps it may not be so obvious that the whole quantity of blood, throughout the 
body, is sometimes in excess. 

That in the adult state, when the growth or increase of the body has been com- 
pleted, blood may be made in greater abundance, and more rich in the materials of 
nutrition than the wants of the body require, is not only conceivable, but true. We 
are able to assign circumstances in which this is likely to happen, and we find that 
under such circumstances it actually does happen. Full hving, and a sedentary 
life, are causes likely to occasion general plethora — and they do occasion it. The 
full diet, so long as the digestive powers are perfect, provides more chj^le, conducts 
into the blood a larger quantity of its proper pabulum. The sedentary life precludes 
that freer circulation of the blood, and that more liberal expenditure of it through the 
skin, and by means of the other organs of secretion, which would occur under more 
active habits. Persons thus circumstanced are apt to grow fat ; the adipose tissue 
seeming, in these cases, to form a kind of safety valve for the diversion of the super- 
fluous blood. Such persons have turgid and florid cheeks, red lips, red mucous 
membranes, and (not uncommonly) ferrety eyes. Their entire vascular system is 
preternatural] y distended. If you open a vein, you find that they bear a large 
abstraction of blood without fainting, and are even refreshed by it ; and the blood 
drawn separates into a large and firm mass of coagulum, with but little serum. 
Keeping to the nomenclature we have already employed, we might say that there 
is here hypertrophy of the blood. 

When inflammation arises in the subjects of this general plethora, it runs high, 
and requires active treatment. But they are not, as you might naturally expect 
them to be, and as many writers state them to be, peculiarly prone to suffer inflam- 
matory complaints. There is a general fullness of the vascular system, but no irre- 
gularit}^, nor any necessary tendency to irregularity, in the distribution of the blood. 

You will observe that the relative proportion of the more sohd to the more fluid 
constituents of the blood is increased in these cases of general plethora : the blood is 
not only more abundant, but it is richer also in fibrin, and in red particles. 

The means to be adopted for redressing this unnatural and unsafe condition of the 
circulation, are those which common sense would suggest. The removal of a por- 
tion of the superfluous blood, a more restricted diet, a larger allowance of active 
exercise. 

It will be worth our while to contrast this state of general plethora with its 
opposite — that in which the blood is scanty and poor — what Andral calls (though 
■with questionable propriety) anmmia. Oligxmia is the cacophonous but more 
exact name assigned to it by Gendrin ; hut poverty of blood is the ordinary English 
phrase for it, and the best of the three. This is a state which we can produce at 
will, by abstracting blood from the body in moderate quantity, but repeatedly, and at 
short intervals. It occurs, also, frequently, in spontaneous disease, and from various 
causes ; from a privation of the materials destined to replenish the blood ; and in 
cases in which these materials appear to be turned to little account, as in chlorotic 
girls. We see it in those who habitually and frequently lose a certain quantity of 
blood, in disease ; in persons, for example, who are subject to piles, and who bleed 
daily from the rectum ; still oftener in women who suffer repeated hemorrhages from 
the uterus. When the drain has been long-continued, these persons become very 
pale ; even those parts which are naturally most red, as the lips and tongue, become 
almost white ; their faces look like wax ; and if still you draw blood from a vein, 
and allow it to coagulate, you will have a small clot floating in an abundance of 
serum, and that small clot will be of a light rosy colour; showing a great diminution 
in the proportion of fibrin ; and a still greater deficiency of the red particles. The 



ANJEMIA. 



43 



blood, as they say, is " turned into water." It is a curious pathological fact, that the 
red particles require more time for their restoration than the other constituents of the 
blood. And I may mention to you now, what I shall have to repeat, that — in con- 
junction with the obvious curative measures comprised in arresting the habitual loss 
of the vital fluid, and in affording sufficient nutriment to the system, — the prepara- 
tions of iron, and the respiration of pure air, have signal efficacy in renewing the red 
particles, and giving back again their native hue of redness to the cheek and lips. 

In general plethora every part is preternaturally full of blood, and the blood itself 
is full of the elements of nutrition. General plethora, therefore, implies, in one 
sense, local plethora of every organ and tissue. In strictness, however, local plethora 
is only predicable of a part that contains more than its share of red blood. 

Now the converse of this is not true, as it might be expected to be, of the opposite 
condition. A deficiency in the whole mass of blood contained in, and circulating 
through the body, does not protect the parts of the body from congestion — from 
having an undue quantity of blood sent to them. Far from it. Local determinations 
of blood are very common in persons in whom the mass of that fluid, and the pro- 
portion of its nutritive materials, have been considerably diminished by disease, or 
by hemorrhage. 

This remarkable tendency, under such circumstances, to an unequal distribution 
of the blood in the capillaries, admits (I think) of this explanation. A due supply 
of healthy blood is requisite for the steady and equable performance of the functions 
of the brain and nerves. When this supply is defective, or uncertain, those functions 
become disordered and irregular, and, in their turn, influence the various sohds, dis- 
turb their action, and derange the balance of the circulation. That the capillary 
blood-vessels may be filled to excess, or completely emptied, by causes operating 
through the nervous system — by moral emotions, for example — we are sure from 
the phenomena just now adverted to, the blush of shame or anger, the paleness of 
fear ; and there can be no doubt that 7norbid congestions, which sometimes are 
separated from those that are consistent with health by very slight shades of differ- 
ence, are often determined through the agency of the same nervous system. And 
persons endowed with great sensibihty or irritability of the nervous system are very 
liable to partitd and irregular congestions of blood. 

But this is not the only ¥/ay in which local congestion may arise. 

We can produce it, upon the surface of the body at least, at pleasure, and that in 
various ways ; by friction, by exposing the parts to a high temperature, by certain 
stimulating apphcations, mechanical (as a cupping-glass), or chemical (as a mustard 
poultice) : we produce an injection of the small cutaneous blood-vessels ; there is, 
evidently, more than the usual quantity of blood attracted to the part, or detained in 
the part — -a degree of redness, which soon subsides if the cause of it be withdrawn 
in time. 

Congestion thus occasioned is not inflammation, but it is the first obvious step 
towards that complex process ; and for this reason it deserves all your attention. 
Apply the exciting cause a little longer, or increase, in a slight degree, its intensity, 
and the phenomena of inflammation begin to manifest themselves. 

I said we can produce local congestion when we please upon the surface of the 
body; but there can be no doubt that a similar state may be produced by analogous 
causes, in internal parts. Look at this representation of the stomach of a dog [one 
of Br. RoupeW s plates). You see one portion of it of a bright red colour, actively 
and vividly congested. This was the consequence of a dose of alcohol. We may 
be certain that something of the same kind is the result of every visit to the gin 
shop. 

Local congestion thus produced, or of this kind, is said to be active. M. Andial, 
whose nomenclature has come much into fashion of late years, calls it sthenic, or 
active hyperoBmia. The arteries, perhaps, have more to do with it, in the first 
instance, than the veins. But it is in the capillary vessels, which are distinct from, 
and interposed between the minute arteries and veins, that further changes are 
wrought, when the process advances a stage beyond mere local plethora. What 



44 



LOCAL PLETHORA. 



has been observed, by the aid of the microscope, with respect to the blood-vessels, I 
will endeavour to describe to you. 

I take the account I am about to give you chiefly from Kaltenbrunner, a German 
pathologist, who has recently investigated the subject experimentally, and whose 
observations are beheved to have been most carefully and skilfully conducted, and 
their results no less faithfully narrated. His observations were made upon the 
circulation as it appeared in the web of a frog's foot, under a powerful microscope. 
It would be idle, and something like committing a fraud upon you, were I to lay any 
stress upon my own knowledge or experience in this matter, for I cannot pretend to 
any great skill in the use of that instrument, and my opportunities of noticing, by 
its help, the phenomena of the circulation, have been too few to render their results 
of much value. Yet it may be in some degree satisfactory to you to know that I 
am not blindly repeating the remarks of others, and that what I have witnessed is 
perfectly in accordance with the statements of Kaltenbrunner, and affords me a strong 
assurance of his accuracy and fidelity. There is another reason, too, why I con- 
sider him the more trustworthy — he has no theories to which he might be disposed 
to bend or accommodate his facts. 

Before I detail to yo\x his account of the phenomena of congestion, I may briefly 
describe the scene which presents itself when the web of a frog's foot is looked at 
through a good microscope. It is a most beautiful and wonderful spectacle, and 
particularly interesting to those who, like ourselves, are desirous of gaining some 
insight into the healthy and diseased states of the circulation. It is a sight which I 
hope and believe you also will have many opportunities of seeing in this place. 
You perceive, then, occupying the circular field of the instrument, a number of 
blood-vessels, through which the blood, with its globules, is in active motion : and 
you see at once that there are three different kinds of vessels before you. First, 
you notice the blood shooting v/ith great velocity along tubes which divide and sub- 
divide into smaller and smaller branches, each branch (speaking generally) going 
off at an obtuse angle : these are plainl}^ arteries. Then, in another part of the field 
of view, you see the blood moving in the contrary direction, more slowly, in larger 
trunks, which are formed by the continual union and accession of smaller and 
tributary vessels of the same kind, that meet, for the m.ost part, at acute angles : 
these you know to be veins ; and all the intermediate and surrounding surface in 
view is occupied with other vessels or channels, which connect themselves with the 
ultimate ramifications of the arteries on the one hand, and with the primary radicles 
of the veins on the other, but which differ from both arteries and veins in these par- 
ticulars — that they interlace and anastomose in all parts, in a very irregular manner, 
and at all angles, and that they retain everywhere the same uniform size ; they 
neither collect into larger and larger trunks, nor separate into smaller and smaller 
branches, but are disposed like the threads forming the meshes of a net, except that 
the interstices are irregular in size and shape. These are the true capillaries, inter- 
mediate between the arteries and the veins, and perfectly distinct in character from 
each, but communicating and continuous with both. 

If now you press upon the animal's leg, so as to obstruct the circulation a httle, 
the motion of the blood is retarded, especially in the capillaries. You see the red. 
globules slowly following one another. These so-called globules are not really little 
spheres, but circular discs, or flat cells. You may sometimes see one of them 
sticking to the side of a capillary channel, and damming up the current ; other glo- 
bules accumulate behind it, till at last they all pass on again together. 

Now Kaltenbrunner irritates the web by pricking it, and soon aftervA^ards the 
following appearances present themselves : — There is an increased afhux of blood 
to the part, so that arteries, veins and capillaries receive a column of blood two or 
three times as great as usual ; the velocity of the blood is accelerated ; the distended 
sides of the vessels seem to tighten round the stream of blood which they contain. 
With this alteration of the circulation, the natural functions of the part begin to be 
modified. The change of the blood from arterial to venous is interrupted. The 
globules, passing with great rapidity through all the vessels, retain the characters of 
arterial globules even when they arrive at the veins ; they present a bright colour, 



ACTIVE CONGESTION. 



45 



stiow a tendency to stick together, and often form little clots, which pass through the 
capillaries, and become visible in the veins. 

One of the natural functions of the web is the secretion of a kind of lymph; but 
this secretion is now suspended. The parenchyma itself begins to be shghtly tumid, 
and assumes a brighter tint than CQmmon. 

All these phenomena begin from a circumscribed spot, of which the circumference 
gradually expands as the affection increases ; and they cease insensibly at that 
circumference. 

This is active congestion. 

A certain period always intervenes between the first action of the irritant cause, 
and the commencement of true congestion. This period, the occuiTence of which 
you will be good enough to bear in mind, Kaltenbrunner calls the period of incuba- 
tion; the period in which the congestion is hatching. 

Active congestion, as such, does not continue long. It either passes on into 
inflammation, as I shall hereafter explain, or it begins to decrease. When it has 
been very sHght, the quantity of blood, and the rapidity of its movement, diminish 
gradually from the circumference towards the centre ; and in this wa}^ the conges- 
tion insensibly vanishes. 

But, in other cases, when it has not been so slight, the congestion terminates by 
an evident crisis, which Kaltenbrunner thus describes : — The blood, receaing fronj 
the circumference of the congested part towards the centre, gives out, by exhalation, 
a hquid. The exhalation takes place by fits, and here and diere, through the sides 
of the capillary tubes, and generall}^ on the surface of the oro-an. The moment of 
exhalation is very transient; but it is repeated often, and in different spots, until the 
congestion has disappeared. It is evidently critical, for the congestion is relieved 
and extinguished in proportion as the exhalation is repeated. 

I shall follow these consequences of active and continued local congestion no 
further at present ; but merely remind you again that the changes I have last men- 
tioned constitute the earliest appreciable modification of stracture leading or belonging 
to inflammation. What we thus may see (and it is what I myself have had some 
opportunities of seeing) in the transparent textures of animals, we reasonably infer 
to take place, under analogous circumstances, in those parts of the body which are 
internal and opaque, and consequently hidden from our view. 

I will just observe, also, that as active congestion is the parent of inflammation, so 
it sometimes causes hemorrhage, and is reheved by it. But, comparing this form of 
congestion with another which I am about to mention, the connection of hemorrhage 
with it is, relativeh% unfrequent. 

One obvious mode of remedying this congestion is the mechanical abstraction of 
blood from the loaded part. But it is seldom that this measure alone suffices ; and 
sometimes it would be ultimately hurtful to adopt it. The state of the constitution 
may be such, that the disposition to local plethora would be increased by the loss 
of blood. Undue susceptibility and disordered action of the nervous system are apt 
to be aggravated by bleeding; and in proportion as the nervous functions are iiTegu- 
larly performed, does the tendency to unequal distribution of blood in the capillary 
vessels augment. We have daily examples of this in hysterical young women. It 
is not, therefore, the mere congestion that we have to consider ; we must look deeper, 
for its cause. Leave a small thorn in the finger : the blood will be collected there in 
consequence of its irritation, and will continue to collect in spite of depletion. But 
extract the thorn, and your remedial measure of taking away blood is at once suc- 
cessful. So it is also with internal congestions of blood — of which the exciting and 
sustaining cause is not always so well known. 

Contrasted, in some important particulars, with active congestion such as I have 
been describing, is that morbid fullness of the capillary vessels which arises Avhen 
the return of the blood from them towards the heart through the veins, is impeded 
by some mechanical obstacle. With this mechanical congestion the veins are 
exclusively concerned. 

Congestion of this kind may be strictly local. It may be confined to a single 
limb, when the principal venous trunk belonging to that hmb is compressed, or 



46 



PASSIVE CONGESTION. 



otherw-ise diminished in size ; and when no collateral and compensatory channels 
for the returning blood have been established. If there be disease of the liver, of 
such a nature as to prevent a free passage of the blood through that organ, conges- 
tion will ensue in all those parts of the capillary system from which the blood is 
conveyed by the veins that ultimately concur to form the vena port«. The force of 
gravity alone is snfficient to produce venous congestion, and consequently conges- 
tion of the capillaries, in parts of the body in which, under ordinary circumstances, 
the circulation through the veins is aided, instead of being opposed, by that force. 
If, for instance, the head be suffered to hrfng downv/ards for a certain time, we see 
the unequivocal signs of such congestion in the tumid condition and the purplish red 
colour of the hps, cheeks, eyelids, and ears. When an impediment to the free 
transmission of blood exists in the heart itself, a tendency to stagnation is produced, 
first in the venoe cavss, then in the smaller ramifications by which these veins are 
fed, and at length in the general system of capillary vessels ; and thus even general 
congestion may proceed from a fixed mechanical cause ; the parts that are the most 
vascular being also the most readily and the most completely gorged. 

There is yet a third form of local congestion, differing, in some respects, both 
from active and from mechanical congestion. The capillaries become loaded, and 
the course of the blood in them is languid and sluggish, without any previous 
increased velocity of the blood in the arteries, and independently of any mechanical 
obstacle in the veins. To this form of congestion the term passive is applied. 
Andral denominates it passive or asthenic hyperasmia. I will tell you the class of 
facts from the observation of which the real existence of this passive plethora has 
been ascertained. 

. In persons enfeebled by age, or by disease, the lower parts of the legs, the insteps 
and ankles, and the skin which forms the surface of old scars, are often habitually 
purplish, or violet coloured. There is congestion of dark blood in those parts. 
You may, perhaps, be ready to ascribe this to the mere influence of gravitjr upon 
the blood, but this cannot be the whole explanation, because the force of gravity is 
the same with all persons, and at all ages. A horizontal position of the limb will 
perhaps diminish the livid redness, or may even sometimes entirely remove it. But 
the depending position ought not to cause it, and would not cause it, if the blood- 
.vessels were in a healthy condition. Neither can the difference of posture be any 
source of irritation to the congested part. The capillaries themselves appear to 
have lost, in a great degree, their natural elasticity ; they easily dilate under the 
pressure of the blood, which, being thus retarded, accumulates in the part. The 
employment of friction, or some stimulating apphcation, wiU often remove this con- 
gestion. 

I say all this is often to be noticed when there has been no cause of irritation 
operating upon the part, and no preceding state of active congestion. But it is 
important to mark the very frequent connection that exists between these con- 
trasted conditions. The one very often succeeds the other: the vessels become 
dilated under the force of the active hyperasmia, and, the irritation ceasing, they do 
not at once recover their tone, but remain passively loaded and distended. They 
are frequently left in the same state upon the subsidence of inflammation. 

Take another illustration from what you may any day witness in respect to indo- 
lent ulcers. You will find that the large, flabby, and livid granulations which they 
present, may be made to contract, and to assume a more healthy and florid hue, by 
local stimulants ; these evidently act by quickening the previously languid circula- 
tion, and unloading the congested capillaries. 

Observe, again, what not unfrequently happens in regard to the e^'e ; a Httle 
organ, indeed, but one that supplies us with more striking lessons in pathology and 
therapeutics than any other portion of the body. You know that the conjunctiva 
and sclerotica, through which, while healthy, colourless fluids alone circulate, are 
traversed, under various forms of disease, by innumerable vessels bearing red blood. 
Now it is notorious that, in certain cases, the application of any stimulating sub- 
stance to the surface of the organ will increase the existing redness, multiply the 
number of visible vessels, and aggravate the complaint. These are cases of active 



PASSIVE CONGESTIOIV. 



47 



congestion, dependent upon irritation that is still subsisting. But it is equally well 
known to practical men that the blood-vessels of the eye are liable to congestion of a 
very different kind. They are seen to be distended, somev/hat tortuous, almost vari- 
cose, and the redness has a browner tinge, and is less vivid, than in the former case. 
In this kind of vascular fullness — or in this stage of it, for it sometimes succeeds to 
active congestion, — emollient applications do harm rather than good, while strongly 
astringent and even irritant substances will often promptly dissipate the vascularity. 
These, again, are cases illustrative of congestion of the asthenic or passive character. 
The strong topical irritants restore to the feeble and relaxed vessels their natural elas- 
ticity, stimulate them to contract upon their contents, and to force onward the red 
blood, which they cease to admit from the arteries ; and the redness vanishes. 

In the production of active congestion the arteries appear to be principally con- 
cerned : in the production of mechanical congestion, the veins : in passive conges- 
tion, the capillaries — which, strictly, are neither arteries nor veins, but lie between 
the arteries and the veins — are the vessels chiefly in fault. 

If we turn our thoughts from the visible textures of the body to those which are 
hidden internally, we shall find reason to believe that these also are equally liable to 
similar conditions of passive congestion. Take those exceedingly vascular organs, 
the lungs, through which the whole of the blood circulating in the living body has 
to pass. The lungs, as might be expected, are very liable to congestion and engorge- 
ment of their capillary vessels. Oft-times this is clearly active, and the result of 
some irritating cause. But it is not always so. Many of you recollect the epidemic 
disorder called the influenza, which was so prevalent here in the spring of 1831, 
and again in the early part of 1837. Among the most constant and striking charac- 
ters of the disease were the symptoms of pulmonary catarrh ; and it was remarkable 
how long, in some persons, these symptoms persisted. After the pulse had regained 
its natural frequency of beat, and when all fever had ceased, the patient would con- 
tinue to breathe with constraint and some labour, to wheeze a little, to cough, and to 
expectorate mucus. As all febrile disturbance had subsided, and no further benefit 
seemed to flow from adhering to what is called the antiphlogistic system, it was a 
reasonable conjecture that this disappointing obstinacy of some of the symptoms 
might depend upon a lingering but passive congestion of the pulmonary mucous 
membrane. And the nature of the juvantia showed the correctness of this con- 
jecture. Tonics and stimulants, so far from aggravating the pectoral symptoms, 
speedily removed or abated them. 

You cannot fail, I think, to perceive the important bearing of these distinctions 
between active and passive congestion upon our notions of disease and our choice 
of remedies. These distinctions are not to be discovered by the knife of the anato- 
mist. You must take care not to confound a knowledge of pathology, in the proper 
sense of that word, with a knowledge of morbid anatomy. Pathology comprehends 
not only the visible changes of structure which accompany disease, and are disclosed 
by death, but the processes by which those changes are effected in the Kving body, 
and the laws w4iich govern those processes. 

There is one important law ascertained in respect to both active and passive con- 
gestion : viz., that it is apt to recur ^ that those parts are most likely to suffer it (or 
inflammation, which implies it) that have suffered it before. We may often turn 
our knowledge of this general fact to good account, in what is termed the prophy^ 
laxis of disease — in devising means for warding off disorders. 

I have stated that active and passive congestion sometimes occur in succession, 
the latter being a sequel of the former. So, also, it may be said of passive and of 
mechanical congestion, that they often exist together. If the capillaries of a part or 
organ be much enfeebled, the mechanical effect of the gravity of the blood may suf- 
fice to bring them into a state of congestion. It is thus that Andral explains the 
occurrence of a gorged condition of the posterior portions of the lungs (evinced by 
symptoms during life, as well as by inspection of those parts after death), in persons 
who, having laboured under no previous pulmonary affection, have been confined to 
a supine position by long-continued disease or debility. This state of the capillaries 
is called by Lerminier the " engorgement of position and by Laennic, " the pneu- 



48 



CONDITIONS OF LIFE. 



moiiia of the dying." It neither proceeds from irritation, nor has it the essential 
characters of inflammation ; although it is apt to be considered an evidence of inflam- 
mation by the mere morbid anatomist. 

Again, as active congestion, when continued or intense, is antecedent and con- 
ducive to inflammation, so is mechanical congestion, when it reaches a certain point, 
the prolific source of hemorrhage, and the almost constant precursor and immediate 
cause of a large class of dropsical accumulations. 

I spoke a little while ago of general plethora, as a state in which the whole mass 
of blood circulating in the body is excessive in quantity, and rich in quality — full of 
fibrin and of colouring matter, thick with globules. But the blood, as a mass, may 
be in excessive quantity, yet poor in its materials, serous, deficient in globules, and 
fibrin, and colour ; and in this condition of the blood, also, as we shall hereafter see, 
dropsies are apt to arise. 

We have now, therefore, laid the foundation for the better understanding of those 
three great classes of disease — Inflammations, Hemorrhages, and Dropsies. 

There is no region or organ of the body exempt from these diseased conditions 
and their consequences ; and of each of them some general account must be given, 
before we come to consider the special diseases incident to the several parts and 
organs. 

But previously to entering upon this general account of inflammation, of hemor- 
rhage, and of dropsy, we have still some other preliminary matters of importance to 
discuss. The causes and modes of death. The causes of disease. A sketch of the 
nature, classification, and import of symptoms. 

Our inquiries hitherto have related to the manner in which the physical condi- 
tions of the various parts of the body are capable of being altered, and their functions 
disturbed or suspended, in disease. But how it happens that some of these altera- 
tions of structure, or interruptions of function, are incompatible with the further con- 
tinuance of life, and put a stop to the working of the whole machine, is an inquiry 
of no less interest, though of a somewhat different kind. 



LECTUEE V. 

Different modes of dying. Pathology of Sudden Death. Death by £.nxmia; 
its Course, Phenomena, and Anatomical Characters. Death hy Asthenia ; its 
Course, Phenomena, and Anatomical Characters. Syncope. Death by Inani- 
tion. Death by Apnoea: Death by Comu: their Course, and Phenomena, and 
the Anatomical Characters common to both. Application of the Principles ob- 
tained from the investigation of the Phenomena of Sudden Death, in elucidating 
the Symptoms and Tendencies of Disease. 

I PROPOSE to devote the present lecture to the following inquiry: — Wherefore it 
is, and how it is, that some of the corporeal changes which we have been consider- 
ing, or the diseased conditions connected with those changes, come to be incompatible 
with the further continuance of life ? how it is that they put an end to the working 
of the living animal machine ? why the machine should not continue to work, though 
perhaps imperfectly, notwithstanding such changes ? 

When our watches stop, we take them to a watchmaker to ascertain why they 
have stopped. The watchmaker knows that there are various ways in which the 
movements of the instrument may have been arrested. The main spring may have 
broken ; or the little chain that connects the barrel with the fusee may have parted ; 
or the teeth of some of the wheels may have become inextricably entangled ; or the 
watch may have ceased to go (as the saying is) "simply because it has not been wound 
up. Now the examination which the watchmaker undertakes in respect to the 
watch, I am desirous of making in respect to the human body. I am going to 
inquire into the several processes and modes of dying — the steps, or ways, by which 



CONDITIONS OF LIFE. 



the vital functions of the body are extinguished. A very little experience in the 
sick chamber, or in the wards of a hospital, will suffice to teach you that, although 
all men must die, all do not die in the same manner. In one instance the thread of 
existence is suddenly snapped ; the passage from hfe, and apparent health perhaps, 
to the condition of a corpse, is made in a moment : in another the process of dissolu- 
tion is slow and tedious, and we scarcely know the precise instant in which the 
solemn change is completed. One man retains possession of his intellect up to his 
latest breath : another hes unconscious, and insensible to all outward impressions, 
for hours or days before the struggle is over. 

We seek to ascertain the laws and mechanism of these mysterious differences. 

The inquiry is not one of merely curious interest, but has a direct bearing upon 
the proper treatment of disease. It will teach us what we have to guard against, 
what we must strive to avert, in different cases. In speaking of particular diseases, 
I shall constantly refer to the facts and reasonings which I am now about to lay 
before you. 

In pursuing this inquiry, we need not go into any deep physiological disquisition 
respecting the conditions that are essential to life. It is sufficient for our purpose to 
remark that life is inseparably connected with the continued circulation of the blood. 
So long as the circulation goes on, life, organic hfe at least, remains. When the 
blood no longer circulates, life is presently extinct : and our investigation of the dif- 
ferent modes of dying resolves itself into an investigation of the different ways in 
which the circulation of the blood may be brought to a stand. 

Observe the ample provision that is made, in the construction of the body, for car- 
rying on and maintaining this essential function. First, there is an extensive hy- 
drauhc apparatus distributed throughout the frame, and consisting of the heart and 
other blood-vessels. Next, there is a large pneumatic machine, forming a* consi- 
derable part of the whole body, and composed of the lungs, and the case in which 
they are lodged. Lastly, the power by which this machine is to be worked and 
regulated is vested in the nervous system. Each of these systems must continue in 
action, or the circulation will stop, and life will come to an end. The functions they 
respectively perform are, consequently, called vital functions : and their main organs 
— the heart, the lungs, the brain (by which I understand the intercranial nervous 
mass) — are denominated vital organs. The functions of any one of the three being 
arrested, the functions of the other two are also speedily extinguished. But the 
phenomena of dying vary remarkably according as the interruption begins in the one 
or the other organ. Hence Bichat, who in his Bechcrches siir la vie et la mort, laid 
the foundation of the distinctions I am about to describe, spoke of death beginning 
at the head, death beginning at the heart, and death beginning at the lungs. This 
nomenclature is, however, unsatisfactory and insufficient, as you wiU presently per- 
ceive. 

That the heart may continue to propel the current of the blood, two things are 
necessary : first, a certain power or faculty of contraction ; and, secondly, a suffi- 
cient quantity of blood in its chambers, to be moved, and also to stimulate them to 
contract. If this, the proper stimulus to the internal surfaces of the heart, be with- 
held, or much deficient, it will soon cease to beat. There are plainly, therefore, 
two ways in which death might be said to begin at the heart ; and these require to 
be distinguished. 

The respiration is entirely subservient to the circulation of the blood. The two 
organs, the heart and lungs, respond intimately to each other. The whole of the 
blood is sent by the right heart to the lungs, simply that it may there be submitted 
to the cheinical action of the atmosphere. The respiratory apparatus is added to 
the body for the sole purpose of thus repeatedly ventilating the blood. 

To this purpose also (setting aside all accidental impediments) two things are re- 
quisite ; first, circumfused air to enter and depart at short intervals ; and, secondly, 
akernating movements of the chest to cause its entrance and exit. 

Now these movements, although they admit of being regulated by the will, are 
essentially involuntary. The ordinary acts of respiration depend upon a certain con- 
4 ' E 



50 



DEATH BY ASTHENIA. 



dition of the medalla oblongata. If this condition fails, the mechanical part of the 
respiratory process, and, consequently, the chemical part also, ceases. 

The respiration hangs, therefore, directly upon the nervous system. 

On the other hand, the action of the heart is not directly or necessarily dependent 
upon any constant nervous influence conveyed to it. The circulation goes on in an 
acephalous ftxtus ; it may be kept up, by maintaining artificial respiration, in a deca- 
pitated animal ; nay, even when both brain and spinal cord have been abstracted from 
the body. 

But though the nervous influence is not necessary to the movements of the heart 
— further than as it is necessary to the respiration, and to the introduction of nutri- 
ment — it has been clearly ascertained that very sudden and extensive injury or shock 
to the nervous system may instantly paralyze the heart, and so stop its action. 

There are certain states, then, of the brain and nerves which, without directly 
affecting the heart, bring the motions of respiration to a pause : and there are cer- 
tain states of the brain and nerves which act directly on the heart and arrest its play. 
That is, there are two different ways in which death might be said to begin at the 
head. 

Hence, I say, the nomenclature employed by Bichat is defective and inaccurate. 

In order to see clearly the steps by which the circulation, and with it life, finally 
terminates, in the various forms of dying, we must study the problem under its sim- 
plest forms. We must examine the cases in which the vital- functions are, each in 
their turn, suddenly stopped, by some known cause, operating upon this or that vital 
organ. We must take advantage of the experiment (if I may so call it) which is 
performed before our eyes whenever a healthy man is cut off at once by external 
violence, or by poison, acting directly upon a particular organ or system of organs. 
The inquiry might be assisted, and, indeed, it has been mainly carried on, by ex- 
periments made upon hving animals of a similar conformation with man. But the 
pathology of sudden death is happily now too well understood to require any further 
recurrence to that painful mode of " interrogating nature." 

Death, as it takes place in disease, is usually comphcated. Many parts are affected, 
and different functions languish, and various disturbing causes are in operation, at 
the same time. Occasionally, however, the process of dissolution is as simple and 
obvious as in death produced by violence ; and in most cases some primary and pre- 
dominant derangement may be traced of this or that vital function ; and a tendency 
is more or less clearly manifest to one or the other of the modes of dying, which we 
may now proceed to consider in succession. 

And first let us examine that form of death which is caused by a want of the 
due supply of blood to the heart. This is called, with much propriety, death by 
anssmia. 

The best examples of death taking place in this way are those in which it is the 
consequence of sudden and profuse hemorrhage. The circulation fails, not because 
the heart has lost its power of contraction, but because blood does not arrive in its 
chambers in sufficient quantity. 

We assure ourselves of this in two ways. In the first place, when the body of 
an animal is examined immediately after death from sudden and copious loss of blood, 
the heart is not found dilated and full of blood, as it would be if it had ceased to act 
from a want of power to contract upon its contents ; but it is found empty, or nearly 
so, and contracted. Secondly: this conclusion is confirmed by the reverse expe- 
riment : by the effect, I mean, of the transfusion of blood. It is a fact well ascer- 
tained, first by experiments made upon animals, and afterwards by most happy trials 
upon the human subject, that in cases of apparent death from violent hemorrhage 
the suspended functions may be restored by conveying a timely supply of blood into 
the vessels of the seemingly dead animal from the veins of a hving animal of the 
same species. Now it is quite clear that this introduction of fresh blood could be 
of no avail in a case where the heart was unable to act upon the blood which had 
already reached it. 

The phenomena which attend this mode of dying are paleness of the countenance 
, and lips, cold sweats, dimness of vision, dilated pupils, vertigo, a slow weak irregular 



DEATH BY INANITION. 



51 



pulse, and speedy insensibility. With these symptoms are frequently conjoined 
nausea, and even vomiting, restlessness and tossing of the limbs, transient dehrium : 
the breathing is irregular, sighing, and, at last, gasping ; and convulsions generally 
occur, and are once or twice repeated, before the scene closes. 

It is thus that women often die, in whom "flooding" happens after childbirth. 
Sometimes the sudden bursting of an aneurism occasions this form of death. It is 
common on the field of battle, and in accidental injuries whereby large blood-vessels 
are wounded. Internal hemorrhage, depending upon diseases to be hereafter 
described, may also prove fatal in the same manner. 

This, then, is one form of death beginning at the heart. Another form, the con- 
verse of this, but spoken of also as death beginning at the heart, is that in which 
there is no deficiency of the proper stimulus to the heart's action, but a total failure 
of contractile power in that organ. This is well denominated death by asthenia. 

Death occurring in this way is not uncommon. The effects of some kinds of 
poison furnish a good illustration of it. There are certain substances which, applied 
to some part or other of the body, speedily extinguish fife : and when, after their 
fatal operation, the thorax is opened, each chamber of the heart is found to be filled 
with its proper stimulus, upon which it has been unable to contract. 

This was distinctly made out by Sir Benjamin Brodie, in his able and scientific 
investigation of the effects of different poisons. You may read with advantage his 
papers on this subject in the Philosophical Transactions for 1811 and 1812. He 
ascertained upon examining the chest after death occasioned by the uj^as antiar, that 
the heart was not empty, but full, there being purple blood in its right, and scarlet 
blood in its left cavities. These are the anatomical characters of this kind of death ; 
and they prove that the action of the heart does not cease from a defect of stimulus, 
but from a loss of its contractile power. 

The state of suspended animation common to both these forms of dying — (the 
ultimate external phenomena being nearly the same in each, and the result in - 
each being the simple failure of the circulation) — is often expressed by the term 
syncope. 

Besides the essential distinctions between them already mentioned, there is this 
further point of diflerence. In death by anssmia, the suspension of the functions of 
the nervous system arises from a Jack of blood which should be sent to the brain 
from the hea7't. Hence the welJ-known effect of mere position. Syncope is sooner 
produced by venesection when the person bled is sitting up than when he is recum- 
bent : and the first remedy for the fainting state is to lay the patient flat upon the 
ground, or even to place his head a little lower than the trunk of his body. In the 
one posture the current of the blood towards the head is impeded by the force of 
gravity ; in the other it is not. In sudden death by asthenia this order is reversed ; 
the nervous system is the part first affected, and through it, consecutively, the heart. 
This appears from the fact that sudden death by asthenia is sometimes produced by 
causes which we know to act primarily upon and through the nervous system ; by 
strong mental emotion — as intense grief, joy, terror. Cases of fatal concussion, 
where the brain is jarred by some bodily shock — and death occurring almost instantly 
from blows on the epigastrium — are of this kind. Lightning and electricity kill too, 
when they kill at all, in the same way. And we shall hereafter see that certain 
varieties of apoplexy, and several other diseased conditions, destroy life by suddenly 
arresting the contractile power of the heart. 

When death by asthenia occurs more slowly, from disease, the phenomena are 
somewhat different. The pulse becomes very feeble and frequent, and the muscular 
debihty extreme ; but the senses are perfect, the hearing is sometimes even painfully 
acute, and the intellect remains clear to the last. The tendency to death of this form 
is remarkably manifest in acute inflammation of the peritoneum, in what is called 
malignant cholera, and in cases of extensive mortification. 

Akin to this form of dying is that in which the living powers are slowly exhausted, 
by fingering and wasting disorders, as in many cases of phthisis, in diabetes, and in 
dysentery ; or by hemorrhages moderate in amount, but frequently repeated ; or b};" 
•any other long-continued drain upon the system. The death is partly, however, to 



52 



DEATH BY APNCEA. 



be ascribed to a deficient supply of the natural stimulus to the heart's action. The 
type of these mixed modes of dying is seen in death by starvation, which may be 
considered intermediate between death by anemia, and death by asthenia. Death 
from inanition can never be sudden. The blood, renewed no longer from without, 
and fed only by absorption from the system itself, diminishes gradually in quantity, 
while its quality deteriorates. Gradually also the contractile power of the heart, as 
"well as of the muscles generally, is weakened ; and from these combined causes its 
movements at length cease. Accordingly after death by starvation the heart is not 
found to be so much contracted, nor so nearly empty, as after death by sudden and 
copious hemorrhage. 

Certain diseases of the throat or the oesophagus, prohibiting the introduction of 
food ; of the stomach, preventing iis retention ; of the digestive organs generally, 
hindering its assimilation, are fatal in this manner. 

We have yet to consider how death is produced by the suspension of the respi- 
ratory function — in other words, by a want of the due arterialization of the blood. 
■ There are two perfectly distinct modes in which this cause of death may happen ; 
distinct, i. e., in regard to the steps of the process, although identical in regard to 
the ultimate result. ' 

1. When the access of air to the lungs is suddenly denied by some direct obsta- 
cle to its entrance. 

2. W^hen the muscular actions required for breathing cease in consequence of 
insensibility, caused by disease or injury of the brain. 

The first of these two forms of dying is commonly called death by asphyxia. 
The second is conveniently termed death by coma. Bichat spoke of them respect- 
ively as death beginning at the lungs, and at the head. 

It is of much importance to get rid, when we can, of improper names. They are 
very apt to warp our notions concerning the real nature of the things they are 
intended to express. This term asphyxia, which is in every body's mouth, is very 
inappropriate, if we look to its etymology, to the kind of death which it has come to 
denote. It signifies, you know, literally, pulselessness, the want of pulse ; and there- 
fore it might express any kind of death whatever ; or if applied to any particular 
onode of dying, it would seem to helong to that we have just been considering, 
namely, death beginning at the heart. And you will presently see that it is pecu- 
liarly mapphcable to all those cases where death results from the non-arterialization 
of the venous blood. Its current signification has, I am afraid, been too long estab- 
lished by custom, to allow of its being restored to its proper meaning without much 
confusion. But at any rate, I can and shall avoid its use, and adopt in preference 
the generic term flp?i6e« (privation of breath) as justly expressive of the mode of 
death to which the word asphyxia is commonly given by authors. The generic 
English term is suffocation. 

The entrance of air into the lungs may be prevented in various ways : by stop- 
page of the mouth and nostrils {smothering): — by submersion of the same inlets in 
some liquid {droivning) ; or in gases which, though not in themselves poisonous, 
contain no oxygen ; such are hydrogen and azote : — by mechanical obstruction of 
the larynx or trachea from within, as by a morsel of food {choking), or from vzith- 
out, as by the bowstring {strangidation; both these varieties are included in the term 
th'iottling): — by forcible pressure made at once upon the chest and abdomen, pre- 
venting all movement of the ribs and of the diaphragm ; this happens sometimes to 
workmen employed in excavating, who are buried, their heads excepted, by the falling 
of a mass, of earth ; it was near happening. Dr. Roget tells us, to an athletic black 
man, of whose body a cast was attempted to be taken, as an academic model, by one 
operation, and in one entire piece. "As soon as the plaster began to set, he felt on 
a sudden, deprived of the power of respiration, and to add to his misfortune, was 
cut off from the means of expressing his distress ; his situation was perceived just 
in time to save his life ;" in this way the victims of Burke and Hare were stifled ; 
and the same immovable state of the lung-case is sometimes produced in tetanus, or 
by the poisonous influence of strychnine, all the respiratory muscles being fixed in 
rigid spasm : — by paralysis of the same muscles, from injury or disease of. the spinal 



DEATH BY APNOSA. 



53 



cord above the origin of the nerves that give off the phrenic nerve, and therefore 
above the origin of the intercostal nerves also; or from section of the phrenic and 
intercostal nerves : — lastly, by such breaches in the walls of the thorax as admit ait 
freely to the surface of both lungs, and spoil the pneumatic machine, as a pair of 
•bellows is spoiled when deprived of its valve. Of course the same consequences 
ensue w^hen both pleuras become filled with liquid of any kind. 

Whenever the privation of air is sudden and complete, the following external phe- 
nomena present themselves. — Strong but vain contractions occur of all the muscles 
concerned in breathing, and struggling efforts to respire are made, prompted by that 
uneasy sensation which every one has experienced who has tried how long he can 
hold his breath, and which, when unappeased, soon rises to agony : this extreme 
distress is transient, being almost immediately succeeded by sensations, not unplea- 
sant, of vertigo, and then by loss of consciousness, and convulsions : at length all 
effort ceases, a few irregular twitchings or tremours of the limbs alone perhaps 
remaining; the muscles relax, and the sphincters yield: but still the movements of 
the heart, and even the pulse at the wrist, continue for a short time after aU other 
■signs of hfe are over; there is no asphyxia (properly so called) till the very last. 

During this process, which does not occupy more than two or three minutes, the 
face at first becomes flushed and turgid, then livid and purplish, the veins of the 
head and neck swell, and the eyeballs seem to protrude from their sockets ; at length 
the heart ceases to palpitate, and life is extinct. 

The internal changes vt^hich correspond v/ith, and cause these outward symptoms, 
have been carefully studied, and accurately, though slowly and lately ascertained. 
They all proceed from the prevention of the chemical alteration naturally produced 
in the blood, within the capillary vessels of the lungs. The blood, continuing venous, 
passes at first in considerable quantity through the pulmonary veins, into the left 
side of the heart, and thence through the arteries, to all parts of the body. This 
venous blood, however, is inadequate to sustain, or sufficiently to excite, the functions 
of the parts it thus reaches. In the brain the effect of the unnatural circulation is 
felt at once ; and shown by the convulsions and insensibility that ensue. The motion 
of the blood in the pulmonary capillaries is also, from the first, impeded, and its 
Current gradually retarded, until it stagnates altogether; the lungs remaining full, 
the right chambers of the heart distended, and therefore less capable of contracting. 
Meanwhile the black blood, flowing more and more tardily and scantily into the left 
chambers, leads, by its unnatural quality, as well as its deficient supply, to feeble 
contractions ; and this side of the heart is comparatively empty. 
■ In this state, even after the heart has ceased to beat, but not long after, if the cause ■ 
which has excluded the air be withdrawn, and fresh air readmitted — in other words, 
if artificial respiration be instituted— the blood in the pulmonary capillaries under- 
goes the required change, becomes arterial, begins again to pass onwards, and by 
degrees the circulation is restored, and the patient saved. 

In this mode of death the circulation is first arrested, and death truly begins, in 
the lungs. 

When the carcass of an animal, that has thus perished of apncea, is immediately 
afterwards examined (so speedy an inspection of the human body being, for obvious 
reasons, seldom practicable or proper), the left side of the heart is found to contain a 
small quantity of dark blood, while its right cavities are greatly distended, and the 
lungs, the cavas, and the whole venous systeni, are gorged with blood of the same 
character. These are, in few words, the anatomical characters of sudden death by 
apnoea. 

• The pathology of this mode of dying has, I say, been thoroughly understood only 
of late. It will not be uninteresting, and may, I think, be useful, to trace briefly 
the successive steps by which the true explanation has been attained. Haller was 
of opinion that the quiescence of the lungs, consequent upon the cessation of the 
akernate movements of the thorax, formed a mechanical impediment to the further 
transit of the blood through them ; and that death resulted from obstruction of the ' 
circulation in the lungs. He was partly right ; but he erred in supposing that the 
Stream of blood was arrested absolutely, and at once, and by a mechanical obstacle 



54 



DEATH BY APNCEA. 



Apnoea, with all its peculiar phenomena, occurs, when atmospheric air is excluded, 
although the lungs continue to play ; as in persons who breathe azote or hydrogen 
gas. It was clearly shown by Dr. Goodwyn, in his Essay upon the Connection of 
Life with Respiration, that the unaerated blood passed through the lungs and entered 
the left auricle and ventricle of the heart ; but he thought that it went no further. 
His notion was that arterial blood is the only stimulus which can excite the contrac- 
tion of the left cavities of the heart, and that, when venous blood arrives in them, 
the organ becomes motionless ; and no blood being sent to the brain, the person dies. 
Had this theory been true, the left chambers would be found fuU of blood after death 
(which they are not), and the mode of dying would not have differed essentially from 
that which we have already considered as' death by asthenia. The well-devised 
experiments of Bichat carried the investigation a step further, and proved that the 
unaerated blood not only reached the heart, but was propelled by the contractions of 
that organ to every part of the body, through the arteries. Having applied a liga- 
ture upon the trachea of a living animal, he made a small opening in one of its 
carotid arteries. Presently the slender stream of blood that issued began to lose its 
florid tint, and to assume the dark colour of venous blood ; but it continued to jiow\ 
and the afflux of this dark blood upon the brain was marked by convulsions and 
insensibility. Bichat conceived, therefore, the erroneous belief that the blood under- 
went no obstruction in its passage through the lungs, but that, remaining unpurified 
and venous, it acted as a poison upon every part to which it was carried by the 
arteries — first upon the nervous system, and ultimately (passing through the coronary 
arteries) upon the muscular substance of the heart itself. There are, however, two 
well-known facts, which, upon this theory, would be inexphcable — the comparative 
emptiness of the left chambers of the heart, and the restoration of the suspended 
functions by the timely performance of artificial respiration. The air could never 
reach and revivify or depurate the venous blood, stagnating in the capillaries of the 
heart. It was reserved for Dr. Kay to correct the unsound parts of Bichat's doctrine, 
and to show that the blood begins to stagnate in the capillaries of the lungs, in con- 
sequence of its failing to undergo the change from venous to arterial; and that the 
movements of the left heart are brought to an end, principally by the deficient supply 
of blood from the lungs. His experiments tend, moreover, to prove that venous blood 
circulating through the arteries has no directly poisonous operation, but is capable, 
though much less effectually than arterial blood, to support, in some degree, the 
irritabihty of the muscles. A muscle will continue to contract longer when supplied 
with venous blood by its arteries, than when supphed with no blood at all. Doubt- 
less, in death by apncea, the movements of the heart are weakened, partly in conse- 
quence of the imperfect stimulus afforded by the venous blood that penetrates its 
substance ; but the main cause of the failure of the circulation seems to be the diffi- 
culty with which the non-arterialized blood finds its way through the capillaries of 
the lungs. This theory is consistent with all the phenomena observed. For a 
detailed account of the experiments and reasonings upon which Dr. Kay's conclu- 
sions are founded, I rhust refer you to his work on Asphyxia. 

Sudden death by apnoea is not very often witnessed as the result of disease. It 
sometimes is caused by a spasmodic closure of the rima glottidis. It is no uncom- 
mon consequence of accidents, in which the upper cervical vertebras are broken or 
displaced. I have seen several instances of death rapidly produced, with all the 
symptoms of sudden suffocation, generally in intoxicated persons, in whom the chink 
of the glottis has been found closely plugged by a fragment of meat, which " had 
gone the wrong way." 

But there are numerous forms of more chronic disease, in which the tendency to 
death by apncEa is plainly discernible, sometimes for a long while' before their fatal 
termmation arrives. And the phenomena are similar in character to those which are 
noticed when the struggle is short. We hear the patients complain of the " want of 
breath ;" we see how they labour to satisfy this want, when it becomes urgent, by 
the elevated shoulders, the dilating nostrils, the energetic action of all the muscles 
that are auxiliary to the respiration; we perceive by the dusky and loaded coun- 
tenance, the hvid hps, and ears, and eyehds, .that the blood is but imperfectly arte.- 



DEATH BY APNCEA. 



55 



rialized. The diminished capability of such blood to support the functions of the 
brain is made evident by the vertiginous sensations, and the delirious thoughts of the 
gasping sufferers ; and after death we find the same distension of the right chambers 
of the heart, while the left are nearly empty — the same gorged condition of the 
pulmonary arteries and venous system generail)^ which constitute the Anatomical 
characters of this mode of dying. These appearances are even more constantly 
visible in the dead body, when apnoea has been gradually produced, than after sudden 
sufTocation ; simply, I believe, because they are more permanent. After sudden 
death, however caused, the blood seldom coagulates ; and the venous turgescence 
consequent upon rapid apnoea, although great at first, has time to subside and disap- 
pear before the body is examined. 

In protracted cases, death does not take place purely in the way of apncea ; the 
heart is weakened, and the nervous influence impaired by the continued circulation 
of imperfectly arterialized blood ; but the symptoms belonging to apncEa are plainly 
predominant. 

When (as is most common) the privation of air is incomplete, and a scanty and. 
insufficient supply is admitted, morbid changes take place in the lungs themselves ; 
the air-tubes and cells become charged v/ith serous fluid, which op.erates as an addi- 
tional cause of suffocation. The same phenomenon is observed when the par vagum 
is divided on both sides. 

Death by apnoea in disease is extremely common. It may be produced by any 
thing which narrows the chink of the glottis ; by warts that sometimes grow there, 
by osdema of the submucous tissue of the larynx, by inflammatory tumefaction of 
its lining membrane : it may result from the presence of what are called false mem- 
branes in the windpipe and bronchi, such as are formed in the distemper named 
croup : it may be the consequence of disease situate in the substance of the lungs 
themselves, rendering them incapable of receiving the requisite quantity of air ; of 
this we have examples in pneumonia, and in pulmonary apoplexy: or it may pro- 
ceed from disorders of the pulmonary mucous membrane, the air-passages becoming 
blocked up with excessive and unnatural secretions, as in bronchitis. Phthisis is 
sometimes fatal in the way of apncea; more commonly it tends to death by asthenia. 
Diseases of the pleuree attended with effusion, and causing f)ressu re upon the lungs; 
diseases of the heart and great thoracic blood-vessels, affecting the quantity of blood 
in those organs ; even certain abdominal maladies, accompanied by swelhng, and 
thrusting the diaphragm upwards — terminate by the same mode of dissolution. 

Death by coma, although common enough, and of much importance to be under- 
stood, need not detain us long. Certain morbid states of the brain (it is unnecessary 
at present to inquire into their nature and origin) produce stupor, more or less pro- 
found; the sensibility to outward impressions is destroyed, sometimes wholly and at 
once, much oftener gradually; the respiration becomes slow, irregular, stertorous; 
all voluntary attention to the act of breathing is lost, but the instinctive motions con- 
tinue; the stimulus conveyed by the pulmonary branches of the eighth pair of 
nerves, and probably by certain branches too of the fifth, still excites, though per- 
haps imperfectly, the reflex power of the medulla oblongata, which sustains the 
involuntary movements of the thorax. At length this function fails also — the chest 
ceases to expand — the blood is no longer aerated — and thenceforward precisely the 
same internal changes occur as in death by apnosa. 

You will observe that the extinction of organic life takes place in exactly the 
same manner in both cases : the difference between the two forms of dying being 
this — that in death by apnoea, the chemical functions of the lungs cease first, and 
then the circulation of venous blood through the arteries suspends the sensibility; 
whereas, in death by coma, the sensibility ceases first, and in consequence of this the 
movements of the thorax, and the chemical functions of the lungs, cease also. So 
that the circulation of venous blood through the arteries is in the one case the cause, 
and in the other the effect, of the cessation of animal life. 

The causes that destroy the sensibility leave no constant or necessary traces of 
their operation. The essential anatomical characters' of death by coma, and of death 
by apnffia, are therefore the same. 



56 



APPLICATION OF PRINCIPLES. 



Death occurring in the way of coma has this peculiar kind of interest belonging 
to it, that it may sometimes be effectually obviated by a mechanical expedient. The 
circulation ceases because the actions of respiration cease — and the failure of the acts 
of respiration arises from a suspension of the nervous power. If it be merely a 
suspensio?! — if the nervous functions are within the verge of recovery — organic life 
may be sustained by the performance of artificial respiration, until the insensibility 
has passed away ; and thus the danger to life, which depended on that insensible 
state, may be escaped. 

Many years ago, in the course of those researches to which I have already 
•referred, Sir Benjamin, then Mr. Brodie, was led to think that by continuing the 
respiration artificially in animals labouring under the influence of narcotic poisons, 
the heart might be kept in action until the stupefying but transitory effect of the 
poison upon the brain had gone off. This idea he soon brought to the test of 
experiment, and the result was such as to justify his ingenious reasoning. He 
inserted some woorara inlo a wound which he had made in a 3- oung cat. After a 
certain time the respiration had entirely ceased, and the animal apj)eared to be dead, 
but the heart could be still felt heating. The lungs were then artificially inflated 
about forty times in a minute. The heart continued to beat regularly. When the 
artificial breathing had been kept up for forty minutes, the pupils of the cat's eyes 
were observed to contract and dilate upon the increase or diminution of hght, but the 
animal remained perfectly motionless and insensible. At the end of an hour and 
forty minutes there were slight involuntary contractions of the muscles, and every 
DOW and then there was an effort to breathe. At the end of another hour the animal, 
for the first time, showed same signs of sensibihty when roused, and made spon- 
taneous efforts to breathe twenty-two times in a minute. The artificial breathing 
was, therefore, now discontinued. She lay, as in a state of profound sleep, for forty 
minutes longer, when she suddenly awoke, and began to walk about. 

Sir Benjamin Brodie had indeed been anticipated in this happy proposition for 
recovering persons apparently dead after taking narcotic poison, after submersion, 
and the hke, — although he does not seem to have been aware of it. The experiment 
had once been tried before, and on the human subject, and with success, though not 
upon such scientific principles. The case is given by Mr. Whateiy, in the Medical 
Observations and Inquiries, vol. vi. A man who had swallowed an immense 
quantity of solid opium, and who seemed to be dead, was restored by the patient 
continuance, on the part of his medical attendants, in a process of artificial breathing. 

It is seldom that we can hope for success from this expedient in the treatment of 
disease ; simply because, in most cases, the injury of the nervous system which has 
produced the insensibility is irretrievable. 

In most forms of apoplexy, and of hydrocephalus, death occurs in the way of 
coma. Sometimes, however, as I mentioned before, the lesion of the nervous sub- 
stance is so extensive and sudden, as to operate like a shock, and cause death by 
asthenia. The tendency to death by coma is also strongly pronounced in sundry 
affections of the brain, both acute and chronic. These will form subjects for our 
consideration hereafter. 

The several modes of dying, then, in cases of sudden death, are clearly enough 
made out. Let me briefly sum up the conclusions at which we have arrived. Life 
cannot be maintained without the circulation of arterial blood : and whenever a 
person dies, he dies either because no blood circulates through his arteries, or 
because venous blood circulates through them. 

When it comes to pass that no blood is circulated through the arteries, we say 
that death occurs in the way of syncope; and this is of two kinds. In the one there 
is not blood enough received by the left side of the heart to stimulate its chambers to 
contract, or to be sent onwards by their contraction ; in the other, there may be 
biood enough, but the heart has not sufficient power to contract upon it. 

Also there are two ways in which death may be brought about in consequence of 
the circulation of the venous blood through the arteries. In one of these, the first 
step is the sudden shutting out of air from the lungs ; the blood which arrives m 



CAUSE OF DISEASE. 



5T 



those organs is not aerated, or rendered arterial, but circulates again as venous blood, 
producing a failure of the animal functions, and weakening the muscles, till it finally 
stagnates in the capillaries of the lungs themselves. In the other, the animal func- 
tions are the first to suffer — insensibihty occurs — the power which governs the 
movements of respiration is withheld — the breathing ceases — and organic life is 
extinguished as in the former case. 

I trust you even already perceive that a right understanding of these matters is 
calculated to throw both hght and interest upon our study of the symptoms and of 
the tendencies of disease. It will enable us to aim with more precision at ful- 
filling the indication so often inculcated by Cullen, of " obviating the tendency to 
death." In this sketch I have merely been able to hint at the important bearings 
of such views upon our practice. My attention was first called to them by the 
lectures of m}^ respected instructor, Dr. Ahson, who was accustomed to illustrate 
them by reference to the phenomena of one large class of disorders. All the 
modes of dying that I have described are apt to take place in fevers. Some- 
times we have to combat the one, sometimes the other tendency. The disease 
often proves fatal in the way of coma ; this happens principally when the brain 
has been a good deal affected, when there have been much headache, dehrium, 
and stupor; sometimes, when the lungs have been seriously imphcated, life is 
extinguished in the way of suffocation or apnosa : and occasionally fever seems to 
terminate fatally in the way of syncope, especially when the stress of the disorder 
has fallen upon the bowels, when there has been continued diarrhcea, and ulcer- 
ation of the intestinal glands. Or if death does not occur precisely in these ways, 
at least it resembles more in different cases, sometimes one form of dying, sometunes 
another. 

It is notorious that very different remedies, and even different plans of treatment, 
have been strongly recommended, in fever, by different practitioners. One probable 
reason of this is, that one plan has been found the most proper to avert the fatal 
event in one form of the disease, and one in another. The tendency to a particular 
mode of death will prevail in, and characterize, a whole epidemic. We shall resume 
these considerations hereafter : in the mean time the facts we have been reviewing 
may teach us the danger of applying, with too much confidence, the experience we 
may have gained of one epidemic to the treatment of another ; and the risk we are 
sometimes liable to, of misjudging, and criticising unjustly, the practice recom- 
mended by other physicians, because it does not appear to accord with the results of 
our own observation. 



LECTURE YI. 

Causes of Disease : distinction between predisposing and exciting causes. Enu- 
meration of causes, as connected with the Atmosphere — Food and Drink — 
Poisons — Exercise — Sleep — Mental and Moral Conditions— Hereditary Ten- 
dencies — Malformations. Temperature. Effects of Heat and Cold. 

The causes of disease are commonly arranged under three heads — as predis- 
posing, exciting, or proximate. 

Of these three, the last mentioned, or the proximate cause, is nothing else than 
the actual disease itself — the actual condition of that part of the body from which 
the whole train of morbid phenomena essentially flows. When we know that part, 
and that condition, v/e name the disease accordingly. It may be inflammation of 
the lungs; or softening of the brain. Vv^hen we do not, we call the complaint 
after the group of symptoms by which it is characterized : iritermittent fever, 
perhaps ; or marasmus. The term " proximate cause" is, therefore, an unnecessary 
term : it is, moreover, to learners, a puzzKng term, and tends to give to the study ©f 
the disease a scholastic and repulsive aspect. I wish you to get into the habit of 
contemplating the whole science of medicine under its simplest and plainest form. . 



58 



CAUSE OF DISEASE. 



I am sure we may very well abolish the term " proximate cause" altogether ; and 
having now given an explanation of its meaning, for your guidance when you meet 
with it in books, I shall never employ it, in these lectures, except perhaps in a quo- 
tation, again. 

In strictness of language, one event is held to be the cause of another event which 
follows it, when the first being absent, the second never occurs ; and the first being 
present, the second never fails to occur, unless some other event intervene to prevent 
it. But the causes of disease will not bear to be spoken of after so strict a 
fashion. We perceive that certain external circumstances [qux nos circumstant) 
often precede such and such diseases ; and that the diseases seldom happen when 
the same circumstances are not previously observable ; and we begin to regard 
those circumstances as exciting causes of those diseases. We find that the dis- 
eases are much more frequent among persons known to have been exposed to 
the agency of the presumed causes than among persons w^ho are not known to 
have been so exposed. The evidence at first is presumptive only. But the more 
uniform their conjunction, and the more rare their disjunction, the more confi- 
dently do we assign to the two consecutive events the relation of cause and effect. 
By this kind of observation a number of exciting causes of disease have been clearly 
estabhshed to be such. 

But recollect, certain circumstances being present, such and such diseases do 
often, not always, follow. Some persons are more Hable to be affected by the ope- 
ration of many of these ascertained causes than others are; and the same persons 
are more hable to be influenced by the same cause at one time than at another. 
And special circumstances, existing in particular cases, will be found to account for 
this variable operation of known exciting causes upon the bodily health. These 
special circumstances may properly be called predisposing causes. Thus, of twenty 
persons exposed to the same noxious influence — to the combined agency of wet and 
cold during a shipwreck, for example — one shall have catarrh, another rheumatism, 
a third pleurisy, a fourth ophthalmia, a fifth inflammation of the bowels, and fifteen 
shall escape without any illness at all. A man does that with impunity to-daj?-, 
which shall put his life in jeopardy when he repeats it next week. It is not, there- 
fore, the exciting cause alone that in all cases determines the disease. Something 
—nay much, or all — will frequently depend upon the condition of the body at the 
time when the exciting cause is applied ; and this condition of the body, which 
we Cd-W. predisposition, will depend upon circumstances then or previously in ope- 
ration ; and these circumstances are, in our language, predisposing causes. 

Do not confound, as many seem to do, the predisposition with the circumstances 
creating it. The predisposition is a certain state of the body — the predisposing 
cause of what produces that state. The cause of the predisposition is the predis- 
posing cause of the disease. A predisposing cause may therefore be defined, to be 
any thing whatever which has had such a previous influence upon the body as 
to have rendered it unusuaUy susceptible to the exciting cause of the particular, 
disease. 

It is sometimes difficult, or impossible, to say of a given cause whether it ought to 
be ranked among the exciting or among the predisposing causes ; whether it has 
pftpared the system for being affected by some other agent, or whether it has itself 
produced the disease ; but for the most part the distinction is real, and sufficiently 
well marked, and of great importance to be attended to. 

Disease may sometimes be averted, even in despite of strong and, fixed predis- 
position to it, if we know, and can guard against, the agencies by which it is 
capable of being excited. A man may inherit a proclivity to consumption, yet 
fortunately escape that fatal complaint by timely removal to a warm and equable 
climate, and by other suitable precautions ; that is, by avoiding whatever tends to 
rouse the dormant tendency into action. On the other hand, disease may often 
be warded off', notwithstanding the presence and apphcation of its exciting cause, 
when its predisposing causes are ascertained and can be prevented. In proportion 
as the body is weakened or exhausted, it yields more readily to the pernicious 
-influence of contagion, or of malaria; but by obviating all causes of debifity, and 



CAUSE OF DISEASE. 



59 



fortifying the system, we walk with comparative security amid surrounding pes- 
tilence. 

, Diseases sometimes occur when no exciting cause, when no cause at all, has been 
apparent. All that we can say of such cases (which are not, however, very fre- 
quent) is, that the causes have not hitherto been discovered. 

Now the ascertained causes of disease are many and various. Whatever minis- 
ters to life, health, or enjoyment, may become the medium, under changing circum- 
stances, of pain, disease, or death. The atmosphere, in which we are constantly 
immersed, is full of dangers. Both the organic and the inorganic world of matter 
around us abound in poisons ; they lurk in our very food, which becomes pernicious 
when taken in excess, or when it consists of certain substances, or certain admix- 
tures of substances ; so that there really was much truth, as well as some humour, 
in the startling motto to Mr. Accum's book on adulterations — " There is death in 
the pot.'''' Our passions and emotions also, nay, even some of our better impulses, 
when strained or perverted, tend to our physical destruction. The seeds of our 
decay are within as well as around us. 

Let us enumerate, however, a little more particularly, the various known sources 
of disease, with the view of making, afterwards, a few practical comments upon 
some of them. 

I shall pass over, in this enumeration, nearly all chemical and mechanical inju- 
ries ; inasmuch as these belong to surgery. 

If we look to atmospherical causes, we shall find that those varieties in the state 
of the air which proceed from mere differences of degree in its natural qualities may 
be productive of disease. Such are, extremes of heat and of cold ; sudden variations 
of temperature ; excessive moisture or excessive dryness ; different electric condi- 
tions ; differences of pressure, as measured by the barometer ; a deficiency of light. 

Again, the atmosphere may be a source of disease in consequence of its being 
loaded with impurities. Malaria, contagions of various kinds, and noxious gases in 
general, may be considered as so many poisons. 

Under the head of nutriment we may place the use of food of which the quality 
is bad and hurtful; this cause also strictly belongs to the class of poisons. Again, 
an insufficient supply of healthy food ; and still more common causes are excess in 
eating, and intemperance in drinking. 

The numerous poisons which are not comprehended under either of the foregoing 
heads are also prolific sources of disease. 

Another great class among the causes of disease might be formed by considering 
together the influence of various trades and avocations which are directly injurious 
to the health of those who pursue them. 

We know, by ample experience, that a certain amount of bodily exercise is essen- 
tial to good health. We see the evil consequences of much overstepping that 
amount, in the deformities and disorders which result from labour too severe, or too 
long continued. But a much more numerous train of complaints follow the opposite 
state — that in which, from indolence, or from necessity, but little exercise is used. 

Excessive indulgence in sleep on the one hand, and long-continued want or inter- 
ruption of repose on the other, are apt to give rise to serious maladies. 

Very many diseases have a mental origin. Excessive intellectual toil — the domi- 
nation of violent passions — the frequent recurrence of strong mental emotions — ■ 
vicious and exhausting indulgences, — each and all will sap the strength, and 
grievously impair the health of the body : and perhaps there is no cause of corpo- 
real disease more clearly made out, or more certainly effective, than protracted 
anxiety and distress of mind. 

When we add to this catalogue of the sources of disease all those morbid tenden- 
cies which are hereditary — and those which flow from original malformation, and 
are congenital — we shall have a tolerably complete list of the manifold dangers to 
which our mortal frames are continually liable. 

There are several points of view under which the consideration of these causes 
of disease might be shown to be interesting. We might inquire, for example, which 
of them are commonly predisposing, which exciting causes ; and w^hat are the cir- 



60 



CAUSE OF DISEASE* 



cumstances which are found to render the same agent at one time merely a predis- 
posing, and at another time an exciting cause. 

We might also separate, with some advantage, those causes of disease to which 
the human body is often and necessarily exposed, from those which consist in agen- 
cies that are of local or temporary existence only. But without mukiplying these 
artificial distinctions, I shall take occasion to advert to them either when speaking 
more in detail of particular causes, or when speaking of the disorders they have 
produced. 

In our investigations into the causes of disease, great caution is necessary in order 
to avoid being misled by individual cases. The circumstances capable of influ- 
encing the bodily health are so various — so many of them are apt to be in operation 
at the same time — and so httle power have we of excluding them, one after the 
other, so as to ascertain the exact efficacy of each — that our observations respecting 
their relative or their actual effects are open to much fallacy. We endeavour to 
escape this source of mistake by repeating and multiplying our observations. But 
it is by tracing diseases as they affect considerable masses of men, placed as nearly 
as possible under the same external circumstances, that we gain the surest and most 
satisfactory evidence in respect to the causes of disease. And hence it is that the 
experience of the medical officers of our fleets and armies is so valuable. Dr. Alison 
has well remarked, that all the circumstances of the whole number of men whose 
diseases fall under the notice of military and naval practitioners are, in many respects, 
exactly ahke : the men are generally healthy adults in the first instance — the cir- 
cumstances in which they are placed are thoroughly known to the observer — and, 
indeed, are often to a certain degree at his disposal ; they are often suddenly changed 
also ; and changed sometimes as to one portion of the whole mass of individuals, 
while they remain unchanged as to another portion ; so that his opportunities of 
observation partake in some measure of the nature of experiments, and being made 
upon a large scale, they are especially interesting and conclusive. In point of fact 
a great deal has been learned, with absolute certainty, upon this subject. 

Hitherto I have simply enumerated the principal causes of disease : — but con- 
ceiving a bare enumeration of this kind to be of but little use, I shall inquire some- 
what more nearly into the nature and mode of operation of several of them now ; of 
others I prefer to speak in connection with the particular diseases to which they 
give rise. 

You will not consider the inquiry superfluous. To know the cause of a disease 
is sometimes to be able to cure, often to be able to prevent it. In some cases the 
cause is beyond our power, but an acquaintance with its nature may teach us how 
to moderate or to remedy its consequences. There are many diseases also over 
which medicine has very little control, but the causes of which, when ascertained, 
may be avoided, or extinguished. Such causes, when they do not happen to be 
removable by individual efforts, are often susceptible of extinction by the united 
measures of a community. And for this reason it is very desirable that correct 
opinions respecting the causes of disease should be widely diffused among the public ; 
— and there is now no way in which information of this kind is so likely to be made 
generally known, as by communicating it to medical students who are about to 
scatter themselves in all directions over the face of the land. 

I shall proceed, then, in the first place, to the consideration of heat and cold, as 
external agencies capable of producing disease. 

The range of atmospheric temperature compatible with human life is very con- 
siderable. Its hmits are probably just those extremes of heat and cold that belong 
to the lower strata of the air in the different parts of the planet on which man is 
destined to exist. Under the burning sunshine of the tropics, and amid the pro- 
found frost of the polar regions, we alike find human dwellers. These different 
degrees of external temperature impress indeed pecuHar physical characters upon 
those who are subjected to them, but they do not, of necessity, extinguish life, or 
even cause disease. It requires more care, however, to preserve life under intense 
cold than under intense heat. In some parts of India the temperature ranges for a 



CAUSE OF DISEASE. 



long time together from 80 to 100, and even 110° of Fahrenheit's thermometer: I 
beheve it sometimes reaches 120°. We can form some estimate of this heat by 
remembering the oppressive effect of the lowest of these temperatures — that of 80° 
— to which the thermometer sometimes rises in this country in the hot weather of 
summer. But these tropical chmates are very thickly peopled. In the arctic coun- 
tries, on the other hand — in the northernmost parts of America, for example — where 
the sun appears above the horizon for a short part of the year only, and where the. 
thermometer sinks to 40 or 50° below zero — we still find, inhabitants, indeed, but 
they are few, and thinly scattered. This mainly depends, no doubt, upon the scanty 
supply of human food in those parts of the world ; but something also is to be 
ascribed to the depressing influence of extreme cold upon the vital powers. Indeed, 
the deficiency of human food is itself owing to the restraining effect of a low tem- 
perature upon organic life. Under a degree of temperature a little greater than that 
at the equator — or a little less than the lowest around the poles — it seems probable 
that man would soon perish. And in this fact we have one striking instance of the 
adaptation of external nature to the physical constitution of the human race. 

But for a short time — and under certain, circumstances — man is capable of 
enduring a very much higher degree of heat than the open and general atmosphere 
ever attains even in the hottest portions of the earth. Whether he could continue 
to exist, even for a little while, under a much more intense cold than ever occurs 
naturally on the surface of the globe, is more questionable. 

It was long believed that the human body could not be safely exposed, even for a 
short time, to a degree of heat much exceeding that which is met with in hot chmates. 
This opinion, which we now know to have been erroneous, Avas strengthened by the 
result of some experiments made by the celebrated Fahrenheit himself, and related 
by Boerhaave in his Chemistry. Some animals were shut up in a sugar-baker's 
stove, wh^re the mercury stood at 146°. A sparrow died in less than seven minutes, 
a cat in rattier more than a quarter of an hour, and a dog in about twenty-eight 
minutes. The noxious air of the stove had probably more to do with the speedy 
deaths of these animals than the heat. The truth, upon this subject, may be said to 
have been discovered by accident. In the year 1760 and 1761, JMM. Duhamel and 
Tillet were appointed to devise some means of destroying an insect which consumed 
the grain in the province of Angournais in France. They found that this could be 
done by subjecting the corn, and the insects contained in it, in an oven, to a degree 
of heat great enough to kill the insect, but not so great as to hurt the grain. In 
order to ascertain the precise heat of the oven, they introduced into it a thermometer 
placed upon the end of a long shovel. The mercury, when the thermometer was 
withdrawn, was found to indicate a degree of heat considerably above that of boihng 
water. But M. Tillet was aware that the thermometer had sunk several degrees as 
it was draw^n towards the mouth of the oven. While he was puzzled to invent 
some way of determining more exactly the actual degree of heat, a girl, who was 
one of the attendants of the oven, offered to go in, and to mark with a pencil the 
height at which the mercury stood. And she did enter the oven, and remained 
there two or three minutes, and then marked the thermometer at 100° of Reaumur, 
which nearly equalled 260° of Fahrenheit. M. Tillet then began to express some 
anxiety for the safety of the girl, but she assured him that she felt no inconvenience, 
and remained in the oven ten minutes longer, during which time the mercury 
reached the 288th degree of Fahrenheit's scale — denoting 76° of heat above that 
of water when it boils. When she came out her complexion was considerably 
heightened, but her respiration was by no means quick or laborious. This experi- 
ment was afterwards repeated. Another girl remained in the oven as long as the 
former had done, at the same temperature, and with the same impunity. Nay, she 
even breathed, for the space of five minutes, air heated to about 325° of Fahrenheit 
— or 113° above that of boiling water. 

The publication of these facts naturally excited the curiosity of scientific men, and 
other experiments were soon instituted. Dr. Dobson, of Liverpool, and several 
other persons with him, shut themselves up in the sweating room of the public hos- 
pital there, the air having been heated till the .quicksilver stood at 224° of Fahren- 

F 



62 



CAUSE OF DISEASE. 



heit. They did not experience any oppressive or painful sensation of heat. Dr. 
Fordyce and Dr. Blagden made some remarkable trials of the same kind. They 
entered rooms artificially heated to a very high, degree, sometimes naked, and some- 
times with their clothes on, and bore the extraordinary temperature of 240°, and 
even 260°, for a considerable time, with very httle inconvenience. In all these 
experiments it was found that the animal heat, as ascertained by thermometers placed 
under the tongue, or grasped in the hand, was scarcely increased at all ; and the 
respiration but Jittle affected ; but the pulse was very much quickened. The fre- 
quency of Dr. Biagden's pulse in one instance was doubled. You may read a 
detailed account of these experiments in the Philosophical Transactions ; but to 
give you a more Hvely notion of the degree of heat to which the bodies of these 
gentlemen were exposed, I may tell you that their watch-chains, and other pieces of 
metal about them, became so hot that they could scarcely be touched ; when the^ 
breathed upon the thermometer, the mercury immediately sank several degrees ; 
each act of expiration produced a pleasant feeling of coolness in the nostrils, and 
they cooled their fingers by breathing upon them. In and by the same heated air 
which they respired, eggs were roasted quite hard in twenty minutes, and beef-steaks 
were dressed in thirty-three minutes; and when the air was blown upon the meat by 
means. of bellows, it was sufficiently cooked in thirteen minutes. 

It is ascertained, then, beyond all doubt, that the human body is capable of 
sustaining these very high degrees of temperature, for a short time, without 
detriment. 

Facts of this kind may, perhaps, appear to you rather curious than useful. Man 
is never submitted to any natural heat of the air even approaching towards that to 
which the authors of the experiments I have been describing voluntarily exposed 
themselves. But a knowledge of extreme cases always tends to throw light upon 
those that lie between the extremes ; and the direct results arrived at in these philo- 
sophic inquiries are not barren of practical utility to members of our prpfession. It 
is not long ago that a man was found almost dead in an oven ; he expired a quartet 
of an hour after he was taken to one of the borough hospitals ; and an inquest was 
held upon his body. The newspaper report of the case (which is the only one I 
have seen) states the temperature of the oven to have been about 120° — a candle 
was m.elted by it in half a minute. Now prior to the trials just mentioned, exposure 
to such a degree of heat would have been held a sufficient cause of death. We now 
know (and it would be discreditable if we could not support our opinion in a court 
of law, or before a coroner, by a reference to authentic facts) that something else 
must have concurred in extinguishing hfe ; and, in fact, it turned out that the man 
was drunk v/hen he went into the oven. 

.But what are the effects, upon the human frame, of a high, yet less excessive, 
temperature of the air ? 

One very constant effect of heat is that of stimulating the or ganic functions of 
the body. We have seen that the temporary apphcation of great heat accelerates 
remarkably the action of the heart : the pulse was uniformly found to be much 
increased in frequency in the persons who made trials of their powers of endurance 
in heated rooms. Vve have evidence to the same purpose in the annual changes 
that take place in the vegetable kingdom at a given place, the sumnaer renewing its 
fohage ; the winter checking and repressing it ; and still more in the superior luxu- 
riance of vegetation in warm climates as compared with cold. And the same 
observation applies to those functions which animals possess in common with plants. 
Towards the poles both man and the lower animals are smaller than at the equator. 
Linnceus rem.arks that the hares, partridges, and other animals which inhabit the 
northern climes, are considerably smaller in size than the same species in more 
southern chmes. And Mr. Tooke, in his View of Russia, observes, "As we ap- 
proach nearer to the north pole, both the animal and vegetable productions of nature 
beconrie more and more stunted. The ordinary stature of the Samo3^edes seldom 
exceeds four or five feet, and their whole exterior corresponds with their dwarfish 
size." The stature of the native inhabitants of hot chmates does not, I believe, 
exceed that which is proper to the temperate zone ; but if, as is generally beheved, 



CAUSES OF DISEASE. 



63 



the human body, Hke plants and fruits, grows faster, and ripens sooner, in proportion 
as we approach the equator, this must be attributed to the stimulus of heat acting 
upon the organic hfe. 

On the other hand, and in some sort as a contrast with this, we may observe that 
considerable heat, when applied for some time together, has a sedative or depressing 
influence upon the animal functions, i. e., upon the nervous system ; causing lan- 
guor and lassitude, want of energy, a disinclination to exertion both bodily and 
mental. 

Under favourable circumstances, and where due precaution is exercised, it is pro- 
bable that a very high degree of natural temperature of the atmosphere may be 
borne with impunity. Sir James M'Grigor informs us (in his account of the passage 
of the army in 1801 from India to Egypt), that during the march over the sandy 
desert of Thebes, where the heat was uniform, though the thermometer in the sol- 
diers' tents was as high as 118°, the health of the troops was equal to that which they 
had enjoyed in any former period in India. 

But there are some forms of disease which are distinctly traceable to heat as their 
cause. 

The effect of hot weather in promoting the cutaneous perspiration is notorious. 
By the same influence the hepatic function is rendered more active. Dr. James John- 
son first, I think, distinctly pointed out the sympathy or consent that obtains'between 
the liver and the skin, under varying conditions of external warmth. Whatever 
may be the explanation of the fact, experience has taught us that a high atmospheric 
temperature, when its operation is continued for some time, has a marked influence 
upon the hver, increasing the quantity of bile that is secreted, and altering its sen- 
sible quahties ; and this disturbance of function is not unfrequently followed by in- 
flammation of the gland itself. In this country we witness, almost annually, the 
effects of a succession of sultry weather, in those attacks of vomiting and diarrhcea 
which are so common towards the latter end of summer, and in the autumn, espe- 
cially when the season happens to have been unusually hot ; and which result, appa- 
rently, from the excessive quantity or a morbid state of the bile. The English 
cholera (a totally different disorder from that which has of late years been called, 
most improperly, the cholera), is, as you know, so frequent and general in some 
years, as to be fairly considered and termed an epidemic disease. In tropical cli- 
mates the same morbific operation of external heat is still more conspicuous ; leading 
not only to violent disorder of the stomach and intestines, with the evacuation of 
large quantities of vitiated and acrid bile, but also to acute inflammation of the liver 
going on to suppuration, and the formation of large abscesses. These last diseased 
conditions are extremely rare in this latitude. The yellow complexions of those 
who return to England after a long residence in India, are to be attributed to that 
disordered stale of the liver, and of its functions, to which such persons are prover- 
bially subject, and which has in them been brought on by the influence of a hot at- 
mosphere, operating for a long space of time together. Hepatic affections, acute or 
chronic, are among the chief diseases to which Europeans, at least, are liable in that 
chmate. 

We have here an example of the distinction I wish you to notice between predis- 
posing and exciting causes. The heated atmosphere stimulates unduly the secreting 
function of the liver. Now a secreting organ is never so apt to be affected by any 
exciting cause of inflammation as when the process of secretion is going on. This 
law, which I mention by anticipation, depends, no doubt, upon the increased afflux 
of blood that accompanies the act of secretion. The excessive activity of the hepatic 
function constitutes thus a predisposition to inflammation of the hver. The hot at- 
mosphere, which creates this predisposition, holds the place of a predisposing cause 
in respect to the inflammation that ensues ; but the exciting cause is exposure to 
cold : one of the most common and best ascertained exciting causes of inflammation 
in general. You are not to imagine that there can be no such thing as exposure to 
cold in a chmate where the temperature of the air is habitually above 80°. Dr. 
James Johnson, in his book on Tropical Climates, observes that on the coast of 
Coromandel the temperature is steady by day, and the nights are hot : but yet, he says, 



64 



CAUSES OF DISEASE. 



nothing is more common than exposure to cold in this place. The European soldier 
or sailor, after the heat occasioned by his employments in the day, strips off his 
clothes, and hes opposite a window or port, his shirt wet with perspiration, to enjoy 
the sea breeze at night. And the same author tells us that the application of cold 
after or during perspiration, commonly produces an attack of hepatitis in some one 
of its various forms. Now the effect of that kind of exposure here described does 
not depend upon the actual temperature, but upon the sensation that is produced, 
and the sensation depends upon the relative temperature ; and there can be no doubt 
that, under the circumstances mentioned by Dr. Johnson, a strong sensation of cold 
would be occasioned, even by a sea breeze as warm as 80°, or warmer. Changes 
of temperature seem to be as readily felt at one part of the thermometric scale, as at 
another, and in whichever direction they take place. Dr. Walsh states, that while 
sailing along the coast of Brazil, after having been long accustomed to a temperature 
of 72°, a strong breeze set in from the sea, and the thermometer fell to 61° ; [i. e., 
to a point which w^e should here call temperate ;) " but," he says, " the sense of cold 
from the sudden transition of temperature was quite painful. After bearing it for 
some time, shivering on deck, it became intolerable, and we all' went below, put on 
warm clothing, and dreadnoughts — and again appeared with thick woollen jackets 
and trowsers, as if w^e had been entering Baffin's Bay, and not a harbour under one 
of the trt)pics." 

It is interesting to compare this statement with Capt. Parry's account of a change 
of temperature at the opposite extreme of the scale, and in the other direction. Having 
previously said that the thermometer had fallen to 13° below zero in the night of the 
21st of October, he goes on thus : — " The wind veering to the southeast on the 24th 
and 25th, the therm.ometer gradually rose to 23°. I may possibly incur the charge 
of affectation in stating that this temperature was much too high to be agreeable to 
us ; but it was nevertheless the fact, that eveiybody felt and complained of the 
change. We had often before remarked that considerable alterations of the tempe- 
rature of the atmosphere are as sensibly felt by the human frame at a very low part 
of the scale as in the higher. The difference consists only in this, that a change from 
40° upwards to about zero, is usually a very welcome one ; while from zero up- 
'wards to the freezing point, as in the instance just alluded to, it becomes, to persons 
in our situation, rather an inconvenience than otherwise." 

Besides the more gradual effects of great heat, direct or indirect, upon the human 
body, it sometimes operates distinctly as an exciting cause, and gives rise to more 
sudden attacks of illness. Persons who are exposed to the direct beams of a hot sun, 
especially during any labour or active exercise, are apt to be affected by what is 
called the sun-stroke, the coup de soleil, insolation : they fall dow^n insensible, and 
often die in a very short time. This disorder is common among troops in long 
marches in India. It is a complaint of which the cause has long been known by 
the inhabitants of hot chmates. There is a case of it related in the Bible. " And 
Manasses was her husband, of her tribe and kindred, who died in the barley harvest. 
For, as he stood overseeing them, and bound sheaves in the field, the heat came upon 
his head, and he fell on his bed, and died in the city of Bethuha." 

Pathologists are not agreed respecting the intimate nature of this distemper ; nor 
about the manner in which it destroys life. Some regard it as a sort of apoplexy : 
and hold that death takes place in the way of coma. But the most approved reme- 
dies of apoplexy — bleeding and other evacuations— have not proved successful in 
reheving it. The natives of India prefer the pouring of cold water upon the head 
to every other curative measure. Our army sergeants also found that stimulants — 
rum and water, for instance — answered better than depletion. I have never seen 
this affection, but I should conjecture that it is more akin to the state we call concus- 
sion than to true apoplexy. It would appear that the sun's rays act upon the brain 
like a shock. The nervous system is suddenly and extensively influenced, and the 
heart's movements arrested, as in syncope. One of Sir Benjamin Brodie's experi- 
ments is in favour of this opinion. He placed a rabbit in a basket in an oven, the 
temperature of which was not more than 150°, and it died in a few minutes, without 



CAUSES OF DISEASE. 



6i 



any apparent suffering. The heart was afterwards found distended with blood, on 
both sides, as after death by asthenia. 

Great heat tends also to the production of certain cutaneous diseases : it is said 
that few Europeans escape, on their first settling in tropical chmates, an eruption of 
pimples, attended with almost intolerable itching and pricking, and lasting for some 
weeks. It is called in India the prickly heat. 

Before considering that most prolific source of disease which is familiar to the 
commonest observation in sudden transitions of temperature, let us inquire what are 
the ascertained effects of extreme cold upon the human frame. Of course I use the 
term cold in its popular acceptation, as if it were something positive, instead of sig- 
nifying the mere privation of heat. It is much more convenient to speak of it in 
this way, and there is no risk of your being misled by my doing so. 

Now this inquiry is of more practical interest to us than that which is concerned 
with the immediate effects of extreme heat. Even in this chmate medical men are 
not unfrequently called upon, in cases of injury or death produced by intense cold, 
either to remedy the morbid conditions it has caused, or to explain the mode and 
probability of its operation in extinguishing life. 

The effects of cold, as might well be imagined, are in many respects the direct 
opposites of the effects of heat. When its application is continued, it acts as a 
sedative upon the organic functions both of animals and of plants. This appears 
from the shrinking of the external parts : the superficial arteries become unable to 
transmit the blood in the usual quantity through the integuments. Hence the skin 
becomes pale, and contracting round the sebaceous glands and the hair-bulbs, exhi- 
bits a roughness which is compared to that of the skin of a plucked goose, and is 
technically called cutis anserina. By the same contraction of the smaller vessels, 
and repressed circulation, the extreme and projecting parts are diminished in size. 
Thus, rings which are tight on the fingers while the body is warm, drop off in cold 
weather — and even the shoes fall from the feet during extreme exposure. The 
heart with the whole arterial system becomes weak. I have already, when speaking 
of the contrasted operation of heat, illustrated the withering influence of a continued 
low atmospheric temperature upon the organic functions, by referring to the dwarfish 
size of both men and the lower animals, as well as of plants, in cold regions. We 
have evidence of the same fact in the tardy development of the functions, and par- 
ticularly, as many travellers affirm, of the sexual functions, in cold climates as com- 
pared with hot ; and in the winter torpor of certain animals, which is very analogous 
with the state of trees and shrubs in that season. 

I need not tell you that to judge of the effects of mere coldness of the atmosphere 
we must take the case of the atmosphere at rest. The air is a bad conductor of 
caloric, and for that reason, a much lower, as well as a much higher degree of 
temperature, can be borne when it is in a state of quiescence, than when fresh por- 
tions of it are perpetually brought into contact with the surface of the body by 
currents of air. " With the thermometer," says Captain Parry, "at -55°," (a most 
fearful degree of cold, you will observe, 55° below zero, i. e., 87° below the freezing 
point,) " with the thermometer at -55°, and no wind stirring, the hands may remain 
uncovered for ten minutes or a quarter of an hour without inconvenience ; while 
with a fresh breeze, and the thermometer nearly as high as zero, few people can 
keep them exposed so long without considerable pain." And speaking in another 
place of the cold, when the thermometer was 49° below zero ; 9 or 10°, that is, 
below -the point at which mercury freezes, he says, " The weather being quite calm, 
we walked on shore for an hour without inconvenience, the sensation of cold de- 
pending much more on the degree of wind at the time, than on the absolute tempe- 
rature of the atmosphere as indicated by the thermometer. In several of the accounts 
given of those countries, in which an intense degree of natural cold is experienced, 
some effects are attributed to which it certainly did not come under our observation 
in the course of this winter. The first of these is the dreadful sensation said to be 
produced in the lungs, causing them to feel as if torn asunder when the air is 
inhaled at a very low temperature. No such sensation was ever experienced by us, 
5 f3 



CAUSES OF DISEASE. 



though in going from the cabin into the open air, and vice versd, we were constantly 
in the habit, for some months, of undergoing a change of from 80° to 100°, and in 
several instances 120° of temperature, in les^ than one minute: and what is still 
more extraordinary, not a single inflammatory complaint (beyond a slight cold, 
which was cured by common care in a day or two), occurred during this particular 
period." 

But when the cold air is in motion, in other words, when there is wind, so that 
fresh portions of cold air are brought, successively, in contact w^ith the surface ; or 
when it is accompanied with moisture, or occurs under other circumstances favour- 
able to its operation, and to be spoken of more particularly presently ; then cold of a 
much inferior degree of intensity may very speedily occasion partial or total death. 
By partial death I mean the loss of vitahty in certain parts of the body only — the 
ears, nose, fingers, toes, and feet. The parts thus affected are said to be frost-bitten : 
and the. mode of managing such accidents falling within the province of surgery, I 
shall confine my remarks almost entirely to the case where general death — death in 
its full and ordinary meaning — ^is either brought about, or impending, in consequence 
of exposure to cold. 

One of the earliest effects of extreme cold upon the system at large has been said 
to be a remarkable and overpowering drowsiness. But I believe you will find that 
most or all of the persons in whom this torpor has been noticed had not only been 
exposed to severe cold, but had been using also a great deal of exercise : and per- 
haps the drowsiness ought to be ascribed, in some measure at least, to that exercise. 
They who attribute it to the cold alone explain the comatose state in this way. They 
say that the chilling of the surface and extremities drives the blood inwards, causes 
it to accumulate internally, and increases the flow of blood towards the head. One 
thing, however, is certain, viz., that drowsiness is not a necessary consequence of 
exposure to severe cold, although it is a very common consequence. Dr. Currie, in. 
his Medical Reports, gives a very interesting account of the shipwreck of an Ame- 
rican vessel on the coast of Ireland. Most of the creAV, fourteen in all, were im- 
mersed, to a considerable depth, for twenty-three hours, in water of which the 
temperature was beheved not to exceed 33 or 34° of Fahrenheit : and he states 
expressly that none of the men were drowsy, and that in no one of the three that 
perished was death preceded by sleep. 

The overpowering tendency of cold when combined with fatigue (and perhaps, 
under certain circumstances, of intense cold alone), to induce sleep, was strikingly 
exemplified in what befel Dr. Solander among the hills of Terra del Fuego. The 
story, as given in Captain Cook's Voyages, is well known. Sir Joseph Banks and 
Dr. Solander had been out botanizing. On their return towards the ship, after 
various hardships, and after having travelled through swamps for a considerable 
way, the weather, which had been very fine, became gloomy and cold, with sudden 
blasts of piercing wind, accompanied by snow. Finding it impossible to get back 
to the ship before the morning, they resolved to push on through another swamp. 
that lay in their way, into the sheker of a wood, where lYiej mJglit build a wigwam 
and kindle a fire. Mr. Banks (as he was then) undertook to bring up the rear. Dr. 
Solander, who had more than once crossed the mountains that divide Sweden from 
Norway, and who well knew that extreme cold, especiaUy when joined with fatigue, 
produces a torpor and sleepiness that are almost irresistible, conjured the company 
to keep moving, whatever pain it might cost them, and whatever relief they might 
be promised by an inclination to rest. " Whoever sits cloivfi,^^ said he, " will sleeps 
and whoever sleeps will wake no more.'''' Thus at once admonished and alajmed, 
they set forwards ; but they had not gone far before the cold became suddenly so 
intense as to produce the effects that had been most dreaded. Dr. Solander was the 
first who found the inclination, against which he had warned others, invincible, and 
he insisted on being suffered to lie down. Mr. Banks entreated and remonstrated 
with him in vain : down he lay upon the ground, akhough it was covered with 
snow, and it was with much difficulty that his friend kept him from sleeping. Rich- 
mond, also, one of the black servants, began to hnger in the same manner. When 
he was told that if he did not go on he would in a short time be frozen to death, his 



CAUSES OF DISEASE. 



67 



answer was that he desired nothing but to lie down and die. The doctor said he 
was willing to go on, but that he must first take some sleep ; although but a short 
time before he had told the company that to sleep was to perish. Mr. Banks and 
the rest found it impossible to carry them, and there being no remedy, they were 
both at length suffered to he down, being partly supported by some bushes ; and in 
a few minutes they fell into a profound sleep. Soon after some of the people who 
had been sent forward returned with the welcome news that a fire was kindled about 
a quarter of a mile on the way. Mr. Banks then endeavoured to wake Dr. Solander, 
and happily succeeded ; but, though he had not slept five minutes, he had almost 
lost the use of his hmbs, and the flesh was so shrunk, that his shoes fell from his 
feet. He consented to go forward with- such assistance as could be given him ; but 
no attempts to relieve poor Richmond were successful He, together with another 
black left with him, died. 

In many instances, before this complete torpor comes on, intense cold has a curi- 
ous effect upon the nervous system, blunting the sensations, and confusing the intel- 
lect, and giving to the person exposed to it the appearance of one intoxicated. It is 
very necessary that you should be aware of this, for there is too much reason to 
beheve that poor wretches who have been picked up by the constables in the streets 
at night, during*, periods of hard frost, have been supposed to be drunk, when, in 
truth, they were only stupefied by the cold. Such a mistake is most likely to be 
fatal to them : instead of receiving the attention and treatment proper for persons in 
their condition, they are liable to be laid aside, by themselves, to sleep off their sup- 
posed debauch, and the morning finds them corpses. It is not at all improbable that 
some of you may be called upon to investigate such cases : and as actual instances 
are more readily impressed upon the memory than any general description, I will 
read you a short history illustrative of v/hat I have just been saying, from Captain 
Parry's Journal. 

" John Pearson * * * had his hands severely frost-bitten, having unfortunately 
gone without mittens, and with a musket in his hand. A party of our people most 
providentially found him, although the night was very dark, just as he had fallen 
down a steep bank of snow, and was beginning to feel that degree of torpor and 
drowsiness which, if indulged, inevitably proves fatal. When he was brought on 
board his fingers were quite stiff, and bent into the shape of that part of the musket 
which he had been carrying : and the frost had so far destroyed the animation in 
his fingers on one hand, that it was necessary to amputate three of them a short 
time after." 

It is what immediately follows this, that I was desirous of pointing out to your 
attention. 

"The effect which exposure to severe frost has in benumbing the mental as well 
as the corporeal faculties, was very striking in this man, as well as in two of the 
young gentlemen wha returned after dark, and of whom we were anxious to make 
inquiries respecting Pearson. When I sent for them into my cabin, they looked 
wild, and spoke thick and indistinctly, and it was impossible to draw from them a 
rational answer to any of our questions. After being on board for a short time, the 
mental facukies appeared gradually to return with the returning circulation ; and it 
was not until then that a looker-on could easily persuade himself that they had not 
been drinking too freely. To those who have been much accustomed to cold coun- 
tries, this will be no new remark, bat I cannot help thinking (and it is with this view 
that I speak of it) that many a man may have been punished for intoxication, who 
was only suffering from the benumbing effects of frost : for I have more than once 
seen our people in a state so exactly resembling that of the most stupid intoxication, 
that I should certainly have charged them with that offence, had I not been quite 
sure that no possible means were afforded them on Melville Island to procure any 
thing stronger than snow-water." 

When persons in this state are suffered to sleep, and the operation of the cold 
continues, they become less and less sensible to external impressions, until death 
closes the scene. 



68 



CAUSES OF DISEASE. 



LECTURE VII. 

Causes of Disease, continued. Laws hy ivhich the operation of Cold upon the 
Bodily Health is regulated. Circumstances that favour its injurious Effects, 
and respect, first, the Body itself; secondly, the manner in which the Cold is 
applied. Modifying influence of certain states of the Mind— -of Sleep — of 
Habit. Means of protection. Influence of the different Seasons. Impurity 
of the Air. Hereditary tendencies to Disease. 

In the last lecture I commenced the consideration of some of the causes of 
disease. 

We learned, by the evidence of authentic facts, that the human body is capable of 
bearing a very high degree of external temperature, for a short time, without detri- 
ment — and even without much inconvenience ; and we learned — also by the testi- 
mony of facts — that the body is equally well calculated to endure, under favourable 
circumstances, a very low degree of atmospheric temperature — or, to speak in' 
popular language, a very intense degree of cold. 

It appears also that a high, but not extreme, atmospheric temperature, when long 
continued, has a stimulating effect upon the organic functions, and a depressing or 
sedative effect upon the animal functions of the body. Long-continued heat predis- 
poses the body to be injuriously influenced by exposure to cold : the diseases apt to 
follow such exposure, under such circumstances, being derangement of the hepatic 
functions — violent disturbances of the stomach and bowels, with a copious discharge 
of vitiated and acrid bile — and acute inflammation of the hver itself. As more 
direct consequences of exposure to extreme heat — in other words, as examples of 
disorders of which extreme heat sometimes proves an exciting cause — I m^entioned 
the coup de soleil, and the eruption called the prickly heat. 

With respect to external cold, I pointed out to you its depressing effects upon the 
organic functions of the body — and, when it becomes very intense, indeed, its directly 
sedative influence upon the animal functions also — producing a state resembling 
intoxication, overpowering drowsiness, and coma, especially when the cold has had 
an auxiliary in fatigue ; and, ultimately, death itself. 

I hardly need say that the effect of external cold upon the body, within certain 
limits of intensity and duration, is totally different from all this. When it is not 
intense — or when, though intense, it is appHed for a short time only — or when its 
refrigerating and sedative properties can be sufficiently counteracted by exercise and 
warm clothing — cold becomes a tonic ; stimulating, refreshing, and invigorating both 
mind and body. Instead of benumbing, it heightens the sensibility ; instead of 
stupefying, it clears and sharpens the faculties, and bestows alacrity and cheerful- 
ness of spirit ; and in this way, among others, cold becomes a very important curative 
agent. 

Here also, therefore, the contrast obtains; a high external temperature relaxes and 
depresses — a low one, under the circumstances just mentioned, braces and enlivens. 

Nevertheless, exposure to cold is one of the most common causes of various com- 
plaints. Many or most of the internal inflammations acknowledge cold as their 
ordinary exciting cause. Acute rheumatism has, perhaps, no other external origin. 
Apoplexy and palsy, and dropsy, are its frequent consequences. " With the excep- 
tion," says Dr. Bateman, in his Observations on the Diseases of London, " with the 
exception of a small number of diseases occasioned by unwholesome occupations, 
and by the contagions, the great mass of human malad'^ in this metropolis is refer- 
able to the climate or statg of the seasons, and to mtemperance : but, of these two 
causes, the vicissitudes of the weather, especially its cold, are by far the most prolific 
sources of mischief." 

It must, therefore, to every one who is engaged, or likely to be engaged, in the 
practice of physic, be a matter of first-rate importance, and of great interest, to ascer- 
tain the circumstances under which the application of cold is the most prejudicial, or 



CAUSES OF DISEASE. 



69 



has the greatest influence upon the body — as well as the means by which the bad 
effects of exposure to cold may often, in a great degree, be prevented. 

There are some short but valuable hints upon this subject in Cu lien's First 
Lines. The late Dr. Currie, of Liverpool, was, however, the first person who dis- 
tinctly pointed out the laws that regulate the operation of cold as a cause of health 
and disease. 

Of the circumstances which favour the morbific effects of cold, some relate to the 
condition of the body itself, some to the particular manner in which the cold is 
applied. The former are predisposing circumstances; the latter accessory. We 
will glance at these in succession. 

It has long been a popular, as well as a professional axiom, that sudden vicissi- 
tudes of temperature are dangerous ; that a previous hot state of the body augments 
the hurtful effect of cold, whether applied externally or internally. But the proposi- 
tion thus broadly stated is not universally true. It is well known that the inhabitants 
of Russia are in the habit, while reeking from their vapour baths, of rolling imme- 
diately in the snow, or plunging into cold water, without suffering from the change. 
Sir Charles Blagden, describing some of the experiments which I mentioned in the 
last lecture, says, " During the whole day we passed out of the heated room (of 
which the temperature ranged from 240"^ to 260°), after every experiment, imme- 
diately into the cold air without any precaution. After exposing our naked bodies 
to the heat, and sweating most violently, we instantly went into«a cold room, and 
stayed there even some minutes before we began to dress, yet no one received the 
least injury." And Captain Scoresby, speaking of the arctic regions, tells us that 
he has often gone from the breakfast-room of the vessel, where the temperature as 
50° or 60°, to the mast-head, where it was only 10°, without any additional clothing, 
except a cap — " yet," says he, " I never received any injury, and seldom much 
inconvenience from the uncommon transition." 

It is plain, therefore, that the proposition which assigns danger to sudden vicissi- 
tudes of temperature requires limitation. The effects of a sudden descent from one 
point to another in the scale of atmospheric temperature vary according to the state 
of the body at the time. Without going into any physiological discussion respecting 
the source of animal heat, I may just remind you of the faculty of evolving heat 
possessed by man and the warm-blooded animals ; by which faculty very nearly the 
same degree of inward temperature is steadily maintained under very different 
degrees of outward temperature. If the external temperature be lower than that of 
the body, the caloric thereby carried off is speedily replaced, in a healthy adult, by 
this evolution of heat from within, aided by clothing, or by exercise. When the 
external temperature approaches the standard heat of the body, sweat soon breaks 
forth, and the superfluous heat is removed by evaporation : for so constant is the 
internal evolution of caloric, that an atmosphere which does not as constantly abstract 
any of it is excessively incommoding: an external temperature of 98°, which is 
about the average heat of the blood in man, is, as you know, extremely oppressive. 
The terms hot, warm, cool, cold, as applied to the surrounding air, are regulated by 
the sensations that it produces upon the average of persons. If the heat be carried off 
as fast as it is generated, and no faster, no particular sensation is felt, and the bodily 
powers are neither stimulated nor exhausted. This equilibrium is maintained (sup- 
posing that no extraordinary exertions are made), when the thermometer stands at 
62°, or thereabouts. We call that point in the scale temperate. All degrees above 
that point, up to TO, are reckoned ivarm ; all above 70, hot. Descending in the 
scale, we speak of the temperature denoted by any degree between the 60th and the 
50th, as being cool ; and every lower degree of temperature is cold. I am speaking 
of the average of healthy men : for remarkable diversities occur among individuals in 
respect to the epithets which they assign, under the guidance of their sensations, to 
particular degrees of the thermometric scale ; their sensations differing according lo 
the power which their constitutions respectively possess of evolving heat. Now if 
this power of evolving heat, thus inherent in the system, be entire, and active, and 
persistent — if it have not been weakened by any of those circumstances which arc 
known to have the effect of weakening it- — no peril need attend even violent altera- 



70 



CAUSES OF DISEASE. 



tions of external temperature. Unusual heat of the body at the time when the cold 
is apphed, so far from implying danger, is really the condition of safety, provided, the 
heat is steady and permanent. You may read, in Dr. Currie's book, numerous 
instances of the cold affusion being employed in the hot stage of fever, and particu- 
larly in cases of scarlet fever, not only with impunity, but with great benefit to the 
patient. The same holds true of the application of cold when the body has been 
heated by exercise — and, indeed, whatever may have been th|^ cause of the increased 
beat — provided always that that cause remains steadily in action, that there is no 
local disease, and that the body is not fatigued, and fast losing its heat. But if a 
person be already exhausted and weakened by exercise — if he be sweating and 
rapidly parting with his heat — and especially if the exercise be over, and he remain 
at rest immediately after and during the application of the cold — then it becomes 
highly perilous, and likely to produce internal mischief. 

The more correct statement, therefore, respecting the appHcation of cold is, that 
it is dangerous — not when the body is hot — but when the body is cooling after 
having been heated. 

This principle obtains alike, I say, w^hether the cold be apphed externally or 
internally ; to the surface of the body, or to the mucous membrane of the stomach. 
Very many instances are recorded of deaih taking place immediately after a copious 
draught of cold water. I believe it will be found that in all these cases, the body, 
after having been much heated and enfeebled by severe exertion, w^as losing its 
preternatural heat from profuse perspiration, and, in genera], from the cessation also 
of the exertion by which this heat was accumulated. Celsus was aware of the 
danger: " ex labore sudanti frigida potio perniciosissima est." The fatal influence 
of cold water thus apphed was experienced, on a large scale, among the troops o5 
Alexander the Great, upon their reaching the banks of the River Oxus, thirsty, 
fatigued, and perspiring from their toilsome march of forty-six miles across the 
scorching sands of the desert. According to Quintus Curtius, Alexander lost more 
of his soldiers on that occasion than in any one of his battles. " Sed qui intempe- 
rantius hauserant intercluso spiritu extincti sunt; multoque major horum numerua 
fuit, quam ullo amiserat proelio." Dr. Currie relates a striking example, which fell 
under his own observation, of sudden death thus produced. A young man had been 
playing a severe match at fives, and had violently heated himself. When it was 
over he sat down on the ground panting for breath, and covered with perspiration. 
In this state he called to a servant to bring him a pitcher of cold water just drawn 
from a neighbouring pump. After holding it in his hand a little while, till he 
recovered his breath, he put it to his mouth, and drank a large quantity at once. He 
laid his head on his shoulder, and bent forwards ; his countenance became pale, his 
breath laborious, and in a few minutes he expired. 

I may take the opportunity of telling you that the remedies to be administered, 
Avhen life is in jeopardy from this cause, are warmth to the epigastrium ; and lauda- 
num in free doses. 

If death does not speedily follow the external or internal application of cold to the 
body under the untoward circumstances I have described, inflammation of some 
internal part is very apt to arise. 

By attending to the principles now laid down, you will be enabled to furnish those 
whom it may be your business to advise with many useful suggestions, and to cau- 
tion them against some common mistakes : mistakes which have had their origin in 
the unqualified credit given to the maxim, that sudden vicissitudes of external tem- 
perature, and exposure to cold while the body is hot, are dangerous ; whereas these 
things are dangerous under certain circumstances only. Thus, you may tell the 
sportsman that wet feet, or a wet skin, need cause him no apprehension, so that he 
continues in active exercise ; and changes his clothes, and avoids all further appli- 
cation of cold, as soon as his exercise ends. You may admonish the bather that 
after walking in a hot day to the river's side, he had better not wait to .cool himself 
a httle before he plunges into the stream ; and in hke manner 5^ou may venture to 
counsel the young lady who has heated herself with dancing, not to finger in the 
entrance hah till the glow has somewhat subsided, but to make the best of her way 



CAUSES OF DISEASE. 



71 



to her carriage, and thence to her bed ; and you may tell your male friends, who 
happen to be similarly circumstanced, that the best thing they can do is to walk 
briskly home in their great-coats. The main points to be remembered are, that "the 
heat which is preternaturally accumulated by exercise is held with little tenacity, is 
dissipated by profuse perspiration, and is speedily lost when to this perspiration is 
added a state of rest after fatigue ;" and that, in these circumstances, the application 
of cold is most apt to be prejudicial. 

Among the circumstances which favour the morbific effects of cold, and relate to 
the condition of the body itself, is to be included — for reasons that must now be 
obvious to you — whatever has the effect of weakening the system, and so diminish- 
ing its capability of evolving heat. The most common of these debilitating circum- 
stances are enumerated by Cullen — " fasting, evacuations, fatigue, a last night's 
debauch, excess in venery, long watching, much study, rest immediately after great 
exercise, sleep, and preceding disease." Ail these, you vrill observe, tend to lessen 
the vigour of the circulation, and to depress the power of generating heat. Con- 
sistent with the same principle is the fact ascertained by Dr. M. Edwards, that the 
faculty of evolving heat is very feeble in old persons, and in the newly born ; it 
being in these classes that we find the greatest number of victims to the power of 
cold. 

The bad effects of cold upon the system depend partly upon the intensity of the 
sensation it produces — but still more upon the duration of that sensation. We are 
seldom the worse for a momentary sensation of cold, however lively it may have 
been ; whereas even slight feehngs of chiUiness, if long protracted, are apt to termi- 
nate in some form of disease. 

By the help of this principle we may explain most of the circumstances which, 
relating to the manner in which the cold is apphed, have been found by experience 
to aggravate its hurtful influence. 

Cold is more likely, ceteris paribus, to prove injurious when it is- applied by a 
wind, or current of air. The sensation of cold is sustained by the continual acces- 
sion of fresh particles of frigid air to the surface of the body. Some striking facts 
in illustration of the refrigerating and depressing effects of a stream of cold air were 
mentioned in the last lecture. 

Again, the injurious operation of cold is augmented, when it is accompanied with 
moisture. Wetness is notoriously the worst way in which cold can be applied. The 
contact of wet or damp clothes with the skin both increases and prolongs the sensa- 
tion of cold. For the same reason, a cold foggy atmosphere is more prejudicial than 
a clear, and therefore drier one, of the same temperature. The heat of the body is 
abstracted more rapidly than it is generated from within, and if it be not replaced 
by exercise, or cordials, the balance of the circulation is deranged, and internal mis- 
chief often follows. 

The same principles serve to illustrate the effect of certain other circumstances, 
adverted to by Cullen, as being counteractive of the morbific tendency of exposure 
to cold: "passions engaging a close attention to one object," — "that state of the 
body in which sensibility is greatly diminished, as in maniacs," — and "the power 
of habit." These circumstances are worthy of a moment's notice. 

Impressions which are unheeded are unfelt and inoperative. As it is scarcely 
possible, when the attention is engrossed by bodily pain, to carry on arfy connected 
train of thought — so on the other hand the senses become impassive in proportion 
as the mind is fixed upon some absorbing subject of reflection, or enchained by some 
powerful emotion : impressions made upon the organs of sense are no longer taken 
notice of; the corresponding sensations, if they are excited at all, are not remem- 
bered, and the effect of such impressions is as if they had never been ; they are not 
followed by the usual consequences. Persons gasping for breath in spasmodic 
asthma will remain for hours at an open window, with scarcely any clothing during 
severe frost, and without suffering from the cold ; their attention is so anxiously and 
exclusively bestowed upon the distress in their breathing, that the coldness of the air 
is unnoticed and unperceived, and has no sensible effect. 

For where the greater malady is fixed 
The lesser is scarce felt. 



72 



CAUSES OF DISEASE. 



The morbific effect of cold upon the system is certainly modified by the degree of 
attention that is paid to the sensation it excites. 

Upon the veiy same principle may be explained the impunity with which some 
maniacs undergo exposure to cold — even when suffering no fever which might 
regenerate the lost heat. " I have seen," says Dr. Currie, " a young woman, once 
of the greatest delicacy of frame, struck with madness, lie all night on a cold floor, 
with hardly the covering that decency requires, when the water was frozen on the 
table by her, and the milk that she was to feed on was a mass of ice." 

Sleep is enumerated by Dr. Cullen among those conditions of the body which 
diminish its power of resisting cold. And certainly cold is very readily caught (as 
the phrase is), when its causes are present, during sleep. But while we sleep sensa- 
tion is in a great measure suspended. This would seem, therefore, to furnish a 
contradiction to the principle that the effect of cold upon the bodily health depends 
upon the strength and the duration of the sensation excited by it. Dr. Alison — I 
speak from recollection of his observations heard many years ago — disposes of this 
difficulty by affirming that the sleeper who thus suffers, does really feel, and is con- 
scious of, the sensation of cold, and that it mingles with and probably suggests his 
dreams. Lord Brougham, in his Discourse of Natural Theology, gives a very 
lively picture of dreams so excited — drawn, as 1 should guess, from his own expe- 
rience. Probably something- of the same kind has occurred to most of us. " Every 
one knows (he says) the effect of a bottle of hot water, applied during sleep, to the 
soles of the feet : you instantly dream of walking over hot mould, or ashes, or a 
stream of lava, or having your feet burnt by coming too near the fire. But the 
effect of falling asleep in a stream of cold air, as in an open carriage, varies thisv 
experiment in a very interesting, and indeed instructive manner : you will, instantly 
that the wind begins to blow, dream of being upon some exposed point, and 
anxious for shelter, but unable to reach it ; then you are on the deck of a ship, 
suffering front the gale — you run behind a sail for shelter, and the wind changes, so 
that it still blows upon you ; you are driven to the cabin, but the ladder is removed, 
or the door locked. Presently you are on shore in a house with all the windows 
open, and endeavour to shut them in vain; or, seeing a smith's forge, you are 
attracted by the fire, and suddenly a hundred bellows play upon it, and extinguish it in 
an instant, but fill the whole smithy with their blast, till you are as cold as on the road." 

Certain it is, that though while sleeping we are not sensible of, or (what perhaps 
is the same thing) do not remember, ordinary impressions, we are nevertheless con- 
scious of unusual sensations ; so that the facility with which we take cold during 
sleep is no real exception to the general law, that the sensation produced by cold is 
concerned in its injurious effects. 

The last of the accessory circumstances mentioned by Cullen is " the power of 
habit.'''' No one can doubt the effect of custom in enabhng the body to resist the 
operation of cold, who has had opportunities of observing how differently an 
inclement temperature is borne by persons whose employments oblige them to 
live much under the open sky, as shepherds, sailors, stage-coachmen ; and by such 
as pursue in-door occupations — m.echanics, tailors, shopmen, and the hke. Pro- 
bably the sensibility of the surface is blunted by habitual exposure. We may 
believe too that the purer air breathed by the out-door labourer, and his more active 
life, confer a more vigorous state of health, and endow him with an ampler facuky of 
evolving animal heat. The fact is unquestionable ; and we may sometimes turn 
our knowledge of it to good account, in gradually fortifying the system against the 
influence of cold that cannot be avoided. An ill-directed apphcation of this prin- 
ciple has led, however, to grave errors, and cost many lives. You will now and then 
hear parents talk of hardening their children, by causing them to brave all sorts of 
weather, by teaching them to be indifferent about variations of temperature, to sit 
in winter time without a fire in the room, and to despise great-coats, flannel, 
and other additions to their usual dress. Fearing to render them effeminate by 
over care and cockering, they run into the opposite and more dangerous extreme. 

This process is often attempted w'lih. children originally delicate, and to such it is 
doubly hazardous. During the early periods of life the inherent protective power 



CAUSES OF DISEASE. 



73 



of evolving heat is comparatively feeble ; and in this chmate it requires to be care- 
fully cherished. 

The experiment of hardening should never be tried on any child or person who 
is ailing or unsound ; who shows any sign of present disease ; or any marked dis- 
position to future, and especially to scrofulous, disease. Whenever it is tried it 
'' must be conducted in conformity with the principles already laid down. The subject 
of the experiment must be sufficiently clothed, and he must not fail to use such ex- 
ercise during the exposure as may be requisite to excite and sustain the adequate 
generation of animal heat. An abiding sense even of chilliness must never be aimed 
at nor permitted. 

The most direct and certain mode of fortifying the body against injury from ac- 
cidental exposure to cold, is afforded by the use of the cold bath, and especially of 
the shower bath. When this is regularly taken in the morning, the surface of the 
body becomes inured to a degree of cold greater than it is likely to encounter during 
the remainder of the day. It is fortunate that we have an easy criterion of the pro- 
priety of continuing this expedient. When the sense of cold does not remain long, 
and is followed by a glow of warmth, the cold shower bath is sure to do good. If, 
however, after the bath, the person suffers headache, and continues to be chilly, 
languid, and uncomfortable, it should at once be given up as useless, and even 
hazardous. 

By observing these simple rules, a healthy child may be made hardy also, without 
the risk which their neglect would impose, of damage to his bodily fabric, and of 
abbreviating, by what was meant to prolong, his mortal span. 

Closely connected with the effects of temperature upon the health is the influence 
of the different seasons of the year. A few remarks upon that influence, as it is 
witnessed in our own climate and country, may properly conclude our present 
subject. 

It is open to the commonest observation that the general health of the community - 
fluctuates with the changing seasons. Catarrhs, and coughs, and pectoral complaints 
of all kinds, are most apt to commence, or to grow worse, in the winter and spring 
months ; while bowel-complaints are more numerous and distressing in the summer 
and autumn. The mucous membranes of the air-passages sympathize with the skin 
under the agency of external cold ; those of the stomach and intestines under that of ^ 
continued atmospheric heat. 

The thoracic disorders are more serious and fatal than the abdominal. Various 
other maladies are hkewise aggravated by cold, or by vicissitudes of temperature. 
Hence the mortality of the winter is always larger than that of the summer ; unless, 
indeed, this rule happens to be disturbed by the intervention of some widely- 
spread epidemic. I am not sure that the superior salubrity of the hotter over the 
colder portion of the year is generally acknowledged, even in this age of enlight- 
ment. 

It is the cold that, more than any other element of the weather, occasions the 
difference. 

There are two small pubhcations by the present Dr. Heberden, to which I 
would direct your attention, as being singularly instructive upon these points. 
One you will find in the eighty-sixth volume of the Philosophical Transactions : 
Of the influence of Cold itpon the Health of the inhabitants of London. The other 
is a separate pamphlet : Observations on the Increase and Decrease of different 
Diseases. 

From a number of tables, framed chiefly upon the weekly bills of mortality. Dr. 
Heberden (in the last-named paper) draws the conclusion that the whole number 
of deaths is greatest in January, February, and March, and least in June, July, and 
August. This is contrary to the notions of the ancients, and perhaps of many of the 
moderns also. Celsus says, " Igitur saluberrimum ver est ; proximo deinde ab hoc, 
hiems ; periculosior asstes ; autumnus longe periculosissimus." 

The difference of place may perhaps account for this difference of opinion. Celsus 
lived in Rome. That city, and the surrounding district, abound in malaria; a cause 

G 



n 



CAUSES OF DISEASE. 



of disease whicli, nappily, is now scarcely known in London, but which, wherever 
it exists, operates most powerfully and most extensively during the autumn. The 
comparative healthiness of the several seasons may doubtless be disturbed, and 
even reversed, by endemic peculiarities of this kind. 

In his paper in the Philosophical Transactions, Dr. Heberden compares the number 
of deaths that took place in London in January, 1795, which was an unusually 
severe month, with the number that occurred in January, 1796, which was an un- 
commonly mild month. Of those two successive winters one was the coldest, and 
the other the warmest, of which any regular account had been kept in this country. 
In the month of January, 1795, the thermometer, upon an average, stood at 23° in 
the morning, and 29°.4 in the afternoon; always, you will observe, below the 
freezing point. In the same month in 1796, it stood at 43°. 5 in the morning, and 
at 50° in the afternoon ; always much above the freezing point. The average differ- 
ence in the two months was more than 20°. 

In the five weeks beginning upon January 1st, 1795, there were 2823 deaths : 
in the five weeks beginning upon January 1st, 1796, there were only 1471. The 
difference, 1352, is enormous. The mortality in the former year was nearly double 
of that in the latter. 

One object which Dr. Heberden had in view in making this comparison was to 
disabuse his countrymen of the notion that, in winter, frosty weather is more favour- 
able to health than mild weather ; a notion which has been embodied in the pro- 
verb, that "a green Christmas makes a fat churchyard." 

It is very instructive to remark in what classes of persons the injurious effects of 
the severe weather of winter is most felt. The increased mortality was found to be' 
chiefly among the very young, and the very old ; in other words, among those in 
whom the recuperative power of generating heat is the feeblest. 

In January, 1795, there were in London 717 deaths of persons above sixty years 
old, while in January, 1796, there were only 153 such deaths; or scarcely more 
than one-fifth of the former number. 

I have often been struck by the unusual length of the newspaper obituaries during 
periods of hard frost ; and by observing how many of the individuals whose deaths 
they record were far advanced in years. Dr. Heberden remarks that among per- 
sons older than sixty, the tide of mortality, as measured by the weekly bills, follows 
regularly the degree of coldness of the weather ; so that any one accustomed to 
examine these lists may form a tolerably accurate judgment of the severity of any 
of our winter months, by noting the ratio of the mortality in persons above sixty. 

The deaths from asthma (under which vague term all kinds of pectoral disorder 
attended with shortness of breath appear to have been included) were 249 in Janu- 
ary, 1795 ; only 29 in January, 1796. In the former of these months there were 
825 deaths attributed to consumption ; in the latter, 342. 

All this accords with what I mentioned before of the effect of cold weather in 
producing or exasperating diseases of the respiratory organs. 

One of the conclusions deduced by Dr. Heberden from his examination of the 
bills of mortality is, that " the number of deaths by palsies and apoplexies is in this 
country always greatest in winter." There are intelligible reasons for this. When 
the surface is chilled, and the blood driven out of the superficial vessels by the cold, 
it must accumulate in internal parts, and so press with increased force towards the 
head. And there is another reason for the frequency of these affections in the 
winter season : it is, as we have seen, the season of pectoral complaints, and of em- 
barrassed respiration. Dyspnoea and fits of coughing greatly impede the return of 
the blood from the head through the veins : and cerebral congestion tends to the 
production of cerebral hemorrhage, especially when the arteries of the brain are 
diseased ; and they often are so. Accordingly we find that in January, 1795, there 
were fifty-two deaths from apoplexy and palsy ; while in January, 1796, the num- 
ber was only thirty-one. 

Since these lectures were first delivered, three Annual Reports of the Registrar- 
General of Births, Marriages, and Deaths in England, have been printed, and 
liberally circulated, by the obhging attention of Mr. Lister, among the members of 



CAUSES OF DISEASE. 



75 



OUT profession. Much of the practical information afforded by these interesting- 
volumes is rendered accessible, even to a cursory reader, by Mr. Farr'& able analy- 
sis of the registered facts ; Vv^hich amply illustrate and confirm most of the inferences 
drawn by Dr. Heberden from the old tables of mortality. 

For example, under the head of " Influence of the seasons," Mr. Farr shcfWs, by 
numerical statements, especially in the third Annual Report, that in London the 
degree to which the mean monthly temperature descends in December, January, or 
February, determines, to a great extent, the mortality of the winter. 

Again, " The causes of death which prove most fatal in the cold months belong 
principally to the pulmonary class, and the cerebral diseases of the aged : those 
which prove most fatal in summer belong to diseases of the bowels." 

The mean temperature of the external atmosphere in London is 50p. In pro- 
portion as the mean temperature of the day and night falls beneath that point, the 
mortality progressively increases. 

" The rise in the mortality," says Mr. Farr, " is immediate ; but the effects of the 
low temperature go on accumulating, and continue to be felt thirty or forty days 
after the extremities of the cold have passed away. The cold destroys a certain 
number of persons rapidly ; and in others occasions diseases which prove fatal in a 
month or six weeks. The practical lesson taught by these facts is obvious. A 
great number of the aged, and of those afflicted with difficulty of breathing, cannot 
resist cold sunk so low as 32^. The temperature of the atmosphere in which they 
sleep can never safely descend lower than 40° : for if the cold that freezes water in 
their chamber does not freeze their blood, it impeded respiration, and life ceases 
when the blood heat has sunk a few degrees below the standard." 

The immense body of authentic facts thus yearly accumulating in these Reports 
constitute most valuable contributions to the science of vital statistics ; and cannot 
fail to throw hght upon the sources, and to point towards the prevention, of many 
very dangerous and destructive disorders. To ascertain the causes of any disease, 
and to display them before the public mind, are, I repeat, large steps towards the 
ultimate removal of such as human endeavours are competent to remove. 

You may trace the influence of the seasons, not only in the prevalence of parti- 
cular diseases in certain portions of the year, but also in the character of other dis- 
orders that are hable to occur in all periods of the year alike ; in the character, for 
example, of fevers. In the majority of cases of continued fever, you will find that 
the pectoral symptoms are most troublesome in the spring, and the abdominal symp- 
toms in the autumn. It is said, also, but I do not know that this is so generally true, 
that affections of the head, in continued fever, are more frequent and severe in the 
winter than at other periods of the year. 

Mere impurity of the air — ^by which I mean impurity that does not result from 
the admixture of any specific poison, such as the marsh poison, and the various con- 
tagions — is a powerful predisposing cause of disease. The prejudicial effect of im- 
pure air is seen, on a large scale, by comparing the inhabitants of great towns, in 
respect of health and longevity, with those who hve in the country. If we again 
refer to Mr. Farr's calculations, founded upon the returns made to the Registrar- 
General, we find it stated, in the third Annual Report, that in cities, as contrasted 
with rural districts, the deaths from consumption are in(ireased 24 per cent. ; those 
from typhus 55 per cent. ; those from childbirth 59 per cent. ; and so of several 
other disorders. " The diseases chiefly incidental to childhood are twice as fetal in 
the town districts as they are in the country." The mean duration of life in the 
two classes of districts differs nearly 17 years ; being in the proportion of 55 years 
(country) to 38 years {towns). 

These differences we can explain only by attributing them to the weakening influ- 
ence of impure air, and the want of sufficient exercise : for, as Dr. Alison has 
remarked, "it is hardly possible to observe separately the effect on the animal eco- 
nomy of deficiency of exercise, and deficiency of fresh air, these two causes being 
very generally applied together. But it is perfectly ascertained on an extensive 
■scale, in regard to the inhabitants of large and crowded cities as compared wdth the 



76 



CAUSES OF DISEASE. 



rural population of the sarae climate, that their mortality is very much greater, 
especially in early life — and the probability of life very much less." There is one 
circumstance which shows that impure air is the more noxious agent of the two, 
namely, the great comparative mortaht}^ in towns, of children under two years of 
age, even although they get as much exercise as their time of life would allow of 
anywhere. 

The noxious and depressing influence of vitiated air is made strikingly manifest 
by the eifect of removal to a purer atmosphere. We are continually obliged to 
recommend " change of air" to our patients. We advise them to go out of' London, 
that their recovery from acute disorders may be accelerated, and that they may 
regain the degree of general strength which is necessary to the cure of many chro- 
nic complaints ; of all those especially that require the use of tonic medicines, among 
which class of remedies no one is so effectual, in constitutions that have been weak- 
ened by a town hfe, as migration to the clear and pure air of the country. 

It is necessary, however, to remember that although impure air has most unques- 
tionably a very hurtful effect upon the general health, there is no specific disease 
which can be distinctly traced to it as an exciting cause. It is as a predisposing in- 
fluence that the impurity operates. For instance, it never generates (as I beheve) 
continued fever, yet it will most certainly aggravate the symptoms, and favour the 
propagation, and augment the mortality, of that, and of other diseases, in a great 
degree. If there be any diseased condition that is strictly the product of impure air, 
it is scrofula. Scrofula (as I shall presently show you) depends in part upon here- 
ditary constitution ; it partly arises also from exposure 1^ cold and wet ; but there is 
much reason for beheving that impure air is a very powerful agent in calUng scrofula 
into action, and in aggravating the strumous diathesis. 

[This statement of Dr. W. is not strictly correct. That specific disease is produced by im- 
pure air is a fact established by the most abundant and conchisive testimony. Wherever we 
find individuals crowded together in localities where filth is accumulated, and a free venti- 
lation is prevented, there, also, we find diseases to prevail, evidently dependent upon the 
impure and stagnant state of the atmosphere ; though other causes, no doubt, conspire to their 
development, and to augment their malignancy. It cannot, certainly, be denied, that it is to 
the impurity of the air, produced by decomposition of the exhalations and excretions of indi- 
viduals regardless of personal and domestic cleanliness, when crowded together in confined 
apartments, that we are to refer the production of the typhus fever, so apt to prevail under 
such circumstances, as well as the typhoid character of most of the diseases with which such 
individuals may become aflected from other causes. Typhus fever, we know, is particularly 
liable to be produced in camps, barracks, hospitals, prisons, besieged fortresses, and on board 
of ships, whenever in such situations a number of persons are crowded together, and cleanli- 
ness and ventilation are neglected ; and it is seldom, if ever, generated when the sources of 
impurity are carefully removed, and a free and constant ventilation secured. 

The dependence of yellow fever upon an impure state of the atmosphere is shown by the 
fact, that it is almost exclusively confined to towns or other situations where the population 
is dense, and many causes exist calculated to impair the purity of the atmosphere ; and by its 
being very generally confined, when it occurs in cities, to the vicinity of the wharves and 
docks, into which the common sewers empty and various impurities are allowed to accu- 
mulate, and which, when acted upon by heat, cannot fail to give rise to a miasm, by which 
the purity of the surrounding atmosphere is very materially impaired. 

In regard to the agency of an impure air " in calling scrofula into action, and in aggravating 
the strumous diathesis," the evidence is by no means so strong as the language of Dr. W. 
would imply. Dr. Phillips, jn his late work on the Nature and Causes of Scrofula, has 
examined this question with a great deal of care; his conclusions are, that "if we regard 
scrofula in the widest signification of the term, so as to include all diseases in which a 
tubercle-like deposit seems to determine the loss of life, namely, phthisis, scrofula, and tabes 
mesenterica, the result may be thus stated : — The mortality from those diseases is larger in 
towns than in country districts, but it is not found that the densest portion of a town is that 
in which the mortality is the largest. Thus, in the four districts in London in which the 
crowding is the greatest, the average deaths from these affections is under 0.46, whilst in four 
other districts, in which there is less crowding, the average deaths amount to 0.51. and in 
Bethnal Green they are under 0.40. If we now narrow the question to the influence of a 
residence in towns and bad air in developing scrofula alone, the result may be thus stated : — 
In the four years' mortality included in the fifth report of the Registrar-General, namely, from 
183S to 1841, in a district comprising towns having a population of 3,759,186, the deaths 
icom scrofula amounted to 758 j and in a district having a rural population of 3,440,501 souls, 



CAUSES OF DISEASE. 



77 



the deaths amounted to 1333 ; or, to state the question more simply, the proportion of deaths 
from scrofula to 1,000,000 living was, in the town districts, 50 per annum, and in the country 
districts, 97. And if, with scrofula, tabes mesenterica be included, the numbers would stand 
as 122 deaths in towns to 160 deaths in the country. Again, let us observe the south-eastern, 
the south midland, and the south-western districts ; there the mortality from scrofula amounted 
to 1 in 12,000, whilst in the densely-packed factory districts of Yorkshire, Lancashire, and 
Cheshire, the mortality from scrofula will be seen to be less than half the preceding mor- 
tality from the same cause, namely, about 1 in 25,000. And suppose we go one step further, 
and compare one portion of the metropolis with another, we find that the total deaths from 
scrofula in the metropolis, when compared with the population, are as 5-6 to 100,000 living, 
whilst in the most densely populated districts, comprising the East and West London Union, 
the Strand, Holborn, or St. Giles, Whitechapel, and Betlinal Green, the proportion is as 5-1 to 
100,000; Bethnal Green being represented by 4-8, and Whitechapel by 4-7 to 100,000 living. 
So in the low, dense, and poor districts of Bethnal Green, Poplar, Stepney, Whitechapel, 
Shoreditch, Westminster, Bermondsey, Rotherhithe, and Lambeth, with a total mortality 
amounting to 21,522, the deaths from scrofula are 45, or 1 in 478; while in the district era- 
bracing Kensington, St. George's, Hanover Square, and St. Marylebone, with a total mortality 
amounting to 14,734, the deaths from scrofula are 30, or 1 in 490. Thus the difference in 
these districts is scarcely appreciable ; but if we compare the western districts of the me- 
tropolis with those of Bethnal Green, Shoreditch, and Whitechapel, we find that the propor- 
tion of deaths from scrofula to the general mortality in the former is as 1 to 490, and in the 
latter to as 1 to 1000. Again, if from considering the influence of localities, we turn to the 
comparative mortality of the sexes, it will be found that 20 per cent, more boys die of scro- 
fula than girls; and yet it must be admitted that girls are more exposed than boys to the 
effects, whatever they may be, of crowded rooms, and exclusion from out-door employ- 
ments." — C] 

I have entered the more fully into the consideration of certain states of the atmos- 
phere, its extremes and its variations of temperature, and its impurity, as causes of 
disease, because there is no part of the course in which I could more conveniently 
introduce them. Most of the other causes of disease, enumerated in my last lec- 
ture, will be discussed in connection with the disorders to which they give birth : 
malaria, for example, when I speak of ague ; contagions, when we come to the 
exanthemata and to continued fever ; epidemic influences, with epidemic distem- 
pers ; improper or insufficient diet, and intemperance generally, with indigestion, 
and the disorders of the alimentary canal ; and so on. There is, however, one re- 
markable predisposing cause of disease, a few observations upon which may serve 
to fill up the little that remains of the present hour. I mean, that disposition to cer- 
tain diseases which is apt to descend from parents to children : hereditary tendencies 
to disease. 

We must distinguish between susceptibility of disease, and a tendency to disease. 
In one sense all persons are born with a predisposition to most forms of disorder. No 
one is protected by nature against inflammation when the causes of inflammation 
come into play. Poisons of various kinds, and specific contagions, which indeed are 
poisons, operate with tolerable uniformity upon all men ahke. 

But there are certain complaints which we may separate in this respect from the 
others : which complaints some persons have a tendency to, and some have not. 
The tendency is sometimes strong and evident, sometimes feeble and faintly marked ; 
sometimes it displa3^s itself in the midst of circumstances the most favourable to 
health, sometimes it requires for its development conditions the most adverse and 
trying. To mention some of these diseases : scrofula, which I soon shall describe 
more particularly, gout, mania, and (I believe [ may add) spasmodic asthma. 

Not only is a disposition to these complaints strikingly pronounced in some per- 
sons, but other persons appear wholly free from such a tendency — nay, even devoid 
of the susceptibility of them. Gout, in those capable of it, may be acquired by 
habits, as it may be repressed and prevented by the opposite habits. The habits 
that, in certain persons, bring it on, are the intemperate use of the luxuries of the 
table, and an indolent or sedentary manner of life : but there are many people in 
whom no amount of rich living or idleness will generate gout. So there are some 
in whom no exposure to impure air, cold, and wet, and no privations — in other 
words, no appliance of the influences calculated to bring the strumous diathesis into 
play — will ever produce any form of scrofula ; will ever render them consumptive, 



78- 



CAUSES OF DISEASE. 



for instance, consumption being one of the most common and fatal shapes of scro- 
fulous disease. There are many who endure the utmost distress and excitement 
of mind, yet never become insane. There are many who never become afflicted 
with asthma, although surrounded by the most powerful exciting causes of that 
complaint. 

Now with respect to these diseases, and perhaps a few others, it is matter of fact 
that they occur much more frequently in persons, some one or more of whose an- 
cestors have suffered from them, than in other persons : the tendency is transmitted, 
i^Mreditary. 

^^lat the circumstances of the parents do influence the physical characters of the 
children, no one can doubt : it is matter of daily observation ; and one of the best 
possible illustrations of the fact is to be found in what are called family-likenesses. 
We see children resembling their father, or their mother ; or both parents at once, as 
mulattoes. 

It has been suggested that the similarity in features and expression, and even in 
moral character, which cannot be denied to exist, may be ascribed to training and 
imitation. But allowing something to that cause, it cannot be all. It was, I re- 
member, a common remark when I was at Cambridge, that the followers and 
admirers of a very good man, the late Mr. Simeon, appeared to come at last to re- 
semble him. So man and vnfe are sometimes fancied to grow like each other. That 
is, the same prevailing cast of thought and feeling, the idem sentire et idem velle, 
may give such an habitual expression and character to the countenance, as shall con- 
stitute, to superficial observers, a likeness. But there are family-hkenesses which 
will not admit of such an explanation as this : similarities in the shape or size, or 
disposition of peculiar features. Every one has heard of, or may remark in por- 
traits, the hereditary thick hp of the imperial house of Austria. Many persons now 
living have had the opportunity of tracing the lineaments of our own royal family 
through at least three generations. The sisters of one of our English dukes are re- 
markably handsome young women, and bear, to this day, a striking resemblance to 
the portraits of their beautiful ancestress, the celebrated Nell Gwyn. And inde- 
pendently of the general cast of features, we trace these family-likenesses in minute 
or unequivocal particulars, as the colour of the hair and eyes, the shape of the limbs, 
the stature of the body, and so on : nay, in more decided peculiarities than these, 
in points of unusual formation. You have heard, probably, of the American calcu- 
lating boy, Zerah Colburn. A great number of individuals of his family, descended 
from a common ancestor, had six fingers and six toes instead of five. The pecu- 
liarity was transmitted through four successive generations ; and probably, could his 
pedigree have been further traced, through many more. I am myself acquainted 
with a gentleman who had the misfortune some years ago to have a bastard child 
laid to his charge. At first he had some misgivings on the subject, and suspected 
that he might have no title to the credit (or I should rather say to the discredit) of 
the imputed paternity ; but all his scruples were satisfied when he found that the 
child had six fingers on each hand, for he had himself possessed two small super- 
numerary fingers, which, had been amputated when he was an infant. Haller gives 
an account of a web-footed family, descended from a mother in whom that configu- 
ration existed. There is now Hving in London a musical composer of some celebrity, 
in whose person nature has played a similar freak ; and whose father, grandfather, 
and great-grandfather, were all web-footed before him. Beyond this point his infor- 
mation does not reach. I am indebted for the knowledge of this instance' to one of 
my former pupils, Mr. Cooper, of Grafton street. 

NoAv there is one very curious circumstance observable in regard to these family- 
likenesses, namely, that they may fail to appear in the child, and yet appear in the 
grandchild ; riiay skip over a generation or two ; may, after lying dormant, break 
out, as it were, in some collateral branch of the family tree. 

This not only proves that certain physical pecuharities may be transmitted, but it 
discloses this remarkable property, that peculiarities no? /(o^sfssec/ by the parent may 
nevertheless be transmitted by him. And this evidently opens a wide field for the 
©peration of hereditary tendencies. A person is not to consider himself as neces- 



SYMPTOMS. 



70^ 



sarily free from a disposition to consumption or gout, because his parents have never 
shown any symptoms of those disorders. 

When one parent only bears the transmissible tendency, the disease appears to be 
most apt to break out in the children who most resemble that parent in their physical 
conformation and appearance. Yet this is a most universal rule. I am acquainted 
with a gentleman who had lost several brothers or sisters by phthisis. The fatal 
disposition is known to exist on his mother's side, Avhile his father's pedigree is be- 
lieved to be quite free from it. All the children that have hitherto become consump- 
tive have resembled the mother in bodily configuration and features, except this 
gentleman, who is like his father's family, but who, nevertheless, labours under un- 
equivocal consumption.* 

■ It becomes a very interesting, and a very important question, whether acquired 
peculiarities can be transmitted. I have been told, by a gentleman attending the 
class, that he knew a man who, having been accidentally deprived of sight, after- 
wards propagated blind children. I beheve, however, such an event to be uncom- 
mon. Dr. Prichard is of opinion that all original or connate bodily peculiarities 
lend to become hereditary, while changes in the organic structure of the individual 
from external causes during life, end with him, and have no obvious influence on his 
progeny. Although this general law is probably true, I doubt whether it be yet 
sufficiently estabhshed by a reference to actual facts. 

I need scarcely say a word respecting the importance to medical men, and indeed 
to all men, of a knowledge of these hereditary dispositions. Such knowledge ought 
to regulate, in some degree, the choice of persons wishing to marry. Where both 
parents have a decided tendency to any complaint, there will be a double probability 
of a diseased offspring. Lawful intermarriages between members of the same 
family are often highly objectionable on the same score. Any inherent defect or 
morbid propensity is aggravated by what cattle-dealers call "breeding in and in." 

Again, if it be known that in any family an hereditary proclivity exists — to gout 
and gravel, for instance, or to consumption — this knowledge ought to warn every 
individual of that family sedulously to avoid the causes which foster and develop 
these diseases ; and medical men, possessed of the requisite information, may give 
most valuable advice and instruction on these points. 



LECTURE VIII. 

Symptoms. Their Uses in relation to the Diagnosis, the Prognosis and the 
Treatment of Diseases. Signs, as distinguished from Symptoms. Pathog^ 
nomomic, Commemorative, Direct and Indirect Symptoms. Examples of Symp- 
toms as they consist of uneasy Sensations, disordered Functions, or changes of 
Sensible Qualities, 

We are perpetually reading and talking about symptoms ; and no wonder, for 
symptoms are the signals by which we learn that disease is present ; the evidence 
upon which our whole art proceeds. We are always, therefore, observing symp- 
toms, analyzing them, striving to interpret their meaning, to ascertain what they 
signify. Without a knowledge of symptoms we can have no knowledge of the art 
of physic. Sagacity in penetrating the import of symptoms constitutes a great part 
of the skill of an able physician. We shall find it useful to take a cursory view of 
semeiology, and to famiharize our thoughts with some of the cardinal symptoms 
themselves, before we speak of them in connection with particular diseases. 

What do we mean by a symptom ? Sujurt^wjua — " Something that happens concur- 
rently with something else." Symptoms, they say, are coincidences, but this is 
merely translating the word cvfiTttu^a into English through the Latin. Symptoms 



* This gentleman, an eminent London physician, has died since this lecture was given. 



80 



SYMPTOMS. 



are sometimes defined to be morbid phenomena — ■" any thing observed in a patient 
out of tlie course of iiealth." But in forming our estimate of disease we must often 
take into account functions that are regular and undisturbed : these have been said 
to furnish negative symptoms. For my own part, if I were called upon to define a 
symptom, I should say, Every thing or circumstance happening in the bod}^ of a 
s^ck person, and capable of being perceived by himself or by others, which can be 
made to assist our judgment concerning the seat or the nature of his disease, its pro- 
bable course and termination, or its proper treatment : every such thing or circum- 
stance is a symptom.''^ 

And I wish you to take notice at once, that it is for the three purposes just adverted 
to, that we cultivate the study of symptoms, viz.: — 

First, To ascertain the seat and the nature of the disease under which our patient 
is labouring : in technical language to form the diagnosis. I am no great friend to 
technical phrases where they can be avoided without inconvenience ; but in some 
cases short temis of art save us a great deal of tiresome periphrasis and circum- 
locution. 

A second object of the study of sj^mptoms is to enable us to foresee and foretell 
the probable course and issue of the disease ; in other words, to frame the prognosis. 

And a third, and pammount use of a knowledge of symptoins, is to direct our 
treatment of the disease. 

I suspect that the immense importance of the first mentioned of these three 
objects — the diagnosis or recognition of disease, is not always clearly seen, either by 
students or practitioners of medicine. Sometimes we are obliged to prescribe for a 
malady, although we are in great uncertainty, perhaps in total ignorance, respecting 
its nature or its situation. But this is always unsatisfactory. On the other hand, 
when we have ascertained where and what the disease is, we apply with much 
more confidence, precision and comfort, those rules for its rehef which we have 
picked up by our own observation, or have been taught by others. This, however, 
is a very limited view of the importance of an exact and true diagnosis. Diagnosis 
forms the indispensable basis of all advances in physic as a practical art. There is 
a common saying, that the knowledge of what a disease is, is half its cure. In one 
sense this may sometimes be true, but in another sense it is not so. Almost all that 
we know concerning the proper treatment of the sick is originally derived from 
observation, not of the nature of diseases, but of the effects of remedies. That 
rhubarb will purge, and opium lull to sleep, and loss of blood occasion faintness, are 
truths which experience alone could suggest, and successive trials alone confirm. 
They are purel}^ empirical truths. No one could guess them beforehand. No skill 
in the discrimination of disease has even a tendency to teach them. In some few 
cases, indeed, we see that certain mechanical derangements exist, which are mani- 
festly capable of mechanical rehef. When parts of the body are displaced, as in 
hernia and dislocations ; or when distension and pressure are evidently produced by 
accumulated fluids ; the mechanical remedies are at once suggested by the physical 
and obvious faults. But with such exceptions, diagnosis does not, of itself, afford us 
any direct information as to the cure of diseases ; but it does this — it defines and 
fixes the objects about which observation is to be exercised, and experience collected. 
When we can once identify a given diseased condition, we obtain the privilege of 
watching the behaviour of that diseased condition, again and again, under the opera- 
tion of therapeutic measures ; and from that time the increase of our knowledge 
concerning the appropriate management of that particular disease becomes progressive 
and sure. The term experience is obviously misapplied, and the results of all 
observation are vitiated, when any doubt exists about the sameness of the objects 
contemplated. It is mainly to this imperfection in the diagnostic part of medicine 
that we must attribute the uncertainty and variation, both of doctrine and practice, 
which have brought so much suspicion, and reproach, and ridicule upon the sciencq 
we profess. False experience, if I may use such a term, has greatly hindered the 
progress of the heahng art ; and false experience springs from false diagnosis. A 
man will tell you that he has cured a score of cases of advanced phthisis ; but he 
has deceived himself : they were not cases of true phthisis, but simply cases of 



* 



SYMPTOMS. 81 

chronic inflammation, with puriform discharge of the mucous membrane of the 
bronchi. He pubJishes an account of his success, and of his plan of treatment ; and \ 
thus he deceives others also : and thus he retards the science wiiich he fondly and 
conscientiously believes he is promoting. Accuracy of diagnosis, then, cannot be 
too highly estimated, nor too diligently sought after. It has been wonderfully im- 
proved within the last twenty years. 

The prognosis, or foreknowledge of the course and event of diseases, has but 
little connection with the promotion of the art of heahng ; but it is not on that 
account less worthy of our attention. Both physician and patient find their advan- 
tage in the capability of the former to determine whether a disease be remediable — 
to foresee the changes that may be expected in its progress — to predict the manner 
in which it will terminate. Knowledge of this kind opens to us a fair and honour- 
able source of credit and reputation ; and it begets a degree of confidence towards 
us, which is beneficial, not merely to ourselves, but to our clients. Our influence 
over a sick person, and the efficacy of many of our remedial measures, are remark- 
ably increased by the reliance he places on our skill, and by our apparent acquaint- 
ance with the nature of his complaint. It is often of material consequence, in another 
point of view, that the fatal character of a disease should be plainly perceived. A 
sick man, made aware of his danger, is furnished with a motive and an opportunity 
for arranging his worldly affairs, in the settlement of which the future comfort and 
happiness of his family may be very deeply concerned; for making his will; and 
also for more solemn preparation for the awful change that awaits him. For these 
reasons medical men have, in all periods, endeavoured to read, in the phenomena 
presented to them by diseases, the event to which those diseases severally tend. To 
form an accurate opinion on this head is, however, one thing — to divulge it, ano- 
ther. There is always some risk of losing, instead of gaining credit, by strong state- 
ments, and confident predictions of the death or the recovery of a patient. If you 
give an unfavourable prognosis, you have a good chance of losing your patient alto- 
gether ; his friends argue very naturally, that you are not infallible, that you may be 
wrong, that you know of no means of safety for him, some other practitioner may, 
and they will grasp at whatever straw comes near them. Do not suppose that this ' 
is merely a selfish view of the matter : it is often of much moment to the patient 
himself, that he should not be tempted to put his life under the charge of impostors, 
who will feed his hopes, and promise largely, and torture him perhaps with their 
discipline, and have no mercy upon his pocket. Many an instance have I known 
of persons dying of consumption, who, when given over by their regular attendants, 
have been brought to London at considerable expense, exchanging the many com- 
forts of home for the inconveniences of a hired lodging, that they might be cured 
by that ignorant and cruel and rapacious quack, Mr. St. John Long. There are 
other reasons, too, why we must sometimes conceal the. truth from our patients. It 
often happens that a person is extremely ill, and in great danger, but may yet reco- 
ver if he is not informed of his peril. To agitate a person in these circumstances 
by telling him he is likely to die, is to lessen, perhaps to destroy, his chance of 
recovery. You kill him if you take away his hope of living. It must be confessed 
that the duty of the medical man in these cases is very painful and embarrassing : 
the patient and the patient's friends are urgently inquisitive to know whether there 
is any danger ; or whether he is not yet out of danger. The rule which I have 
always adopted in circumstances of this kind, when 1 see clearly that the case is 
hopeless of cure, is to fix as well as I can upon that person among the family or 
friends of the patient to whose prudence the real state of the maUer may be the 
most safely confided. If I think that there is a possible chance of recovery, and 
that a knowledge of his danger by the patient would diminish that chance, of course 
I urge the necessity of s})eaking to him with assumed cheerfulness and confidence ; 
if I see that the case is absolutely and inevitably mortal, either soon or at some little 
distance of time, I leave it to the discretion of the person with whom I communicate 
to disclose or conceal my opinion as he or she may think best. There are, I believe, 
practitioners, who make it a point, on principles of worldly pohcy, never to speak 
6 



82 



SYMPTOMS. 



despairinglj^ of a patient ; but I cannot regard such a rule of conduct as honest, or 
justifiable, or consistent with one's Christian duty. 

Now I, would have you observe that symptoms do not serve equally or indiffer- 
ently the three several purposes that I have spoken of. The same symptom or set 
of symptoms may indeed at once reveal the nature of the disease, and foreshoAv its 
result, and indicate its treatment. When we have discovered what the disease is, 
we may want no further information to tell us how it will terminate, or how we are 
to prescribe for it. A man previously sound and well, shivers, then becomes hot, 
and afterwards sweats, and then reverts to his natural state of comfort and good 
health : and the same series of phenomena recur every other day. We pronounce 
the disease to be a^ue ; we predict that, in this chmate at least, the patient will 
recover; and we give him quinia ; all upon the strength of the same set of symp- 
toms. But this is not necessarily the case : certain symptoms may disclose to us what 
the malady is, and where it is situated ; other symptoms teach us whether our patient 
is hkely to survive or not ; and a still different set instruct us what is the proper 
method of cure to be attempted. We see a number of httle pustules scattered over 
his skin, and we know that our patient is labouring under small-pox. His chance 
of recovery will be singularly different, according as the spots upon his face run 
together, or remain separate and distinct from each other; and we investigate the 
state of his pulse, and his breathing, of his bowels and his brain, before we can ven- 
ture to prescribe for him. Those symptoms, or combinations of symptoms, which 
disclose the place and nature of the disease, we call signs of disease ; those which 
teach us what to do, M-e call indications of treatment. We speak also of prognos- 
tic signs. By keeping these distinct ends of the study of symptoms in mind, Ave 
shall be enabled to group them to advantage, and to avoid huddling confusedly 
together symptoms that speak, not indeed a different language, but upon a different 
topic. The ancients, who knew but little of the intimate nature of diseases, but 
■who paid great attention to symptoms, have laid down most admirable rules in 
respect to prognosis : which shows not only that the prognostic signs are more 
easily made out, in man)^ cases, than the diagnostic, but also that they may be inde- 
pendent of them. 

1 have just spoken of symptoms as being signs. These words are not, however, 
exactly synonymous, although they are frequently employed as if they were so. 
Even those medical writers who admit a distinction between them, have not always 
succeeded in clearly pointing out the difference. Signs are deduced from symptoms, 
by arranging and comparing them, and noticing the circumstances under which they 
occur. Symptoms are obvious to all persons alike — to the nurse as well as to the 
physician : signs, for the most part, are such to medical eyes alone. Let me try to 
make this plainer by the help of an illustration. Symptoms may be considered as 
resembling so many words. When taken separately, or when put together at ran- 
dom, the words have no force or signification. Arrange them in due order, reduce 
them into a sentence, and they convey a meaning. The sentence is a sign or 
expression of something which is thus revealed. Symptoms become signs when 
their import can be interpreted. 

A certain craclding sound, of which T shall have much to say hereafter, is heard 
(we will suppose) in some part of a patient's lung, by the ear applied outside his 
thorax. The sound is a symptom ; any one Avho hstens may perceive it. It is 
even so far a sign that it denotes the unnatural presence of a hquid in the lung, and 
the passage of air through that liquid. But the hquid maybe one of several — 
mucus, or serum, or pus, or blood : we cannot tell by the sound alone which of 
these it is. But if we learn that the person in whose lung the sound is audible has 
been ill for a day or two only, that he has pain in his chest, cough, embarrassed 
breathing, and fever, we conclude that he is labouring under that serious disease, 
inflammation of the lung. The crackhng sound alone could not assure us of this ; 
nor without the addition of this sound could the pain, the laboured breathing, the 
cough, or the fever. Taken collectively, the symptoms constitute a diagnostic sign, 
and bespeak the existence of pneumonia. 

, Sometimes a symptom, or set of symptoms, becomes a sign, by its relation to what 



SYMPTOMS. 



83 



has gone before and what follows it. To adhere to our illustration, the meaning 
becomes evident from the context. By comparing, at short intervals, in the sup- 
posed case of pneumonia, the extent and character of the sounds heard during respi- 
ration, we ascertain whether the disease be advancing or receding ; and thus con- 
vert the sounds, or their variations from day to day, into ^prognostic sign. 

We always strive, then, to penetrate beyond the symptoms to the disease of which 
they are significant. But we do not always succeed in this, and when we do not 
(as in the case of ague), we are driven to the necessity of regarding the combina- 
tion of symptoms as the disease. 

You will often hear of pathognomonic symptoms. A pathognomonic symptom 
is one which, when it occurs, settles infallibly the nature of the malady ; becomes a 
positive sign or token of a particular morbid condition. But there are very few 
symptoms, if there be any, which, taken singly, can ever be said to be strictly pa- 
thognomonic signs ; yet a symptom which in itself possesses little or no value may 
become very significant when conjoined with others. 

Much hght is often thrown upon symptoms by what the French caR commemo- 
rative circumstances — that is, by a knowledge of the previous history and condition 
of the patient. For example, a person may have palpitation and other marks of dis- 
ordered action of the heart, and doubts may exist whether these symptoms depend 
or not upon organic disease of that organ. The question is often determined in the 
affirmative, by our learning that the patient has had one or more attacks of acute 
rheumatism of the joints. 

There are some other general division of symptoms, which it is useful to attend 
to. Thus some symptoms are said to be direct, and others to be indirect symptoms. 
Direct symptoms relate to the very part which is affected ; indirect symptoms are 
such as " declare themselves through the medium of some other parts, or through 
the medium of the constitution at large." There are some cases in which the direct 
symptoms are of much more value than the indirect ; and there are other cases in 
which those which are indirect are the most important ; and there are yet many 
more which require for their elucidation a knowledge of both the direct and the 
indirect symptoms. 

Again, there are many symptoms of which we receive no information, except 
through the statements made by the patient himself ; and there are many others of 
which we learn the existence by means of our own observation, by the exercise of 
our several senses. The relative importance of these varies too in different cases. 
Of course those symptoms which we are able to ascertain for ourselves are the most 
trustworthy ; but both sorts of symptoms shed mutual hght upon each other. We 
should constantly be making mistakes if we rehed solely upon what our patients tell 
us. On the other hand, the value of the information we derive from their state- 
ments is made apparent by the difficulty we are apt to experience in investigating 
the diseases of children ; of those who are dumb ; or, what is much the same thing, 
who speak no language that we understand. 

Now, setting aside that notice of the healthy functions which is sometimes neces- 
sary in order to determine the relative value and meaning of other symptoms, and 
regarding those symptoms only which consist of morbid changes, they may all be 
classed under three heads: 1. Uneasy, unnatural, or impaired sensations: 2. Dis- 
ordered or impeded fund ions : and 3. Alterations of structure or of appearance; 
changes of sensible qualities. When these last come within the direct cognizance 
01 our senses, they are called, usually, physical signs. 

Uneasy or altered sensations we can only be aware of through the testimony of 
the patients themselves. The symptoms belonging to the other classes fail, gene- 
rally, under our own notice. 

Uneasy or altered sensations comprehend a large class of morbid symptoms. By 
their occurrence persons sometimes become conscious that they are unwell before 
any other symptoms are observable. Of all the uneasy sensations pain is the most 
common and the most important. It rarely happens that it is not felt, at one period 
or another, in inflammatory disorders ; and it very often occurs, and is very acute 
too, when there is no inflammation at ail. I shall have occasion, in a subsequent 



84 



SYMPTOMS. 



lecture, to lay before you the criteria between pains that accompany inflammation, 
and pains that are independent of it. Upon that point of distinction the whole ques- 
tion of treatment commonly depends ; and it is often a most difficult point to de- 
termine. 

There are many different kinds and degrees of pain. Different kinds of morbid 
action are accompanied hj different kinds of pain ; and the same kind of morbid 
action — inflammation, for example — produces different modifications of pain, accord- 
ing as it affects different parts. The pain that belongs to inflammation of the lungs 
differs from that which is felt in inflammation of the bowels. Bones, muscles, ten- 
dons, ligaments — the bladder, the kidney, the uterus — all modify, in a manner pecu- 
liar to themselves, the pain that is produced in them by injury or disease. Difl^er- 
ent epithets are given to the different varieties of pain — i. e., persons endeavour to 
explain how they feel by likening their sensations to something which they have 
felt before, or fancy they have felt. Thus we hear of sharp pain — shooting pain — 
dull pain — gnaiving pain — burning pain — tearing pain ; and so on. 

If pain be felt in a part only when it is touched, i. e., when pressure is made 
upon it, the heightened sensibility is called tenderness : — the part is said to be ten- 
der. This is a very important kind of pain, as we shall see hereafter. A part may 
be both painful and tender : or painful without being tender : or tender without 
being otherwise painful. 

Pain often takes place, not in the part really affected by disease, but in some dis- 
tant part. Inflammation of the liver or diaphragm will cause pain of the right 
shoulder : the mechanical irritation of a stone in the bladder produces pain at the 
extremity of the urethra : inflammation of the hip-joint occasions pain in the knee : 
disease of the heart is often attended with pain running down the left arm : many 
headaches result from irritation of the stomach. We call these instances of indirect 
or sympathetic pain. Some of them admit of no very obvious explanation : — others 
have been ascribed to connections between the sentient nerves of the two parts ; 
" especially when the part really injured is internal, and that to which the feeling is 
referred is external, and both derive their sentient nerves from the same larger 
branches." You will perceive that a due estimation of these sympathetic pains is 
of no small importance. 

I may observe of pain in general, that it is differently felt — or at any rate differ- 
ently complained of — b}^ persons of different constitutions and temperaments. There 
are even, I fancy, national differences in this respect. I have been present, as you 
may believe, at a great number of surgical operations, and I have been struck with 
the different degrees of patience with which the same operation has been borne by 
Irishmen and by Scotchmen. The Irishman, generally speaking, either feels more 
acutely, or gives more free vent to his feelings in cries and exclam-ations : the Scotch- 
man, on the contrary, most commonly preserves a resolute silence. In complaints 
that are attended with low spirits, and hypochondriacal symptoms, there is reason 
to beheve that the pain spoken of often depends, in a great degree, upon the eager 
attention that is paid to it. The accounts given by such patients of their sufferings 
are always to be received Avith a grain of allowance ; and this is often an embar- 
rassing circumstance in practice. Patients take it ill if they do not seem to be im- 
phcitly credited ; and yet if they are not convinced that much of what they suffer 
depends on their great attention to it, they will never get well. You will often find 
that they cease to feel pain — i. e., they forget to attend to their complaints — when 
their attention is otherwise strongly arrested ; as by conversation, or music. I ad- 
verted to this principle in my last lecture. 

Besides pain, in all its modifications, there are many other, and very interesting, 
uneasy sensations. Itching is an uneas}^ sensation nearly aUied to pain. As severe 
mechanical irritation will cause pain, so a slighter degree of it will cause itching. 
Itching occurs in many cutaneous diseases, and it gives a name to one of them, 
whicn is emphatically called the itch. And the Latin word signifying the same 
sensation, prurigo, is made use of to denote other forms of disease of which itching 
is the most prominent symptom. It often affects some one of the natural outlets of 
the body. It occurs about the rectum, from the motions of little worms that nestle 



UNEASY SENSATIONS. 



85 



in the lower part of that gut. This prurigo podicis, which does not always depend 
on the cause just mentioned — and the prurigo pudeodi in the female — are sometimes 
most distressing complaints ; harassing the patients continually, preventing sleep, 
excluding them from societ}?-, and requiring medical treatment. Acrid matters in 
the intestines will sometimes produce a kind of itching there ; and the call to void 
the fgeces is perhaps more akin to itching than to any other sensation : sometimes, 
indeed, it amounts to pain. The tickling often felt in the windpipe, and provoking 
the person to cough, appears to be of the same nature. Tingling and pricking are 
sensations v^^hich have also some analogy with itching. 

Nausea is another uneasy sensation. It is sometimes a direct symptom of disease 
or disorder of the stomach, to which the sensation is referred. Sometimes it is a 
very important indirect symptom, taken in conjunction with others, of disease in 
some part at a distance from the stomach — in the kidney, for example, or in the 
brain. The nausea which is so troublesome to pregnant women is another instance 
of a morbid sensation sympathetic of irritation in a distant organ. 

Another example of an uneasy sensation we have in giddiness, or dizziness — 
technically, vertigo. It sometimes results from disease within the head ; sometimes 
it is an indirect consequence of disorder of the stomach ; or of mere debility and an 
approach to syncope. 

Patients will also complain of an undefinable sensation which they usually call 
sinking — a sensation which is referred to the epigastric region. This is frequently 
a source of much distress to hysterical women ; and it is occasionally the forerunner 
of death at the close of severe diseases which have a tendency to end fatally in the 
way of syncope. 

Many other symptoms might be mentioned which belong to this class of uneasy 
sensations, and for our knowledge of the existence of which we must depend upon 
the accounts given us by the patients themselves. Sensations of weight ; and of 
tightness and fullness ; drowsiness, tenesmus, strangury, heartburn ; and various 
depraved conditions of the special senses. In the majority of diseases the appetite 
is lost or impaired ; but sometimes excessive hunger accompanies and denotes 
disease. We sometimes derive the first suspicion of the existence of diabetes from 
the preternatural keenness of the appetite. Thirst is a very constant and striking 
symptom in all febrile and inflammatory disorders ; and in the disease just now 
mentioned, diabetes, it frequently constitutes the whole distress of which the patient 
is sensible. The appetite may be perverted, as well as deficient or excessive. 
Chlorotic girls will eat cinders, sealing-wax, slate-pencil, and such trash. So women 
who are pregnant either have or pretend to have inordinate longings for particular 
kinds of food— -longings which are evidently fostered by encouragement. They are 
not, I beheve, common at present in this country ; and they are less frequently heard 
of among the poor, who have not the means of gratifying them, than in the higher 
classes of society. 

The class of uneasy sensations you see then is a very large one, and some of the 
morbid feelings are of very great moment. However, there are not many diseases 
which consist altogether of uneasy sensations ; and when we find that pain or 
uneasiness is complained of in any part or organ, we next proceed to inquire whether i 
the functions of that part or organ are disturbed or suspended. If we discover any 
interruption or derangement of function, we have additional reason for concluding 
that the part so afi^ected in its sensations and in its functions is actually the seat of 
disease. This is an inquiry which we can prosecute with much less assistance from 
the patient himself ; and mostly with no assistance at all ; and even in spite of any 
erroneous opinions which he may have formed, and is anxious to state upon the 
subject. The study of disordered functions is of great practical value. 

The functions of the brain and nerves — of the heart and blood-vessels— -of the 
respiratory apparatus — and of the digestive organs — are all of vital consequence. 

Some of the impeded or disordered functions which relate to the brain and nerves 
are in fact identical with the last class of symptoms, and consist of altered or morbid 
sensations : sensation being one of the natural functions of those parts. Deprava- 
tions, for instance, of the sense of touch ; numbness ; the total absence of sensation, 

H 



86 



SYMPTOMS. 



which we call ansesthesia. Symptoms of this kind do not constitute primary diseases 
but they often portend or accompany very serious alterations in the brain, or in some 
part of the nervous system : and it is from that circumstance that they derive the 
great interest and importance which belong to them. The same may be said of; 
perverted conditions of the other senses. The sense of vision is often impaired, and 
in various ways and degrees, from mere dimness or imperfection of sights to total 
blindness. And this total blindness may occur without any other appareyit disease, 
the humours and fabric of the eye itself being in all evident respects healthy and 
right ; it may come on, too, so gradually, and increase so slowly, as not to be disco- 
vered for a long time, even by the patient himself. Mr. Day, the great blacking man, 
of the firm of Day and Martin, who died not long since, was almost entirely bhnd. 
He told me he first discovered that the sight of one eye was gone, one day when he 
attempted to look at a distant object through a telescope. He could see nothing, and 
he imagined that the httle brass plate which shdes over the eye-glass had not been 
withdrawn. There was, however, no such obstacle ; and he too soon found that 
when the other eye alone was closed, he was in total darkness. This slate of blind- 
ness is called amaurosis, and it may depend upon pressure made upon the retina, or 
upon the optic nerves, or upon the brain at the origin of those nerves. There are 
other causes also, to be mentioned hereafter, of amaurosis. Its approach is some- 
times marked by the fallacious appearance of black spots upon the objects the patient 
is looking at, or floating before him in the mr—muscse voUtantes. Some of the 
other depravations of sight are still more extraordinary, and except that they are not 
uncommon, might almost be considered fabulous. Thus persons sometimes see things 
around them apparently in motion, when in truth they are not so. This is, in fact, 
a symptom I have mentioned before — vertigo. If the patient shuts his eyes, and 
consequently can see nothing, he feels as if he were himself turning round, while 
in reality he is at rest. Persons in this state fancy sometimes that the bed on which 
they lie is sinking rapidly down with them into some abyss. A still stranger depra- 
vation of the sense of vision is that in which a person sees only one half of an 
object at which he is steadfastly looking. One man, in passing along the street, 
imagined that every body he met had only one eye. The late Dr. Wollaston was 
subject to this optical delusion : he frequently found that only one half of the object 
he looked at was visible : and he wrote ail ingenious paper in the Philosophical 
Transactions to explain this. After his death a tumour was found in his brain, 
interfering with the optic nerves. The celebrated Mr. Abernethy had once a tem- 
porary affection of the same kind, dependent no doubt upon some shght and transient 
injury of the brain. He was thrown, I beheve, from his horse — at any rate he 
received a violent blow on his head, which stunned him ; and when he had recovered 
a little, he was taken home in a hackney-coach. On his way he amused himself 
with reading the names of the tradespeople placed in front of the shops, and he was 
greatly surprised to find that one half of each name — the last half — seemed blotted 
out. He describes this in his lectures, in his whimsical way, by taking his own 
name as an example : " I could see as far as the ne (said he), but I could not see a 
bit of the %." 

Those very wonderful cases of spectral illusion which sometimes occur, come 
within the class of symptoms we are now" considering ; they throw a strong light 
upon many of the well-authenticated ghost-stories — which were in fact merely 
instances of disease or derangement in the brains of the ghost-seers. It would be 
out of place to go into any detail upon this interesting subject here. You will find 
some excellent examples of these spectral illusions in Dr. Hibbert's book on Appari' 
Hons, in Sir David Brewster's Natural Magic, and in Sir Walter Scott's Letters on 
Bemonology. 

The sense of hearing is liable to analogous disorders. Sometimes it becomes pre- • 
ternaturally acute ; and this is a bad symptom when it does occur. I was called, a 
year or two ago, to see a gentleman in the Temple ; he had been taken ill only a 
few hours before, but I found him dying ; the pulse was gone from his wrist, and 
his skin was cold, but his intellect was entire, and he complained of nothing but the 
distress he felt from the loud noises that were made by those around him, in moving 



DISORDERED FUNCTIONS. 



87 



about and in speaking, although, in fact, all noise was as much as possible suppressed, 
and conversation was carried on in whispers : but his hearing was painfully acute. 
He died the same evening ; I beheve of an irregular form of cholera. It is always 
right that patients should be protected from the irritation which might arise from this 
source ; for that degree of noise which would not interfere with the sleep of a healthy 
person will often not only prevent it in a sick man, but bring on delirium, and aggra- 
vate greatly the disease under which he labours. The custom of strewing the streets 
with straw before the houses of those who are seriously ill, is, in many cases, a very 
proper precautionary measure. 

The opposite fault, obtuseness of hearing, is much more common. Deafness is 
frequently attributable to some physical imperfection in the organ of hearing. But 
it is with cases in which it has a deeper origin, that the physician is chiefly con- 
cerned. It often occurs in fever, and is not then thought a bad symptom : it cer- 
tainly is a much less unfavourable circumstance than morbid acuteness of hearing ; 
and it probably depends upon a disordered state of the brain, which is not in itself 
very dangerous. 

What is called tinnitus aurium, is an instance of the depravation of the sense of 
hearing. It seems sometimes to result from the too strong throbbing of the arteries. 
It occurs in many disorders, and is not unfrequently a symptom of diseased cerebral 
vessels, and a precursor of apoplexy or palsy. It is sometimes in itself extremely 
annoying. Curious and undefinable sounds are heard by some patients — -sounds 
like a rushing wind, like the falHng of a cataract, the ringing of a bell, or the beat 
of a drum. A female patient of mine, in the Middlesex Hospital, last year, who had 
disease of the bones of the ear, with symptoms that threatened some implication of 
the brain, afSrmed that she heard a perpetual noise in her ear hke the singing of a 
tea-kettle. I have lately been consulted by a gentleman from the country, who had 
no other complaint than a constant hissing, which worried him greatly, in one ear. 
Another had watched with curious anxiety, and described to me very graphically, 
the successive variations which this troublesome symptom underwent in his own 
person. It began suddenly, with some headache, and had lasted six weeks. At 
first it v.'as a loud roaring, like that of the sea ; in a few days it came to resemble 
exactly the whisthng of the wind among the trees in winter ; afterwards he could 
have believed that the room was filled v^^ith humming gnats ; and finally the noise 
settled down into the gentle sound of a distant waterfall, it haunted him incessantly. 
Sir David Brewster relates the case of a lady, subject to spectral illusions, whose ear 
was mocked by unreal sounds, as her eye by unreal visions. Being in her right 
mind, and perfectly aware of the infidehty of her senses, she repeatedly heard, not 
vague noises merely, but voices and sentences, when none were uttered. 

Affections of the intellect — of what are sometimes called the internal senses, are 
very common and very important symptoms of disease. Incoherence of the trains 
of thought — palpably false belief — extravagant perversions of the judgment. These 
affections are sometimes considered as primary diseases themselves ; they very fre- 
quently accompany certain febrile diseases ; and they are not uncommon in diseases 
that are unattended with fever. There is more or less derangement of the internal 
senses from the very beginning of continued fever. The power of attention is im- 
paired. That kind and degree of mental exertion which would afford gratification 
and amusement when we are well, become laborious and irksome when we are ill ; 
and to compel, or to urge the attention, under such circumstances, is injurious. 
This state is probably only the first degree of delirium, and therefore these shght 
approaches to derangement of the internal senses are by no means to be disregarded 
It is curious that the delirium of fever is always most marked during the night ; thia 
seems to be owing to the circumstance that the erroneous notions and wandering 
thoughts of the patient are not corrected by impressions made upon his external 
senses. You will find, conformably with the same principle, that your patient 
sometimes ceases to be delirious upon your visiting him : the sight of a new face 
rouses him for a time, but he soon relapses. 

Voluntary motion is another function connected with the nervous system, and one 
which affords a great variety of important symptoms. Like the power of the §eqsei5, 



88 



SYMPTOMS. 



it may be excessive, or deficient, or perverted. Excess of voluntary motion is not 
con:imon, nor very important. Maniacal patients sometimes exhibit an extraordinary 
degree of muscular strength ; indeed, in the delirium of fever something of the same 
kind may be observed. 

But the opposite state, that in which the power of voluntary motion is deficient, 
muscular debility is exceedingly common. Debihty is an original and essential 
part of fevers. It appears before there has been time for it to be produced by the 
exhaustion of disease. It is not always proportional to the other symptoms, and 
does not necessarily imp]y any great degree of danger. This sudden and early 
weakness has been a very striking symptom in our two recent visitations of influ- 
enza. Persons previously in apparent good health would be seized as they walked 
along the street, and be glad to sit down in a shop, or a carriage, and to get home 
and go to bed. Young and strong persons would be thus rapidly prostrated. 

In some instances debility does not appear till late in the disease, of which it then 
forms an important prognostic symptom, and an important guide for our treatment. 
It shows us that there is a tendency to death by asthenia, and we have to endeavour 
to keep the patient ahve by supporting his strength as well as we can, this being the 
chief or the only indication. 

Debihty is occasionally the principal symptom of the whole disease — as in hemi- 
plegia, paraplegia, or in more partial palsy, palsy of one limb, even of a finger, or of 
a single muscle, as of the levator palpebrarum. This, though it may seem trivial in 
itself, is far from being so in reahty ; it often forms a fragment only of a most serious 
disease. From such partial manifestations of palsy we presage a more general and 
alarming attack ; as the loosening of a few stones in the wall announces the com- 
mencing earthquake. A shght degree of paralysis, affecting some of the muscles of 
the eye, will produce a squint, and consequent double vision ; and this occurs not 
only in hydrocephalus, when it is a most significant phenomenon, but also as a pre- 
lude to more extensive palsy. General palsy is sometimes prefaced by a similar 
affection of the tongue, producing a faltering and indistinctness of speech. 

Spasm is an instance of disturbance and perversion of the power of voluntary 
motion. It consists in an irregular and violent contraction of muscular parts — 
involuntary, even when the voluntary muscles are concerned. Cramp is a famihar 
example of it ; and we have been taught, since the cholera came among us, to regard 
cramp as sometimes a very formidable symptom : not formidable in itself, but 
formidable in respect to the condition that gives rise to it. Tonic spasm is the prin- 
cipal symptom, also, of that frightful disease — frightful in its phenomena and in its 
frequent fatality — tetanus. • The convulsions of epilepsy and hysteria, and the 
jactitation of chorea, are ordinary examples of the perversion of the function of 
voluntary motion. Sometimes convulsions bode great danger, sometimes none at all. 

So, also, tremoVy which is near akin to spasm, is a sign, frequently, of a morbid 
state of the greatest peril ; while it is sometimes violent without being attended with 
the smallest hazard. 

If we now turn to the greatest function of respiration, we shall find that it affords 
a very large number of morbid symptoms, and those of the highest importance. 

Dyspnoea, difficulty of respiration, is one of the most prominent of those symp- 
toms. It may depend upon various causes. In inflammation of the lungs or pleurse, 
there are several circumstances in operation to impede the breathing; for example, 
pain, which would be enough of itself ; the effusion of lymph into the texture of the 
lung, or of serum into the cavity of the pleurse, mechanically resisting the entrance 
of air. In dyspnoea the breathing is almost always most difficult when the patient 
is lying flat on his back. One reason for this is plain. In the supine horizontal 
posture the action of the diaphragm is obstructed by the weight and pressure of the 
viscera ; and the erect position obviates this. Upright breathing, orthopncea, has 
come to be considered as a distinct modification of dyspncea. The patient cannot lie 
down. 

Sometimes, as in asthma, the difScuky of breathing comes on in separate parox- 
ysms ; the respiration becomes all at once noisy, wheezing, and laborious. A 
person who had never seen any cases of this kind would imagine that the patient 



DISORDERED FUNCTIONS. 



89 



was at the point of death — that it was all over with him ; but the most frightful of 
these attacks are seldom attended with any immediate danger. They depend 
frequently upon organic disease of the lungs, heart, or aorta; sometimes they seem 
to be purely spasmodic ; sometimes to result from transient congestion of blood in 
the lungs. 

Cough is a violent spasmodic action. A full inspiration is taken ; then the glottis 
is closed pretty firmly; and in expiration the air is forced suddenly out, and with 
it, frequently, mucous or other matters which had irritated the air-passages. It seems 
to be one of the efforts of nature to expel from the lungs things which ought not to 
be there. There are several varieties of cough. It is a symptom belonging to so 
many dangerous complaints — pneumonia, pulmonary consumption, and diseases of 
the heart — that it always demands strict attention. No one who has once heard it 
can ever mistake the hooping cough. There is also a startling obstreperous sort of 
cough, shattering one's ears almost, like the noise of a person coughing through a 
brass trumpet — which depends upon some pecuhar state of the nervous system, > 
implies no danger, and is more distressing to the bystanders than to the person who 
utters it. I beheve you may often distinguish the cough of inflammation of the 
lungs from that of phthisis, and each from the cough of hysteria, by their respective 
sounds : but we have much better methods of distinguishing them — viz., by the 
concurrence or the absence of certain other sounds belonging to the breathing, and 
ascertained by auscultation. 

Sneezing is another morbid symptom, which, though it may appear trifling, is not 
to be overlooked. It is a very common symptom in catarrhal affections. When 
sneezing occurs in combination with cough, it affords a presumption that the 
cough is not phthisical. Sneezing may even happen as a primary disorder, occur- 
ring in long-continued paroxysms. I have at present under my care a young 
lady of an hysterical disposition, whose main distress consists in violent and pro- 
tracted attacks of sternutation, which have harassed her almost daily for many 
months. One of our bishops is subject to very inconvenient fits of this kind. He 
will begin to sneeze and go on sneezing incessantly for a long time together. I 
believe that he finds an effectual remedy for these attacks in plunging his head into 
cold water. 

I say nothing here of those direct symptoms of pulmonary disease which are 
ascertained by the sense of hearing — by auscultation and percussion. I shall 
enter fully into that subject hereafter. A systematic account of symptoms, if this 
were the fitting place for it, which it is not, would require a dozen or twenty lec- 
tures. In order to perceive the relation of symptoms, taken one by one or in diverse 
combinations, to the various known forms of disease, you. must have some prior 
knov/ledge of diseases. But I am obhged to suppose (however incorrect the 
supposition may be in respect to some among you), that you are mere beginners, 
and have still to learn even the rudiments of such knowledge. Different dis- 
eases may have many symptoms in common. The same symptom may bear a 
very different import according as it is combined with other symptoms ; or con- 
nected with this or that disorder. The proper place for a comprehensive and 
complete review of symptoms would, therefore, be at the end of a course of lec- 
tures on the practice of physic. When the various forms of disease had been 
gone through, in reference to the symptoms belonging to them, then would be the 
time to take the converse aspect of the case, and to consider the long fist of symp- 
toms in reference to the diseases they denote or accompany. All that I am at 
present attempting, is to give you some general notion of what symptoms are ; to 
put before you, as samples, a few of the most prominent; and to show you, even 
by this cursory and imperfect view of them, of how great importance it is that we 
should make their relations to each other and to different diseases, and their sig- 
nification, diagnostic, prognostic, and therapeutic, the objects of our most dihgent 
attention. 

I might find matter for two or three lectures, if my present purpose would admit 
of them, in the symptoms that are drawn from the functions belonging to the a'r- 
culation. Everybody knows how much importance is attributed to the state of the 

h2 



90 



SYMPTOMS. 



arterial pulse. It is expected of us, as a matter of course, that before we think of 
prescribing for a patient we should at any rate feel his pulse. And really the in- 
formation obtained by that httle touch of the wrist is often of the most interesting and 
iustructive kind. But it requires practice and intelligence to appreciate that infor- 
mation. The qualities that we most attend to in the pulse are its frequency, its 
regularity, iis fulness, and its force. It is necessary that we should know the number 
of beats which the heart habitually makes in heakh ; for it varies much in different 
persons. Its average number of pulsations in a healthy adult is from TO to 75 ; but 
there are persons who, when they are quite well, have always a pulse of 80 or 90 ; 
and there are others in whom the pulse seldom rises above 60. In early life the 
pulse is more frequent, in old age it is more slow, than the standard I have given. 
Cxteris paribus, its beats are more numerous in the standing than in the sitting pos- 
ture ; in the sitting than in the recumbent. If we do not inform ourselves of these 
peculiarities, we may fall into great mistakes. In disease the pulse may acquire a 
degree of frequency which is scarcely calculable ; and the less so because, when, 
it is extremely frequent, it is also extremely feeble ; it will reach 150, 160, or 
even 200 beats in a minute. In other cases, — as in apoplexy sometimes, and in 
some organic affections of the heart — the pulse will become extremely slow. The 
slowest pulse I ever felt was that of a man sixty-eight years old, who was for some 
time a patient of mine, with diseased heart and dropsy. His pulse was often no more 
than 25 in the minute. He died suddenly in his chair, and I was very desirous of 
examining his body, but his widow would not allow it. In the 17th volume of Dun- 
can's Medical Commentaries a case is related in which the pulse was as slow as 
nine beats in the minute. We learn a good deal in certain disorders from the vari- 
ations and fluctuations of the pulse in respect to frequency — in hydrocephalus, for 
example, and in continued fever. 

Irregularity of the pulse is another condition which is often full of meaning, and 
of interest. 1 hope, as the lectures proceed, to be able to point out the bearings of 
these several qualities of the pulse upon our views of disease, and especially upon 
its treatment. At present I must repeat that I pretend to do no more than furnish 
you with a few samples of the phenomena that characterize disease. Irregularity 
of the pulse is natural to some persons. I have a brother who enjoys very good 
health, and whose pulse is habitually irregular ; I have been told that when he was 
ill with a fever at school, it became regular. I have heard of several precisely similar 
cases. There are two varieties of irregular pulse — in one the motions of the artery 
are unequal in number and force, a few beats being from time to time more rapid 
and feeble than the rest : in the other variety a pulsation is from time to time entirely 
left out—the pulse is said to intermit. These two varieties may coincide in the 
same person, or they may exist independently of each other. 

Irregularity of the pulse may be caused by disease within the head ; by organic 
disease of the heart ; by simple disorder of the stomach ; or it may be merely the 
resuk of debility and the prelude to the complete stoppage of the heart's action from 
asthenia. How important it must be to ascertain and construe each of these mean- 
ings of the same symptom ! It may indicate mortal disease — it may imply no danger 
at all ; it may afford no clue to any available treatment ; or it may teach us how to 
ward off impending dissolution. 

Another most important quality of the pulse is what is called its hardness, or 
incompressibihty. You find that you can scarcely abolish the pulsation by any 
degree of pressure ; the blood still forces its way through the artery beneath your 
finger. Sometimes it is felt to strike a large portion, also, of the finger, and then 
we say that the pulse is full, or large, as well as hard. When it strikes a very 
narrow portion of the surface of the finger, it is compared to a thread ; it is a small 
pulse : and if at the same time it be hard, such a pulse is often described as a wiry 
pulse. It requires some education of the finger to appreciate with exactness the 
several varieties of the pulse, even those which are practically important ; for many 
have been mentioned by authors which are purely fanciful or useless and unneces- 
sary refinements. 

. Now this hard pulse I shall soon have to speak of again, in connection with the 



DISORDERED FUNCTIONS. 



9i 



treatment required in inflammation. It is one of the best warrants we have, in 
many cases, of the propriety of bleeding our patient. It does not occur, however, 
m all inflammations, and it may occur when there is no inflammation. It may 
depend upon hypertrophy of the left ventricle of the heart, and then it is beyond 
the reach of blood-letting as a remedy. It often seems to be connected with a 
morbid condition of the artery itself, brought on, as Dr. Latham has suggested, by 
the pernicious habit of dram-drinking. It is, however, at all times considered so 
much a guide to our practice, that whenever it occurs, it is very necessary to make 
careful inquiry into its real cause. 

Before I conclude this rough review of symptoms, I must point out one or two 
that belong to the third class mentioned ; viz., changes of sensible quahties. These 
include variations in the temperature of the body ; in the colour of the surface, and 
especially of the face ; the diminution or increase of ^Ik ; the latter, when general, 
we call corpulence ; when partial, swelling ; and various other symptoms, especially 
those which are detected by auscultation. 

Wasting, or emaciation, is sometimes the first observable symptom of disease. It 
occurs in complaints that are not commonly dangerous — as in dyspepsia, and in 
hypochondriasis, which is often connected with dyspepsia : and when it does appear, 
it marks the reality of the disease. This wasting happens also in many fatal mala- 
dies — in phthisis pulnionahs, for example — and in dropsy, although the dropsical 
enlargement sometimes masks it. It accompanies many acute diseases, and is 
reckoned an unfavourable symptom ; for it shows that the body is not properly nour- 
ished. Sometimes the emaciation is so extreme that the integuments give way — 
the bones of the patient are said to come through his skin. 

We have examples of symptoms that consist in changes of colour, in the flushed 
face of fever; in the pallor belonging to many diseases; in the contrast exhibited 
by the white cheek with its central red spot, so characteristic of hectic fever ; in the 
yellowness of the skin and conjunctiva in jaundice ; in the dusky hue of the coun- 
tenance and the lividity of the lips noticeable whenever the due arterialization of 
the blood in the lungs is interfered with; and in a long catalogue of cutaneous 
disorders. 

Various and full of meaning are the conditions and appearances presented by the 
tongue. A patient would think you careless, or ignorant of your craft, if you did 
not, at every visit, look at his tongue, as well as feel his pulse. 

Let me once more remind you of the pecuHar importance of accustoming your- 
selves to take notice of the symptoms comprised in the last two classes, and especially 
in the last class, that you may attain to a quick perception of them. Changes of 
sensible quahties speak for themselves, and speak the truth. They cannot deceive 
us, as the verbal statements of even conscientious patients respecting their uneasy 
feelings might. They direct us in the choice and order of our inquiries : nay, they 
frequently spare us the necessity of putting many questions ; questions that might 
be irksome or fatiguing to our patients, or offensive to their natural dehcacy, or even 
hurtful by letting them know our thoughts respecting their disorders. Of the changes 
in sensible quahties we judge by our own eyes, and ears, and fingers, and often by 
our noses also ; and the change is sometimes, of itself, perfecdy characteristic of the 
complaint. 

Many more morbid phenomena, or symptoms, or tokens of disease, might have 
been mentioned ; but I have said enough, I hope, to rouse your attention to the 
extent and the fertility of this field of study. When we next meet I shall begin to 
consider one of the special forms of disease to which ah parts of the body are hable 
— a disease that meets us at every turn — I mean inflammation. 



92 



INFLAMMATION. 



LECTUEE IX. 

Injfammuiion. Its Morbid and its Salutary Effects. Sketch of the Local ana 
Constitutional Phenomena of Inflammation as it occurs in External Parts. 
Examination of the Symptoms of Inflammation; Pain; Heat; Redness; 
Swelling. State of the Capillary Blood-vessels and of the Blood in a part 
inflamed. 

Inflammation must needs occupy a large share of the attention of both the sur- 
geon and the phj^sician. In nine cases out of ten the first question which either of 
them asks himself upon being summoned to a patient is, " Have I to deal with 
inflammation here ?" It is continually the object of his treatment and watchful 
care. It affects all parts that are furnished with blood-vessels, and it afiects different 
parts very variously. It is more easily excited by many external causes, and there- 
fore it is more common than any other special disease. A great majority of all the 
disorders to which the human frame is liable begin with inflammation, or end in 
• inflammation, or are accompanied by inflammation during some part of their course, 
or resemble inflammation in their symptoms. Most of the organic changes of 
different parts of the body recognize inflammation as their cause, or lead to it as 
their eflect. In short, a very large share of the premature extinction of human life 
in general, is more or less attributable to inflammation. 

Again, inflammation is highly interesting not only in its morbid phenomena and 
destructive consequences, but in its- heahng tendencies also. It is by inflammation 
that wounds are closed, and fractures repaired — that parts adhere together when their 
adhesion is essential to the preservation of the individual — and that foreign and 
hurtful matters are conveyed safely out of the body.' A cut finger, a deep sabre 
wound, alike require inflammation to re-unite the divided parts. Does ulceration 
occur in the stomach or intestines, and threaten to penetrate through them ^ Inflam- 
mation will often forerun and provide against the dano-er — o-lue the threatened mem- 
brane to whatever surface may be next it — and so prevent that worse and universal 
inflammation of the peritoneum, and the almost certain death, which the escape of 
the contents of the ahmentary canal into that serous bag would infallibly occasion. 

[We doubt very much the correctness of this statement. Is it true, that wounds are closed 
and fractures united by inflammation, in the proper acceptation of the term 1 Union of 
divided surfaces, it is true, may be a resuh of inflammation ; but, that what has been termed 
by surgeons " union by the first intention," takes place altogether independent of inflamma- 
tion, and that the occurrence of the latter is calculated to impede or prevent it, must be evi- 
dent, we think, to any one who will carefully watch its phenomena. Neither is it, we con- 
ceive, correct to describe the adhesions of tire peritoneum which often precede the perforation 
by an ulcer of the coats of the stomach or intestines, and prevent the escape of the contents 
of the latter organs into the cavity of the abdomen, as ^provision to guard against the uni- 
versal and fatal peritonitis that would otherwise occur. The inflammation by which the 
adhesions alluded to are produced, is as strictly a morbid process as that which caused the 
ulceration of the alimentary canal, and cannot, with any propriety, be viewed as a process 
setup, in anticipation of the escape of the contents of the alimentary canal into the peritoneal 
sac, and to guard against the danger that would hence result. The danger is, we admit, 
occasionally lessened or even entirely prevented by the adhesions, but we have no right to 
infer from this circumstance, that the adhesions occurred to provide against its occur- 
rence. — C] 

The foot mortifies ; is killed by injury or by exposure to cold ; — inflammation, if 
it be not anticipated by the knife of the surgeon, will cut off the dead and useless 
part. An abscess forms in the liver — or a large calculus concretes in the gall- 
bladder: how is the pus or the stone to be got rid of? If they make their way to 
the external surface of the organ, as they always tend to do, they enter the cavity of 
the abdomen, and excite fatal peritonitis. But a natural safeguard arises ; partial 
inflammation precedes and prepares for the expulsion ; the liver or the gall-bladder, 
as the case may be, becomes adherent to the wails of the abdomen on the one hand, 



INFLAMMATION. 



93 



or to the intestinal canal on the other; and then the surgeon may plunge his lancet 
into the collection of pus — or the abscess or the calculus may eat their own way 
safely out of the body — through the skin, or into the bowel. Inflammation, hmited 
in extent and moderate in degree, becomes conservative by preventing inflammation 
more severe and more widely spread, which would be fatal. This is what I mean 
when I speak' of the curative properties of inflammation ; and surely this process, 
which may save hfe or destroy it, deserves and demands our most careful study. 

But inflammation has a still further and pecuHar claim upon oar attention. The 
salutary acts of restoration and prevention just adverted to, are such as nature con- 
ducts and originates. But we are ourselves able, in many instances, to direct and 
control the effects of inflammation — nay, we can excite it at our pleasure ; and hav- 
ing excited it, we are able, in a great degree, to regulate its course. And for this 
reason it becomes in skilful hands an instrument of cure. This instrument the 
surgeon employs when, after letting out the water of a hydrocele, he wilfully excites 
inflammation of the tunica vaginalis, whereby its cavity is obhterated, and the re- 
accumulation of the fluid rendered impossible. It is by availing himself of the same 
agent that he is enabled to remedy many afflicting deformities : — to unite the cleft 
lip ; to close up the fissured palate ; to restore the dilapidated nose. There is no 
other special disease which is thus at our command ; we cannot, if we would, pro- 
duce a tubercle 'or a cancer. For all these reasons inflammation possesses a very 
high degree of interest for us—and for every one who would inquire, with any pros- 
pect of success, into either the pathology or the treatment of diseases. 

Of the amount of our knowledge respecting the intimate 7iature of inflammation, 
I shall have occasion to say a few words by and by. We first become acquainted 
with inflammation in its symptoms, and as it displays itself externally. After we 
know what they are, it may be right, and cannot but be interesting, to inquire how 
they come about. Now the symptoms which, when they exist together in an ex- 
ternal or visible part, betoken or denote inflammation of that part, are four in number: 
pain — redness — heat — swelling; preternatural redness, and preternatural heat. 
These, from the earliest ages, have been recognized as the signals of outward inflam- 
mation. "Notse inflammxationis (says Celsus) sunt quatuor — rubor et tumor cum 
Galore et dolore." 

No definition, however, or general description, can be made to embrace all the 
forms in which inflammation presents itself. We can give no useful account of it 
in the abstract ; and therefore I shall first sketch the phenomena of inflammation 
under one of its most common external forms ; and taking this as a type of the 
disease, proceed afterwards to trace its modifications and varieties, and to fill up the 
picture. 

Let us suppose, then, that a healthy man receives some local mechanical injury — 
that he falls, for instance, against a window, and gets a piece of glass stuck into his 
arm. In a short time he begins to have pain in that part of the arm, and this is soon 
succeeded by redness, and increased heat and swelling. The skin becomes of a 
bright red colour; the swelling increases. In the immediate place of the injury the 
sweUing is firm and hard, and exquisitely tender : at some distance from that centre, 
although there is still swelling, the parts are softer and more yielding. In the seat 
of the redness and swelling the patient experiences a sense of heat, a burning pain ; 
the part is sensibly hotter than natural to the touch of a bystander ; and if its actual 
temperature be measured by means of a thermometer, it will be found to exceed the 
temperature of the neighbouring surface. The part is inflamed. This is what is 
called phlegmonous inflammation. ^T^^yiiov^ is a Greek word, and inflammatio is a 
Latin word, and they both mean the same thing, viz., a burning, or a flame. Phleg- 
monous inflammation is, therefore, in truth, a tautological phrase. But custom has 
assigned a particular signification to the epithet phlegmonous ; — it denotes that kind 
of violent inflammation in which the affected part seems all on fire ; and chemistry 
teaches that, philosophically speaking, there is actual and excessive combustion going 
on in that part. 



94 



INFLAMMATION. 



If the inflammation reach a certain degree of intensity, other signs of disorder 
present themselves at a distance from the injured spot. The patient usually at first 
feels chilly and feeble ; but soon the temperature of the whole of the surface rises, 
the skin becomes hot and dry, the pulse more frequent and fuller and harder than is 
usual ; lassitude comes on, with headache, and wandering pains in the limbs. The 
patient is unable or unwilling to exert himself, and finds that he is unapt for any 
mental efibrt ; he cannot command his attention, gets confused, and restless, and 
sleeps ill ; he loses his appetite, his tongue becomes white, his mouth is parched, 
he is unusually thirsty, and the various secretions of the body are deranged and 
diminished. 

This is inflammatory fever. This is an indirect symptom of inflammation, mani- 
festing itself through the medium of the system at large. Various names have 
been given to this general derangement of the vascular and nervous systems : con- 
stitutional disturbance— sympathetic fever — symptomatic fever. It matters httle what 
term is used, provided that we affix always the same meaning to it : but inasmuch 
as the word fever, in this and in other languages, is taken to express a specific dis- 
ease, it would perhaps be better to employ the term pyrexia, as Cullen and others 
have done, to denote that secondary febrile state which grows out of, or is associated 
with primary local inflammation. 

Now what is the end of this remarkable state of things ? Why, it may end in 
one of two or three different ways. Supposing the piece of glass to have been 
extracted, and proper measures to have been taken for subduing the inflammation, or 
even supposing that no other measure has been adopted except removing the bit of 
glass, then it will often happen that the phenomena just described will gradually 
recede and disappear ; the pain will abate, the redness fade, the swelling diminish, 
the heat decline, the pyrexia cease; until the part at length regains its usual sensa- 
tions and its natural appearance. When inflammation subsides in this way it is said 
to be resolved, to terminate by resolution ; and this is its most favourable and desira- 
ble mode of terminating, whenever inflammation occurs as a morbid process. 

But in many instances the inflammation does not thus subside. The irritant cause 
still remains in action — or the original intensity of the inflammation has been too 
great to admit of resolution — or the means proper to abate it have not been used — 
or have not succeeded. The symptoms already described continue, and are aggra- 
vated in degree : at length the swelling begins to assume a more projecting and 
pointed form, and the skin in its centre to look white ; the central part of the swell- 
ing, formerly so hard, becomes softer — the pain is of a throbbing kind : a pulsative 
sensation, keeping time with the beats of the heart, is experienced in the part, and 
often a feehng occurs as if something had given way within it : at last (if art does 
not interpose) the cuticle breaks, and a yellow cream-like fluid is poured out, which 
we call pus, and upon its escape there generally ensues a considerable and speedy 
abatement of all the local symptoms of inflammation — of the pain, the heat, the 
redness, the tumour. 

This is suppuration. 

Meanwhile, especially if the suppuration be long-continued, and the discharge of 
pus profuse, the character of the general febrile excitement undergoes a change. 
Slight but frequent shiverings, or feelings of chilhness, take place, followed by flushes 
of heat, which end in perspiration. 

This is hectic fever. 

If the injury has been still more serious, and the inflammation more intense, the 
part which it has invaded perishes by the violence of the disease : there is a partial 
death. In that case the vivid red colour alters to a purplish or livid, or even a 
black, or greenish-black hue, the tension of the part exists no longer, the cuticle is 
elevated by a sanious fluid, the pain ceases, the part is devoid of all sensation — is 
dead and putrid, and exhales a pecuhar and offensive odour. 

This is mortification. 

When the injury has been extensive, a corresponding and characteristic change 
is again observable in the constitutional febrile disturbance. The patient grows 
more and more feeble, and deUrious ; he has involuntary starlings of the tendons of 

4 



INFLAMMATION. 



95 



the voluntary muscles ; his pulse is weak and very frequent ; his tongue becomes 
dry, brown, tremulous ; his lips are black with accumulated sordes ; his countenance 
is shrunk, haggard, damp, and ghastly ; his stools and urine escape from him with- 
out his appearing to be conscious that they do so. 
This is typhoid fever. 

Under more favourable circumstances the dead or mortified part, which is called 
a slough, separates from the hving parts, and leaves a breach of surface. The sepa- 
ration is effected by a vital process which is denominated ulceration ; but which I 
need not now describe. The cavity thus formed gradually fills up, and heals in a 
peculiar way. 

There is one other circumstance, not to be omitted in this rough outline of the 
local and general phenomena and effects of inflammation. If during its progress 
blood be drawn from a vein, it exhibits, after standing and coagulating, the pecuhar 
appearance known by the name of the bu^y coat, i. e., on the surface of the coagu- 
lum, and to a certain depth in its substance, the colouring matter of the blood leaves 
the fibrin, which is therefore seen of a yellowish hue, or buff colour. 

Taking the preceding statement as a groundwork, let us look back upon it, and 
trace its particulars a little more in full. The four characteristic signs of inflamma- 
tion being pain, heat, redness, and swelling, it will be useful to examine more closely 
each of these symptoms in its turn. 

The pain varies much in different cases of inflammation, both in degree and in 
kind. It is differently felt, casteris paribus, by different persons, according to their 
natural susceptibihties. It varies from the shghtest degree of sensibility to the utmost 
agony and torment. Parts which, when sound, are endowed with little or no capa- 
city of sensation (as tendons, ligaments, cartilage, bone), become often exquisitely 
sensible under inflammation. The orga.ns of sense are variously affected in this 
respect. Thus the specific sensibihties of the mouth and nose are blunted by inflam- 
mation- — those of the eye and ear are often rendered painfully acute. There are 
great diversities also in the kinds of pain. Sometimes it is of a dull aching charac- 
ter, as in toothache ; sometimes it is a pricking, tingling, smarting sensation — this is 
the case in some forms of inflammation of the skin, as in erysipelas for example, and 
in herpes; sometimes it is sharp and piercing, as if the part were stabbed or cut 
with a knife — such is frequently the feehng in inflammation of the serous mem- 
branes, in pleurisy for instance ; sometimes the pain is tensive or stretching ; and 
sometimes there is scarcely any pain at all. This last chiefly happens in the mu- 
cous membranes and in the parenchymatous textures of organs. Very often the 
pain is a "bulking" or throbbing pain — every beat of the heart makes itself felt in 
the tender part. The pain of inflammation resuks, no doubt, from the implication 
of the nerves in the diseased process. The stretching of the vessels and textures 
adds to the pain. Everybody who has been plagued by boils (and few escape them) 
has had proof of this : the pain is most harassing a short time before the ripening 
little tumour gives way, or is laid open by means of a scalpel ; but as soon as the 
distension is thus reheved, perfect ease and comfort ensue. It is the same in com- 
mon earache. It is upon this principle, I believe, that the differences in regard to 
pain, which occur in different structures under inflammation, are partly to be ex- 
plained. Speaking generally, there is more pain felt in external inflammations, and 
in the inflammation of investing membranes, than in infla'mmation of the substance 
of the viscera, or of the lining membranes ; and it has been conjectured that this 
may be because, in the latter cases, the parts affected have fewer nerves of common 
sensation. But I do not think this explanation satisfactory. If it were well founded 
we should not have such exquisite pain in some of the textures already mentioned, 
which appear to be furnished with very few nerves of common sensation, and 
scarcely feel at all in their healthy state : tendons, hgaments, and cartilages, I mean 
I think it will be found that most pain is felt in those parts which are least capable 
of yielding — in which the tension produced by the sweUing, or the tendency to 
sweU, is the greatest. The substance of the liver, spleen, and viscera generally, is 
soft and yielding — the mucous membranes are spongy in their texture, and often 
attached to the subjacent parts in loose folds, and they allow of an accum.ulation of 



96 



INFLAMMATION. 



blood within them without becoming much stretched, or very tense. The investing 
serous and fibrous membranes are more tightly apphed, and much less capable of 
yielding : and their inflammation is usually attended with severe pain. 

The pain that belongs to inflammation sometimes precedes any other apparent 
change. This is specially observable in respect to internal parts. Sometimes the 
pain is continued and uniform. Sometimes it is continued, but irregular in severity, 
having periods of great exasperation : sometimes again it is intermittent, and even 
periodic. 

It is an unsettled question that has often been mooted, whether in inflammation, 
the state of the blood-vessels is determined by that of the nerves, or the reverse. 
Mere nervous pains are known sometimes to be followed by congestion of the part 
in which they are felt. Whatever may be the true state of this question of priority, 
it is certain that the disordered condition of the blood-vessels, when produced, greatly 
augments the sensibihty of the part. We may suppose that this depends, partly on 
over-distension and stretching of the vessels and fibres, partly on pressure made upon 
the nerves by the swelling. 

It is importanrto remark of the pain belonging to inflammation, that it is usually 
aggravated by pressure: frequently it is not felt at all, except when pressure is 
somehow^ made upon the affected part — intentionally by the medical man — or acci- 
dentally, from the movements or position of the patient. This is tenderness. 

And this is a point which requires a little further notice. I say the aggravation 
of the pain by pressure is an important circumstance, because it continually helps 
us to distinguish pain that is inflammatory from pain that is not inflammatory. Thus 
pain of the abdomen may resuk from cohc, or spasm — from a distension of the intes- 
tines by air, and a stretching of the textures and nerves belonging to them : and this 
sort of pain will mostly be reheved by pressure ; you will find patients lying upon 
their bellies across the back of a chair for the sake of obtaining ease : but if the pain 
proceed, as it may, from inflammation of the peritoneum — oh! then the gentlest 
pressure, even that of the superincumbent bed-clothes, causes intolerable torture. 
The suddenness with which the pressure is made — and its being made on a part 
only of the suffering organ — these circumstances have much to do with the augment- 
ation of the pain ; and it is curious, and instructive too, to know that gradual pres- 
sure, applied uniformly to the whole organ or part under inflammation, is sometimes 
so far from enhancing the pain, that it relieves or removes it. Dr. Elliotson puts a 
very good case in illustration of this. " If (he says) you have a blister upon the sole 
of the foot, or at the ball of the great toe, and you rest gradually upon the part, the 
pain becomes mitigated, till at last it seems to be almost entirely removed ; but the 
moment you take off the pressure, and raise the foot from the ground, you feel the 
part begin to throb — to throb with violent pain." 

Now all this exemphfies what I said just now — that though a deranged condition 
of the nerves, marked by pain, may, for aught I know, first lead to the vascular full- 
ness — yet the same fuhness, and the distension which it implies, will greatly increase 
the pain. In fact, the expulsion of the blood by means of well-regulated pressure 
is made the foundation of certain proposed methods of cure. This has been lately 
recommended^n hernia humoralis, or swelled testicle — what is now more scienti- 
fically called orchitis. It gives one a sort of horror even to think of pressure being 
made on the healthy testicle — much more \vhen it is rendered preternaturally sen- 
sible by inflammation : yet, when properly managed, it is said (by Dr. Fricke, of 
Hamburgh, and others) not to increase the pain, but entirely to remove it, so that 
the patient can at once walk about the room ; and the disease is thus ultimately cured. 
In the same way it has been proposed to cure erysipelas, and gout, and rheumatism. 
Without inquiring here into the general merits of this remedial expedient, I may 
remark that pressure, so employed as to benefit an inflamed part by supporting its 
strained and oppressed capillaries, must be steady, gentle, continued, and (above all) 
uniform pressure. All these conditions are strictly supplied in an apparatus recently 
devised by Dr. Arnott ; whose air-press promises to be scarcely less useful to suffer- 
ing humanity than his earlier contribution to the comfort of the sick — the water-bed. 

It is sometimes necessary to recollect, especially when the existence of internal 



HEAT. 



97 



inflammation is suspected, that all expression of the sense of pain, and probably all 
sensation of pain, may be prevented or abolished by the presence of stupor or coma. 
So also, if the nervous connection between the inflamed part and the sensorium be 
cut off', no pain is felt. Limbs in a state of palsy are often (though not always) des- 
titute of sensibility also ; and inflammation readiiy occurs in them, but is accom- 
panied with no pain. 

That mere pain will not constitute inflammation, must, I think, be plain to you. 
Spasmodic contractions of the muscles, stretching and tension of the tissues, a par- 
ticular state of the nerves, and other conditions which do not imply inflammation, 
may, nevertheless, be attended with severe pain. 

Let us next consider the heat. 

Of course, as I hinted before, this means preternatural heat : the temperature of 
the part exceeds that which belongs to it in health ; but in truth, the heat is not in 
general so much increased as the sensations of the patient or his heightened sensi- 
bility would persuade him it is ; nor even so much as a bystander might suppose. 
The heat of inflammation does not rise above the maximum heat of the blood in the 
central parts of the body. The natural heat of the blood is about 98° or 100°, but 
in fevers and inflammatory diseases it has been known to reach 107°, and the 
maximum heat of the blood in fever is probably the limit of the temperature as it 
exists in inflamed parts. The surface of the body, in its natural state, is not quite 
so warm as the internal parts, and the extremities are generally less warm than the 
trunk ; so that the contrast between an inflamed and a healthy part, in respect to 
heat, is greater in the extremities than on the trunk. Thus if a bhster be placed 
upon the chest, the heat of the part inflamed by its apphcation will not exceed that 
of the neighbouring heahhy surface by more than a degree or tv/o ; while a blister 
applied upon the leg may occasion a difference of five or six degrees. John Hunter 
took great pains to ascertain the degree of heat produced in inflammation. He ex- 
cited inflammation in the cavity of the thorax of a dog, and in the vagina and rectum 
of an ass, and he could not find that the temperature of the parts thus inflamed ever 
exceeded that of the blood at the centre of the circulation. He did not neglect the 
opportunities that came before him of making similar observations on the human 
body. He had occasion to tap a patient in St. George's Hospital for hydrocele : as 
soon as he had let the fluid out, he introduced a thermometer through the puncture 
made by the trocar, and placed it in contact with the testicle. He found the tempe- 
rature to be 92°. He repeated this experiment the next day, when inflammation had 
set in, and then the thermometer rose to 98|°. So that here an increase of 6|° had 
taken place in consequence of the inflammation ; but even this, you see, did not go 
beyond the natural warmth of the blood. 

The increase of heat depends upon the increased influx of arterial blood, and 
therefore of oxygen, into the part. Animal heat appears to be derived, in all cases, 
from the mutual action that takes place between oxygen and the elements of the 
tissues, their carbon and hydrogen ; the tissues themselves undergoing meanwhile 
perpetual changes, which, in the natural condition of the body, belong and are 
necessary to health. In a part that is inflamed this kind of combustion is, I say, 
excessive in amount ; while unnatural metamorphoses occur in the affected tissues. 
It is, however, a curious fact, a fact worth remembering, that the heat of inflam- 
mation does not transgress or surpass that of the blood in the central parts of the 
body. 

Heat alone neither constitutes nor imphes inflammation : for parts of the body may 
be made preternaturally hot by holding them before the fire, by friction, by exercise, 
while there is no inflammation. 

I apprehend that increased heat is essential to inflammation, in some stage or other 
of its progress, although there are cases in which the augmented temperature is not 
perceived or appreciated. Sometimes the increase of heat is very shght, and may 
be easily overlooked, there being, nevertheless, unequivocal inflammation, redness and 
swelling, which go slowly into suppuration. The heat is often concealed from the 
observation of the physician or the surgeon, by the situation of the part affected, and 
it escapes the notice of the sufferer, because the sensibiHty to heat is less generally 



98 



SWELLING. 



diffused througli the body than the susceptibiHty of common sensation. The heat 
of inflammation is usually less felt and less complained of by the patient than the 
pain. A vivid sensation of heat is pain. 

The redness of inflammation must also be preternatural in degree, for many parts 
of the body are by nature, and in health, more or less red. This phenomenon 
depends upon the greater quantity of blood contained in the vessels of the part, and 
sometimes also upon the extravasation of a portion of the blood into the affected tex- 
ture. There is more blood than usual in those vessels which naturally carry red 
blood ; red blood enters too into vessels which in the healthy state are destined to 
receive and convey colourless fluids only, or which naturally adm.it so few of the red 
particles, that from their paucity, and the quickness of their motion, they cannot be 
seen. We are sure of this from what takes place in ophthalmia. Doubtless, also, 
the redness is sometimes increased by the formation of new vessels which admit the 
colouring particles of the blood in visible numbers. 

That the vessels which naturally circulate red blood are actually distended and en- 
larged in inflammation, there can be no doubt. John Hunter (whose treatise on In- 
flammation is a mine in which ah succeeding writers have dug), excited inflammation 
in one of the ears of a rabbit, and then killed the animal. He next injected the 
head and ears from the aorta, so that the fluid injected, passing through both the 
carotids, was driven with equal force towards each ear. The arteries of the in- 
flamed ear were enlarged one-third beyond their natural size, and arteries in it Avere 
injected which had no visible counterparts in the sound ear. That the apparent 
increase in the number of blood-vessels is often owing to the circumstance that red 
blood enters tubes which already existed, but which did not previously "admit the 
colouring matter, or did not admit it in sufficient quantity to be visible, is evident 
from the rapidity with which the redness may be produced in many textures : in the 
eye, for example, it may be effected in a few seconds ; and many of the vessels 
which become suddenly apparent are evidently continuations of the trunks that 
could be seen before. 

There is much variety in the tint of the redness of inflammation, depending on 
the kind and degree of the inflammation, and on the nature of the part affected. 
Sometimes the redness is bright and vivid, as if the part were full of arterial blood : 
this generally happens in the acuter forms and the earlier stages of inflammation. 
Sometimes the redness is dark, or livid, or purphsh ; more as if the part were 
gorged with venous blood : this occurs in some of the chronic or sluggish forms of 
inflammation, and it is often the case when there is a tendency to gangrene. Some- 
times the redness is distinctly circumscribed, or in patches ; and sometimes it is dif- 
fused in a general blush over a large space. 

The redness may, and often does, remain for some time after the inflammation has 
ceased. 

Now seeing that redness accompanies inflammation of the external parts, we pre- 
sume that it exists also in internal inflammation : indeed we may convince ourselves 
that it is so. If a portion of intestine be drawn out through a slit in the parietes of 
the belly of a dog, and suffered to remain exposed to the air, it wiU soon inflame ; 
and inflaming, it grows red. We see also that internal parts are left red after death, 
which parts we have no other reasons for knowing had been inflamed during hfe : 
and we infer that redness may have been present during life, although we find none 
remaining when the body is examined. That when it has been owing to mere full- 
ness of the natural blood-vessels, it may disappear with parting life we know, because 
the same thing happens externally, as in erysipelas and scarlet fever : but in such 
cases the inflam.mation has not gone to any great height. 

Tt is proper to remark that, as the absence of redness is no proof that there has 
not been inflammation, so its presence is no proof of the contrary. There are many 
kinds of redness, both within the body and on its surface, that have nothing to do 
with inflammation : yet some of these are very apt to be mistaken for traces of 
inflammation. I shall endeavour to instruct you how to avoid such a mistake, when 
we come to examine the morbid anatomy of particular forms of disease. 



INFLAMMATION. 



99 



While inflammation actually exists, redness, of some shade or. degree, is seldom 
absent, even though the other symptoms may be scarcely apparent. 

Lastly, let us take a glance at the swelling. This also depends, in some degree, 
upon the distension of the blood-vessels ; but no great amount of swelhng can be 
attributed to this cause ; and as much as does proceed from it occurs early in the dis- 
ease. Some, also, and usually almost the whole, of the swelhng, results from the 
presence of matters poured, out into the interstices of the affected part. These 
effused matters are of very different kinds, although they are all modifications of the 
same liquid, the blood. I mentioned, in describing the condition of the part inflamed, 
that the central portion of the swelling is, at first, hard and resisting, while, at a 
greater distance from the centre, the swelling is softer, and yields more readily when 
pressed by the point of the finger, and, sometimes, even pits a Httle under that 
pressure. Now, the central hardness is to be ascribed to an effusion into the areolar 
texture of the part, of a fluid, which, transparent at first, speedily becomes opaque 
and more consistent, and at last assumes a soHd form. This is what is commonly 
called, in this country, coagulable lymph. The softer swelling at the circumference 
of the tumid part proceeds from the effusion of a thinner fluid of serum into the 
areolar tissue. Under very violent inflammation, blood, in substance, is poured out 
into the same parts. When the central portion of the swe]Kng softens and becomes 
pointed, this part of the whole enlargement is owing to the presence of a quantity 
of pus. The different hquids that I have now been mentioning are of great import- 
ance, and play a conspicuous but diversified part in altering textures. Blood, serum, 
albuminous fluid or coagulable lymph, pus. They are called the products of inflam- 
mation. We are sure that inflammation has been at work, if we meet with certain 
of these products. We are not sure that there has been inflammation if we perceive 
mere redness : — we are not always sure if we find serum only : — we are not sure 
if we find blood alone : — we are tolerably certain if we discover pus ; we are cer- 
tain, at least, that there has been inflammation somewhere, though doubts have been 
started whether the pus is not sometimes conveyed from an inflamed part to other 
parts of the body. We are quite sure that there has been inflammation in a part if 
we find coagulable lymph in that part. This often remains, as a monument of the 
inflammation, during life ; it frequently becomes organized, furnished with blood- 
vessels ; and a great number of changes, some reparative, some morbid, depend 
upon its presence. I shall have to^recur to these products of inflammation here- 
after. 

The degree of swelhng in different cases depends partly on the intensity of the 
inflammation, partly on the nature and texture of the structures affected. 

I need scarcely observe that swelling may exist without any inflammation. Her- 
nia, simple anasarcous enlargements, dislocations, will occur to you as every day 
examples of swellings that have no necessary connection with inflammation. 

On the other hand, inflammation may exist without any appreciable swelling. 
Inflammation of the sclerotijf coat of the eye, for instance, may be present, without 
any swelling cognizable by our senses. 

We have seen, in this review of the symptoms of inflammation, how much they 
severally depend, the pain, the swelling, the redness, and the heat, upon the increased 
influx of blood into the part. . 

It may not be uninteresting to pause here for a moment to inquire what has been 
ascertained in respect to the actual condition of the capillaries of an inflamed part, 
and of the blood they contain. Much has been learned on these points by patient 
and minute observation with the microscope, and by reasoning upon the facts thus 
brought to light. Kaltenbrunner, Gendrin, Miiller, and others, have corrected many 
erroneous notions which formerly prevailed upon this subject. 

In order to comprehend the minute phenomena of inflammation, you must have a 
clear conception of the constituent elements of the blood, and of the main changes it 
is liable to undergo. The rough anatomy, rather than the chemistry of the blood, is 
what I allude to. 

The blood consists of red particles, or globules, and of a transparent colourless 
fluid cahed lymph, or hquor sanguinis. Miiller succeeded in separating these two 



100 



BLOOD AND BLOOD-VESSELS. 



constituents of the blood by filtering through paper that of a frog, which contains 
very large red globules. The hquor sanguinis thus obtained separates spontaneously, 
by coagulation, into two parts, into serum and fibrin, the last having previously ex- 
isted in solution in the hquor sanguinis. 

When the coagulation is suffered to take place without any attempt to remove the 
red particles, these are entangled and enclosed in the fibrin as it becomes sohd ; and 
the common well-known appearance of clot and serum results. You may even then 
•wash out the red particles from the clot, and leave the fibrin. 

I must now recur to the experiments and observations of Kaltenb runner. I should 
have told you, on a previous occasion, that various stimulant substances, mechanical 
or chemical, when applied to the web of a frog's foot, will produce irregular dis- 
turbances in the circulation, which irregular disturbances you are not to confound 
with true congestion : in like manner you must avoid confounding them with the 
phenomena of inflammation, which are always preceded by those of true conges- 
tion. Kaltenbrunner found, likewise, that (just as in congestion) a certain interval 
of time generally happened between the application of the exciting cause and the 
apparent development of the inflammation. This accords with what w^e observe to 
be the case in respect to local injuries, and to those local internal inflammations that 
are apt to be produced by exposure to cold. There is a pause before the mischief 
lights up : or (to take the metaphor from the eggs of birds) there is a period during 
which the inflammation seems to be hatching, and it is called accordingly the period 
of incubation. Kaltenbrunner describes inflammation to be a regular process — as 
he had also described congestion to be. 

On looking, then, at the web, to which some violence had been done, he observed, 
after the first irregular disturbances were over, and when the period of incubation 
had elapsed — he found (I say) that an afllux of blood took place to the part about to 
be inflamed ; the velocity of the blood in the vessels was greatly accelerated ; the 
vessels themselves were distended and tense, and therefore disposed to tighten upon 
the blood they contained — the functions of the part, that is to say, the secretion and 
absorption of lymph, were interrupted ; the blood underwent an evident change — 
or it failed to undergo the proper changes: its globules stuck together, and the 
parenchyma of the Aveb became tumefied. Now all this is just what I represented 
to you in a former lecture as constituting the state of the blood-vessels under active 
congestion; and I also told you, at the same time, that such congestion was just one 
step short of inflammation. The congestion now described increases, until, at length, 
this remarkable alteration happens : the capillary tubes, instead of tightening upon 
their contents, dilate, or grow larger; the circulation, at first so rapid, begins to be 
delayed in some of the capillaries ; the direction of its motion becomes uncertain ; it 
osciilates, as it w^ere, irregularly in those vessels, and at last stops akogether, the 
globules cohering in irregular masses, and thus points of stagflation are formed ; 
and these points of stagnation, if the affection goes on increasing, augment in size, 
and multiply in number. Around them, beyond their circumference, The circulation 
remains still very rapid, and the congestion persists. This is inflammation — of 
which the characteristic or pathognomonic feature is the formation of these points 
of stagnation. 

Now one early consequence of the stagnation of the blood is, that a portion of it 
transudes through the sides of the vessels containing it : the serum, or the liquor 
sanguinis, or even sometimes the blood itself; red particles and all. The eflijsed 
serum remains, or is absorbed, as serum. The fibrin, when it has so transuded, 
concretes, and thus the interstices of tissue are filled up, and layers of coagulable or 
coagulated lymph are formed upon the surfaces of inflamed parts, constituting false 
membranes. Under certain circumstances, already adverted to, other or further 
changes take place. Microscopic investigation has recently discovered a number of 
colourless corpuscles floating in the liquor sanguinis. These corpuscles, passing into 
the interstices of the inflamed tissue, or stagnating in its capillaries, suffer remarkable 
changes, assume a yellow colour, and are thus transformed into globules of pus. So 
that pus is nothing else than altered blood. During the inflammatory state, the cor- 
puscles sometimes appear to multiply with surprising rapidity ; and are poured forth, 



BLOOD AND BLOOD-VESSELS. 



101 



in. their new shape, like a secretion. Pus streams, almost, from certain mucous 
membranes under inflammation. Whether the colourless corpuscles be independent 
of the red globules of the blood ; or whether, as some suppose, they are originally 
derived from the red particles, are questions which must be regarded as being adhuc 
sub judice. 

Certainly much which used to be thought mysterious in the process of inflamma- 
tion has been rendered more simple and intelligible by modern research. Most of 
the events or consequences of that process are traceable to the stagnation of the 
blood in the capillaries, and to the changes which the stagnant blood subsequently 
undergoes. 

I must not omit to tell you what Kaltenbrunner says about the direct absorption 
that takes place in the inflamed part. He found that the colouring matter, and the 
adipose matter, were thus taken away. The web of a frog's foot is speckled over 
with little stars of five rays, caused by a black pigment. The extremities of these 
rays gradually disappear until mere black points are left in the places of the stars. 
He says that he has been lucky enough to catch the exact moment when the blood, 
circulating rapidly in the canals, has detached a particle from one of the rays, and 
carried it into the torrent of the circulation. In the sound state, the mesenteric vessels 
of the rabbit are surrounded with much fat. When the mesentery is inflamed, the 
adipose cells soon empty themselves : a number of capillary canals are developed 
upon the walls of those cells, and it is probable that the fat is carried off by the 
blood circulating in these canals. 

Another curious and interesting sight witnessed by Kaltenbrunner, was the form- 
ation of new blood canals. He says that in an organ recently inflamed, when the 
circulation is accelerated, globules of blood may be seen to sally, all of a sudden, 
from some capillary, pass into the surrounding parenchyma, force themselves a 
channel, and reach another capillary canal. Thus a new capillary channel is 
formed ; the blood circulates through it ; its formation is often the work of a few 
seconds only. As the same thing is repeated in different parts, a rich net-work of 
new capillary canals is added to the original set, whereby it happens that organs 
which in the sound state are but slenderly furnished with capillary vessels (as the 
mesentery of the rabbit) present an astonishing number of them under inflammation. 

While new capillary vessels form, the old ones dilate, and assume the appearance 
of small arteries or veins according as they are continuous with the arteries, or 
border on the veins. 

The fact has long been known that when coagulable lymph has been poured out, 
in inflammation, blood-vessels gradually form in it, whereby it obtains a vascular 
connection with the surrounding textures, and becomes a hving portion of the body : 
and these microscopic disclosures of the manner in which they form appefir to me 
' to possess a peculiar interest. 

I should be making a very wasteful use of your time and of my own, if I entered 
into the undecided and unprofitable disputes that have been raised respecting the 
vital conditions of the vessels engaged in inflammation. While some have pretended 
that the actior^of the smafl vessels is increased, others assert that it is diminished : 
that the vessels are in a state of atony. For my own part I have never yet seen 
any conclusive evidence that the capillaries possess any vital contractile power dis- 
tinct from their elasticity. And granting them such a power, it is extremely difficult 
to conceive how any increase in their vital contraction should produce the changes 
that are observed in inflammation. Certainly we have no warrant that any such 
contraction takes place, in the results of microscopical examination of the vessels of 
an inflamed part. The inquiry might be more , properly directed, 1 think, towards 
the vital conditions of the nerves of the part : but here we are wholly in the dark. 

1 do not think it so evident as some have supposed it to be, that a greater quantity 
of blood than is natural passes through an inflamed part in a given time. It is quite 
true — and it is proper that you should be aware of it — that the arterial trunks leading 
to an inflamed part often pulsate with more than ordinary force, and, if opened, pro- 
ject a jet of blood further than they would naturally project it. it is true also that 



102 



INFLAMMATION. 



a venous trunk leading from an inflamed part will discharge blood faster and more 
copiously than a corresponding vein leading from a sound part. Mr. Lawrence 
declares that he has frequently tried this experiment, and alwaj^s with similar results. 
Finding it necessar}^ to bleed a patient whose hand and forearm were inflamed, he 
has directed a vein to be opened in both arms at the same moment ; and he has 
ascertained that about three times more blood flowed, in a given time, from the vein 
of the inflamed limb than from that of the sound. But it scarcely follows from this 
that more blood circulates through the w^hole of the part actually inflamed : the 
activity of the circulation in the vessels that remain pervious, and are merely con- 
gested, around the focus of inflammation, is greatly increased, and more blood circu- 
lates through the limb : and yet the blood may be stagnant, or scarcely circulate at 
all, in the very part that is strictly and truly inflamed. However, the fact of this 
increased afllux of blood towards the parts concerned in the inflammatory process is 
an important one. 



LECTURE X. 

Inflammation continued. Biiffy Coat of the Blood. Terminations or Events of 
infMmmation. Resolution — Delitescence — Metastasis. Effusion of Serum. 
Effusion of Coagulahle Lymph, or Fibrin. Organization of this Lymph. 
Suppuration. Ulceration. 

In the last lecture, after giving a very general sketch of the phenomena of inflam- 
mation, I particularly considered its four characteristic symptoms, pain, heat, redness, 
and swelling: and endeavoured to describe the changes that take place in an 
inflamed part, as they are seen through a microscope. 

There is one very remarkable and important circumstance which is not often 
absent in cases of inflammation, but which hitherto I have barely mentioned : I 
mean a peculiar appearance of the blood itself after it has been drawn from a vein. 
A portion of the fibrin at the upper surface of the coagulum parts with its colouring 
matter ; so that upon the deep red clot there is to be seen a layer of yellowish, or 
sometimes of a bluish white colour, varying in thickness from a hne or two to per- 
haps three-fourths of an inch. This uppermost whitish layer of the coagulum is 
called in this country the buffy coat of the blood. Sometimes the surface of the bufly 
coat is fiat and wide ; but often it is contracted and concave ; i. e., the diameter of 
the bufly surface is less than the diameter of the lower portion of the clot, and it is 
hollowed out into a cup-like form. Accordingly the blood is said, in these circum- 
stances, to be both bufled and cupped. The formation of this bufly coat appears to 
be favoured by many circumstances which have nothing to do with the disease under 
wdiich the person may be labouring ; such as the size of the aperture in the vein, 
the manner in which the blood fiows, the form and size of the vessel that receives it: 
but it does not occur at all except in certain conditions of the system ; and it belongs 
so especially to the state of inflammation, that blood having the bufly coat upon it is 
often spoken of as inflammatory blood, or, with less ' propriety, as inflamed blood. 
Both these expressions indeed are incorrect, for inflammation sometimes exists with- 
out bufly blood ; and huffy blood sometimes occur without inflammation. The phe- 
nomenon is, however, upon the whole, a very valuable index of the nature of many 
cases of disease, and an important guide in their treatment. 

Now this crust, or upper layer, or bufl}^ coat, consists of pure fibrin, mixed with a 
certain quantity of serum, which M. Gendrin says is fuller of albumen than the rest 
01 the serum. You will not fail to notice the great analogy that subsists betvreen tlie 
oufly coat, and the coagulahle lymph poured out in inflammation, either into the 
texture of the part, or (as I shall show you more particularly by and by) upon its 
surface, forming what are called false membranes. Both in appearance, and in 
chemical composition, the two seem to be identical ; and no doubt exists in my mind 



\ 



BUFFY COAT OF THE BLOOD. 103 

of tlieir being actually tlie same substance: the separation in the one case taking 
place from the blood while contained in its proper vessels ; in the other case from 
the blood after it has been removed from the body. 

There has been a great deal of speculation among pathologists as to the cause of 
this bufFy coat. From its situation it is plain that gravity has something to do with 
its formation: that the red particles, leaving the colourless fibrin before it coagulates, 
sink downwards by their own weight. But though the subsidence of the red par- 
ticles is occasioned by their greater specific gravity, their separation from the fibrin 
is not to be explained upon that principle alone. If it were, then it would follow 
that the slower the coagulation of the blood, the more time would there be for the 
sinking of the red particles, and the thicker and more decided would be the bufFy 
crust : and it used to be supposed that this was the true explanation of the phenome- 
non. Carelril observations, however, have shown that the formation of the buffy 
coat often takes place when the coagulation of the blood is unusually rapid. Dr. 
Davy and M. Gendrin both state, as the result of much attention to the subject, that 
the coagulation of blood drawn from a vein during inflammation begins sooner, and 
is more quickly completed, than that of healthy blood. But certain observations 
made and published by Dr. Stokes have settled this question. He noted the appear- 
ance of the blood in twenty-seven cases. In fifteen of these the buffy coat presented 
itself; in twelve it did not. Now in three of these twelve, the coagulation of the 
blood did not begin till from twenty to forty minutes after it was drawn ; and in four 
others there was no coagulation for eight minutes. So that there was plenty of time 
for the red particles to have left the fibrin, and subsided ; but they did not do so. On 
the other hand, in twelve out of the fifteen cases in which the blood was buffed, the 
coagulation took place in five minutes ; and in the remaining three it was delayed 
only fourteen minutes. 

The slowness of the coagulation, therefore, although it may and doubtless does 
favour the subsidence of the red particles when they have a tendency to subside, 
cannot be regarded as the cause of the buffy coat. The red particles very soon begin 
to subside when they subside at all : you may tell, immediately after it has been 
drawn, and prior to any coagulation, that blood is about to buff, by a peculiar bluish 
hue on its surface. A German writer, Shroeder Van der Kolk, has stated observa- 
tions to the same purpose, showing that in the blood abstracted by venesection during 
inflammation there is an unusual disposition to a separation of the fibrin from the red 
particles; a sort of repulsion heXwean iYiem. This separation takes place in mere 
films of blood, so thin as not to permit a buffy stratum to lie above a red stratum. 
The fibrin and the red particles then separate from each other latterly by horizontal 
movements, and the films acquire a speckled or mottled appearance, quite as charac- 
teristic of the state of the blood as the buffy coat itself. 

That the formation of the buffy coat depends, however, upon some vital change 
in the blood appears probable from this — that it will sometimes vary greatly in 
different portions of blood abstracted at the same bleeding. Thus, if the blood be 
received into four different cups in succession, it will, perhaps, be buffy in the first, 
and in noAe of the others; or it will be buffy in the last only; or in the second and 
third only, the first and fourth cups being free from buff. Attempts have been 
made to explain these rapid variations. Some have fancied that the inflammatory 
state having been remedied by the removal of a certain quantity of blood, the blood 
that flows subsequently is, therefore, without the usual index of the presence of 
inflammation ; but this explanation will not apply at all to those cases in which the 
portions last drawn are the only portions that exhibit the buffy crust. Others have 
suggested that the state of the nervous system is principally concerned in these 
sudden changes ; that the depression caused in the outset of the bleeding by fear, 
and the faintishness produced towards its termination by the loss of blood, may pre- 
vent the appearance of the buffy coat on the first and last cups, when it shows itself 
only in those that are intermediate between the first and last. We cannot rely 
much on these hypothetical explanations : I mention them to impress upon your 
memory the facts which they are intended to explain. 



104 



INFLAMMATION. 



There are two or three different forms presented by buffy blood ; and with these 
you ought to be famihar. 

In one form the buffy coat is thick, tough, contracted, puckered at its circum- 
ference, and its surface is cupped. There is a complete separation of the red parti- 
cles, and a strong aggregation of the particles of the fibrin among themselves. The 
red portion of the coagulum is also, in these cases, round and contracted, of a globu- 
lar shape, firm, detached from the sides of the vessel, and floating, generally, in 
transparent serum. 

This is usually seen when the inflammation is violent ; when it occurs in strong 
and vigorous constitutions ; and more I beheve when it has its seat in certain tissues, 
in fibrous and serous parts especially. 

In another form, the whole coagulum is large, hke a cake, or of the figure of the 
vessel containing it, not so much collected into a spherical shape ; and t?ie buffy coat 
is thin and flat, and easily broken. Here there is an imperfect separation of the 
colouring matter from the fibrin, and no great aggregation of the particles of the 
latter. This kind of buffy blood is apt to accompany shght or partial inflam- 
mation. 

In a third form, the buffy coat is thick and abundant, but it is fiat and soft, loose 
and flabby, hke paste ; and the coagulum often adheres by its edges to the vessel in 
which the blood has been received : there has been considerable separation, and but 
slight aggregation. The serum is apt to contain a few red particles distinct from the 
clot. Such blood is commonly said to be sizy. Dr. Alison states that when it is ob- 
served, some other cause of general disorder of the system (continued fever, for 
example) usuaUy co-exists with the local inflammation. Probably the qualities of 
the blood are akered, independently of the inflammation ; the buffy coat taking place, 
in consequence of the inflammation, upoil blood which was previously in a diseased 
or unnatural condition. 

It is a curious fact that blood drawn by leeches never exhibits the buffy coat. It 
seldom appears (yet I have seen it) upon blood that has been removed by means of 
cupping glasses. 

Arterial blood is liable to the buffy coat. I have myself, twice at least, seen it 
upon blood drawn from the temporal artery. One of the patients was violently 
maniacal when the blood was taken. The other was labouring under acute inflam- 
mation of the membranes of the spinal cord, of which inflammation he died. 

Blood is more likely to buff, cseteris paribus, when it is made to flow in a full 
stream, and when it is received in a deep and narrow vessel. 

On the other hand, the formation of the buffy coat appears to be hindered, when 
the blood trickles from a small opening in the vein, and when it is caught in a large 
flat vessel. It is said also, that the buffy coat may be prevented by adding to the 
blood a solution of caustic potass ; by keeping it for some time in a state of agitation ; 
by receiving it in a very cold vessel ; or by suffering it to fall from a height of three 
or four feet, [n this last case M. Gendrin supposes that the prevention is owing 
partly to the agitation which the descent of the stream produces in the blood already 
in the vessel, and partly to the circumstance that the blood is cooled as it passes 
through the air. 

It is seldom, I beheve, that the buffy coat appears on blood drawn at the very 
outset of inflammation ; generally a day or two elapses before it shows itself. This 
is just what we might expect if it be true, as it has been conjectured, that this un- 
natural property of the blood is acquired only in the course of its transit through the 
vessels of the inflamed part. 

I have dwelt the longer upon this pecuhar appearance of the blood, because it 
really is of very great importance in determining the nature of various complaints, 
and in directing our treatment of them. Speaking generally, when a given organ 
is inflamed, the buffy coat is more marked in proportion to the intensity of the in- 
flammation : when the organ is not known, it is more hkely to be of a fibrous or a 
serous texture, in proportion as the blood is more decidedly buffed. The appearance 
of the buffy coat is especially valuable as an indication of treatment in cases con- 
cerning which we are in doubt whether they are inflammatory or not. On the 



/ 



BUFFY COAT OF THE BLOOD. 105 

Other hand, if we have good evidence, in other symptoms, of the existence of in- 
flammation, we are not to be shaken in our opinion by the absence of the buffy 
coat. Inflammation may certainly exist without it. I am not speaking now of shght 
cases of inflammation, which do not disturb the general system. You would not 
look for buffy blood in the inflammation that supervenes on a cut finger, or in a 
small boil ; but in serious inflammation, attended with pyrexia, the buffy coat may 
be wanting. It is not unfrequently absent in inflammation of the mucous mem- 
branes, especially in inflammation of the mucous hning of the bronchi. 

I stated before — what is quite necessary to remember — that buffy blood is not con- 
fined to cases of inflammation. The blood of persons affected with general plethora 
is often found to present a bufly coat : and the same thing is true in respect to 
pregnant women. 

Buffy blood is no necessary measure of the danger of the disease. The blood 
drawn in acute rheumatism is always very much buffed and cupped: yet so long 
as the disease is confined to the joints, it is quite free from danger. 

Neither is the appearance of buff on the blood, taken by itself, a sufficient war- 
rant for abstracting more blood : for the blood will sometimes, in common inflam- 
mation, continue to be buffy, long after it has ceased to be useful, or safe, to bleed 
the patient. 

[In nearly all the strongly developed acute inflaramations, there is an excess of fibrin and of 
the colourless or lymph globules of the blood. From three parts in a thousand, which, accord- 
ing to Andral, is the average proportion in health, the fibrin has been found to rise to six or 
eight parts. In some cases, MM. Andral and Gavarret found it as high as ten parts in the 
thousand ; namely, in pneumonia and acute articular rheumatism. The excess of fibrin was 
noticed by Andral in cellular inflammation, or simple phlegmon, in acute inflammations of 
the skin, as in burns and erysipelas, in mercurial stomatitis, in phlegmasiee of the mucous 
membrane of the respiratory and digestive organs, in acute cystitis, either simple or com- 
bined with nephritis, in all of the phiegmasise of the serous membranes, in inflammation 
of the lymphatic glands, and in softening of the brain. But it does not follow the pustules 
of small-pox, the exantheme of measles or scarlatina, or the patches in dothinenteritis. 

The increase of fibrin in the blood is manifested so soon as the inflammation begins, M. 
Andral is inclined to believe, from what he has remarked in cases of burns, that the disease 
commences in the solids before the change occurs in the blood. The sympathetic fever in 
.the phlegmasicB is, he thinks, due to the alteration in the blood from the excess of its fibrin. 
With the increase of fibrin, the proportion of red particles remains unafiected. Even in 
anemic cases, and in low fevers, in which there is a dimirmtion in the proportion of fibrin, 
the latter becomes abnormally increased whenever inflammation supervenes. 

To this it may be objected, remarks Williams, that this fever frequently rises high before 
the blood has begun to exhibit the bufiy coat, often subsides when the buSy coat is most 
abundant, and is sometimes wholly absent when the blood is both buffy and cupped, as in 
sub-acute rheumatism. But he admits that it is very probable the excess of fibrin may con- 
tribute to the excitement, and it certainly materially afiects the duration and products of 
inflammation. 

It would appear very certain that the formation of the buffy coat in inflammatory diseases 
is in a great degree dependent upon this excess of fibrin. It is found only in cases where 
the proportion of fibrin is abnormally augmented. In anemia, the only disease excepting 
inflammation, in which the buffy coat is observed, notwithstanding the quantity of fibrin 
may be abnormally small, still it is very generally in excess in relation to the red globules. 
The buffy coat forms, also, upon the blood drawn during the latter period of pregnancy: 
when the blood also presents an excess of fibrin. In inflammation the buffy coat is fre- 
quently not present in the blood drawn in the early period of the disease, the fibrin no! 
being as yet sufficiently abundant, while it becomes less and less marked as the intensity of 
the disease and the excess of fibrin diminish. 

In cases of indirect prostration, incident upon great intensity of inflammation, the blood 
first drawn may be without the buffy coat; it becoming apparent only as the pulse and heat 
of the surface rise, as they often do in such cases, under the use of the lancet. 

According to Andral, the newly-formed fibrin in inflammation coagulates more slowly 
than the old. — See Andral, Patholog. Hcematol. ; and Williams, Principles of Medicine. — C] 

Some pathologists enumerate several terminations of inflammation. Others quar- 
rel with that word, as inappropriate ; alleging, with great truth, that the inflamma- 
tion does not necessarily cease or terminate whenever these so-cafled " terminations" 
happen. Some of them are in fact " co-existent states, or successive stages in the 



106 



INFLAMMATION. 



progress of tlie same inflammatory disease." It has been proposed to speak rather 
of the local effects of inflammation : but even this phrase is not free from objection, 
for sometimes (though rarely) there are no local effects produced, beyond the four 
sj^mptoms which characterize the inflammation itself. I think the events of mfiam- 
mation is an expression not open to similar cavils. I have no ambition to introduce 
new modes of speech, unless when those already in use are inexact or inapplicable. 
It is enough if you clearly comprehend the meaning of the terms I employ. Among 
the events of inflammation I include only the loccd changes observed in its course. 
To those which are constitutional I must afterwards revert. 

You will recollect that I did allude, in the last lecture, though in a very brief 
manner, to these local events of inflammation. Their frequency and importance 
render it necessary that we should consider them somewhat more particularly. 

One of these events is the simple subsidence or resolution of the inflammation : 
this may strictly be called a termination also. The congestion of the blood-vessels 
increases till the blood stagnates in some of the capillary canals towards the centre of 
the affected part, which is then said to be inflamed; but the disease goes no further ; 
there is no escape of the blood, nor of any part of the blood, nor of any of the con- 
stituents of the blood, beyond its natural channels : or, at any rate, there is no sensible 
evacuation into the inflamed tissue, or next to none. The inflammation begins to 
recede ; the stagnant blood is again set in motion ; if there have been some slight 
effusion, it is re-absorbed ; the rapidity of the circulation in the surrounding vessels 
diminishes ; and the part returns, in all respects, to its former condition and integrit}^. 
This may be considered the spontaneous cure of inflammation ; and to this event 
there seems to be always a natural tendency. It may be promoted, sometimes, by 
art. 

When the process of resolution is unusually sudden and rapid, (as it occasion- 
ally is, the well-marked phenomena of inflam^mation completely disappearing in a 
few hours.) it is called by our neighbours, the French, delitescence. And when the 
symptoms of infl-ammation thus suddenly desert one part, and show themselves im- 
mediately afterwards in another (as not unfrequently happens in respect to the joints 
in acute rheumatism, and between the parotid gland and the testicle or mamma in 
the mumps), metastasis is said to take place. 

This transference, as it were, of morbid action from one part to another is a very 
curious circumstance. It is one which we sometimes endeavour to imitate. We 
excite inflammation upon the surface, where we know its effects will be of com- 
paratively httle consequence, in the hope of diverting it from some internal organ in 
which it threatens to work serious or even fatal changes. Yv"e follow the same 
principle perhaps when we apply purgative medicines to the mucous membrane of 
the ahmentary canal. To denote the mode of cure, by stimulating distant parts, the 
terms counter-irritation, derivation, and revulsion are employed. 

Most commonly, even under moderate inflammation, some amount of extravasation 
takes place into the texture or from the surface of the part. 

The first effect or event of that kind which we notice, is the pouring out or effusion 
of serous hquid. The liquid is so like the serum of the blood, that it is called serosity 
or serous hquid ; and there can be no doubt, I conceive, that it consists of the serum 
of the blood, shghtly modified perhaps. You will recollect my stating that the 
swelhng wliich accompanies phlegmonous inflammation is not equally firm through- 
out the whole extent of the inflamed part that it is hard in the centre, softer towards 
the circumference ; and that in the latter situation it sometimes retains for a few 
seconds the impression of one's finger; — pits. Now this results from the effusion 
of serous fluid into the areolar tissue immediately surrounding the part inflamed : it 
is neither more nor less than (Edema, — oedema (which may exist also quite inde- 
pendently of inflammation) being a filhng or infiltration of the areolar tissue with 
serous fluid. Anasarca is an example of the same state, on a larger scale. Now 
anasarca is very constantly produced by some impediment to the passage of the 
blood along the veins ; the serous portion of the stagnating blood transudes through 
tne coats of the vessels : and I apprehend that the same explanation may be given 



COAGULABLE LYMPH. 



107 



of the less extensive oedema which takes place around a phlegmon ; the blood 
being stagnant in the neighbouring capillaries. 

But whatever may be the intimate cause of serous effusion, it is one of the earliest 
events of inflammation; and in some cases it is its most important event; producing, 
mechanically, new symptoms, and giving rise to conditions of the most perilous kind. 
The quantity of serous fluid poured out in a short time is often immense. One of 
the pleura may be thus filled in' a few hours, and the whole of one lung strongly 
compressed, and the respiratory apparatus reduced to one half of its customary effi- 
ciency. And if inflammation ,and effusion should take place on both sides of the 
chest at once — if double pleurisy should occur, as it sometimes does — the patient 
must presently perish by apncsa, unless his condition is recognized, and free vent is 
given to the fluid. More tha^n once or twice have I seen persons snatched from the 
brink of suffocation by what is called tapping the chest. Fatal coma is no uncom- 
mon result of the effusion of serosity, as an event of inflammation, into the ventricles 
of the brain. 

Even in the areolar tissue, where it is properly enough called oedema, a very 
trifling amount of this serous effusion may be sufficient to destroy life : when, for 
instance, it takes place into the submucous areolar tissue of the glottis, closing up 
by its pressure that httle chink, the rima glottidis, and suffocating the patient after 
another fashion. Here also art may come to the rescue : an artijicial chink or hole 
is made for the entrance and exit of air, below that part of the larynx in which the 
disease is situated, and the patient is delivered from imminent death. I have had 
two cases under my own care, and have seen several others, in which life ivas so 
preserved. I allude to such cases now, merely to convince you of the importance 
of attending to this event of inflammation, and of studying tlie indications of its 
existence. 

Sometimes some of the small vessels give way, and hemorrhage into the part 
becomes an event of inflammation. Some sKght degree of this occurs probably in 
most cases ; and we frequently find that the colouring matter of the blood is mixed 
with other effusions, giving to the serous liquid a deep tinge of red. 

I hinted before, that we must not infer inflammation from the presence of serous 
effusion alone. Serum will exude, I believe, from loaded veins, even after death ; 
but this never can be much in amount. It is certain that dropsical effusions may be, 
and very often are, the result of congestion of a purely mechanical kind. 

A third event of inflammation is the effusion of what is called coagulable lymph, 
which, as I explained to you before, appears to be nothing else than the fibrin sepa- 
rated from the other constitueffts of the blood, and concreted. It is poured forth, at 
first, in a state of solution, or in a soft semi-fluid condition, and mixed with more or 
less serosity ; but the fluider parts of the effusion are either soon reabsorbed, or soon 
separate themselves from the fibrin, which becomes firmer, and at length solid. The 
hard central portion of a phlegmon, in its earliest stages, owes its hardness to the 
presence of coagulable lymph in the natural interstices of the inflamed part ; and a 
similar interstitial deposit of the same substance is common in various parts of the 
body, as a result or concomitant of inflammation. What is called hepatization of 
the lung is one instance : the spongy texture of the lung is blocked up and solidified 
by this lymph. In certain cases of erysipelas, as well as in phlegmonous infl.am- 
mation, the subcutaneous areolar tissue is rendered dense and hard in the same way. 
The white opaque spots which are often seen upon the cornea are produced by 
lymph interposed between the layers of that naturally transparent structure. But 
the most striking examples of the effusion of coagulable lymph are to be seen upon 
the surfaces of inflamed membranes : it forms a web or layer which by degrees 
assumes, itself, a membranous appearance ; and is accordingly cafled by morbid 
anatomists a false or an adventitious membrane. Sometimes several layers of this 
kind are spread over each other, forming adventitious membranes of great thickness. 
When coagulable lymph is thus poured out between membranes that are habitually 
in contact with each other, it often causes them to cohere ; just as two leaves of a 
book may be made to stick together by a layer of paste put between them. This 
resuk is very common indeed with serous membranes, especially the pleurse, the 



108 



INFLAMMATION. 



pericardium, and the peritoneum. Lymph is said also to be poured out, under 
violent inflammation, from mucous surfaces. In croup, the interior of the trachea is 
inflamed, and a substance exudes which assumes a membranous form, and adheres 
more or less firmly to the sides of that tube, or is coughed up in ragged fragments. 
A similar efliision takes place occasionally from the mucous lining of the alimentary 
canal, and is expelled, with the other contents of the bowels, in shreds, or in tubular 
portions, which are, in fact, casts of the interior of the gut. I say coagidable lymph is 
said to be thus poured out ; but it is more than doubtful whether the false membranes 
in these cases are really composed of fibrin. Similar films form within the uterus, 
and are moulded to the exact shape of its cavity, and marked with indentations that 
correspond to its rugss ; and these membrane-like casts are at length separated and 
extruded. These last are not very common ; but I show you one which came from 
the uterus of a young woman who was a patient of mine in the Middlesex Hospital 
not very long ago. You may see lymph deposited like beads, upon the anterior 
surface of the iris under inflammation ; or gluing its posterior surface to the crystal- 
line lens behind it, and rendering the pupil irregular, and sometimes immovable. 
The internal surface of the heart, and especially its valves, are often studded with 
portions of lymph much resembling warts. When the opposite sides of an artery 
are brought together by a hgature, they inflame, and become united by the same 
medium. Coagulable lymph is effused, in the course of a few hours, upon the 
edges of a cut wound ; and they adhere, under favourable circumstances, when 
placed in mutual apposition. This surgeons call union by the first intention; and 
the inflammation which is accompanied by all kinds of exudation of lymph, or fibrin, 
is called adhesive inflammation ; or the adhesive stage of inflammation. 

It is seldom that coagulable lymph alone is thus poured out. Sometimes it is 
tinged with the colouring matter of the blood. Oftener it is mingled with, or at first 
dissolved in, a large quantity of serous fluid. When this happens in serous bags — 
as in the pericardium or pleura — the thinner fluid may keep the opposite membranes 
apart ; and for some time, or entirely, prevent their agglutination. Sometimes the 
agglutination is partial, and the uniting portions of lymph are stretched out, by the 
distending effect of the fluid effusion, or by the natuml movements of the parts, into 
strips or bridles of adhesion. 

I must call upon you to notice, in passing, that although this event of inflamma- 
tion may sometimes perhaps have a detrimental or destructive consequence, yet that 
in a vast majority of instances it is distinctly a salutary and conservative event. 
Vision may, no doubt, be destroyed by a plug of lymph which shuts up the pupil 
of the eye. A portion of intestine may become strangulated by a band of adhesion. 
Of this, which is a mere accident of the adhesion, I have seen some fatal examples. 
The closure of the trachea by the membrane of croup is not, in my opinion, a fair 
case in point. There are, at any rate, but few exceptions to the rule, that the effu- 
sion of coagulable lymph proves beneficial by preventing some worse event of the 
inflammation. It is better that inflammation of the areolar tissue should be limited 
and hemmed in by a barrier of lymph, than that it should extensively diffuse itself. 
It is better that the bag surrounding the heart, when it happens to be inflamed, 
should become adherent to that organ, than that the inflammation should run on into 
suppuration, and fill the pericardium, and oppress the heart, with pus. In the one 
case hfe may continue for several years ; in the other it seldom lasts many days. It 
is clearly more desirable, and more consistent with the safety and comfort of the 
patient, that his lungs should be fastened to his ribs, than that they should be com- 
pressed and flattened against his vertebral column. I shall have occasion so fre- 
quently to speak of this protecting and reparative tendency of adhesive inflammation, 
that I do not more than point it out to you at present. 

When lymph has been effused upon an inflamed surface, it very readily becomes 
vascular and organized. Red streaks begin to be visible in it. These are incipient 
blood-vessels, which may soon be seen to communicate freely, and to be continuous 
with the blood-vessels of the inflamed part. The plastic lymph is fashioned into a 
definite structure, and made a hving constituent portion of the body. It is in truth 
this remarkable plastic property belonging to the effused lymph, tliis aptitude for 



COAGULABLE LYMPH. 



109 



being organized, which invests the adhesive inflammation with its guardian and repa- 
rative character. None of the other fluids poured out under inflammation are capable 
of this change. It is in this way that the hps of recent wounds, and the surfaces of 
inflamed membranes in contact with each other, are permanently stitched together 
(if I may use so homely a metaphor'), by living vascular threads. By this needle- 
work of nature parts recently severea from the body may sometimes be replaced ; 
or even transferred and affixed .to other situations, as in the Talicotian operation, 
whereby a new nose is engrafted in the place of that which had been lost. It is 
thus that ulcers fill up ; successive layers of lymph exude, and are in succession 
attached to the ulcerated surface, and incorporated by this organizing process, until 
the breach of texture is repaired. The lymph thus organized comes at last to resem- 
ble, very exactly, areolar tissue, more or less condensed. 

The length of time required for the pouring out of coagulable lymph in inflamma- 
tion — and for its organization after it has been poured out — is variable under differ- 
ent circumstances. It is often effused very early. Dr. John Thompson found a 
distinct layer of it covering wounds he had made in an animal, in less than four 
hours after they were inflicted ; and cases are related, in which vascular organiza- 
tion of the effused lymph has appeared to have been effected within the space of 
twenty-four or thirty-six hours. Sometimes, on the other hand, many days seem to 
elapse before any such organization is observable. 

When serous fluid and coagulable lymph have been poured out in considerable 
quantity, and simultaneously, the serous fluid is often rendered turbid by the admix- 
ture of small portions of lymph, or of albumen, diffused through it ; and flakes of 
lymph sometimes float in it, or settle, in virtue of their specific gravity, at the lowest 
part of the cavity containing the effiised matters. 

Several conditions seem necessary to ensure this adhesive form, or adhesive stage 
of inflammation. The inflammation must reach a certain degree of intensity, or no 
lymph will be effused ; it must not go beyond a certain degree of intensity, or the 
next event I have to mention, the formation of pus, will interfere with the adhesive 
process. We learn also from what takes place in recent wounds, that seclusion 
from the air, and the absence of all other causes of irritation, are necessary for adhe- 
sion, or union by the first intention. 

The formation of pus — suppuration — is a fourth event of inflammation, to which 
brief allusion has already been made. 

Many opinions have been broached respecting the nature of pus, and the manner 
in which it is formed. I shall not trouble you by discussing, nor even by narrating 
them, but limit myself to stating what are the notions held on these points by the 
most able and the most recent observers. 

Pus, then, as I told you before, is altered blood. It is an opaque, smooth, yellow- 
ish fluid, of the consistence of cream, and having no smell. I speak now of well- 
formed, or what is called good, or healthy pus ; what the old writers spoke of as 
pus laudabile. This has been thought an absurd epithet: but it serves as well as 
any other to express what was meant, viz., that kind of pus which accompanies 
benign forms of inflammation, and indicates that all is going on regularly, and pro- 
mises a fortunate ending : pus, in short, the appearance of which was to he com- 
mended. It is certainly not more absurd than the term healthy pus. This pus 
laudabile was described as being album, Iseve, et sequale — hght-coloured, smooth, 
and homogeneous. This description of good pus has descended from the time of 

Hippocrates, who says, To 8s tCvov, apcd-tov %svxov ts hai, xai ofiaTiop, xai Xsiov, xcu 7]xt,6'ta, 

6Dffw83j. It consists of yellowish globules, diffiised through a thinner fluid, which 
resembles in some respects the serum of the blood. " If six or eight ounces of good 
pus be suffered to stand in a phial, it will separate into two portions : a yeflowish 
matter will sink to the bottom, and there will be a slightly yellow, clear, superna- 
tant fluid, hke oil in appearance, but not greasy to the touch." The sediment con- 
sists of the globules ; which Gendrin supposed to be the red globules of the blood, 
altered ; deprived of their coloured envelops, and swollen or enlarged. But, as I 
stated before, the opinion now prevalent among pathologists is that these pus-globule« 
are transmitted "colourless corpuscles ;" moreover, that they are hollow cells. 



110 



INFLAMMATION. 



There are various modifications of pus ; and its qualities are liable to rapid altera- 
tion b}' various circumstances. Sometimes the globules are few in proportion to the 
more watery part ; and then the pus is said to he ichorous. It is sanious vchen 
some of the colouring matter of the blood is poured out with it. It is sometimes 
viscid and slimy, from an admixture of mucus ; or flaky and curdled, which is com- 
mon in scrofulous persons. Sometimes, also, instead of being inodorous, it is horribly 
fetid. All abscesses that form in or about the alimentary canal are apt to contain 
pus of an offensive odour; as those which occur in the tonsils and near the rectum. 
A patient of mine, in the hospital, had a fluctuating tumour in the epigastrium, 
which Mr. Arnott opened. There came out the collapsed bags of two or three 
hydatids, and a quantity of stinking pus. The liver, no doubt, was the seat of the 
suppuration in this case — and perhaps the stench might be owing to the death and 
decomposition of the hydatids. 

Great pains have been taken by many persons to discover some sure criterion 
between pus and m.ucus. Healthy pus and healthy mucus are so totall}^ tinlike 
each other, that they never can be confounded together. But sometimes we can 
scarcely say whether we are looking at mucus so altered as to resemble pus, puri- 
form mucus — or at genuine, though not perhaps praise worthj^, pus. I shall tell )^ou 
what has been made out upon this point hereafter, when I treat of phthisis ; and I 
shall show you at the same time that the distinction has not that great importance 
Vv'hich is sometimes assigned to it. 

Pus may be poured out into one of the natural cavities of the body, and then it is 
cahed purulent elusion. It may be contained in a closed cavity, which is not natu- 
ral, but formed by lymph and condensed areolar tissue ; and then the collection of 
pus is called an abscess. It may also proceed from a free surface of the body — as 
the slvin, or a mucous membrane, or a superficial sore. 

In the natural cavities of the body pus seems, sometimes, to mingle gradually 
with the serous effusion, which grows turbid and whitish, and at length distinctly 
assumes a puriform character. But in much the greater number of cases the forma- 
tion of pus is preceded by the effusion of coagulable lymph, with or without the 
eflusion of serous fluid. The pus in these cases appears to be poured forth or 
secreted by the coagulable lymph after it has become organized. Its formation 
seem.s to characterize a more advanced stage of inflammation — to denote that the 
inflammation has been pressed a httle beyond the adhesive stage. This was the 
opinion of John Hunter, who was the first to teach us anj^ thing worth knowing 
about the process of inflammation. It is also the opinion of Gendrin, one of the 
latest and most successful investigators of that process. Hunter thus expresses him- 
self on this subject : — " The new formed matter pecuhar to suppuration is a remove 
further from the nature of the blood than the matter formed by adhesive inflamma- 
tion." And Gendrin says, " betvv'een the purulent fluid of inflamed tissues, and the 
organizable coagulable fluid (f. e., between pus and coagulable lymph), there is but 
one degree of more.''^ 

Even the preventing or the allowing the access of air to the surface of a recent 
cut will make all the difference between adhesion and suppuration. And the same 
influence of the air in promoting the suppurative process in preference to the adhe- 
sive is remarkably seen in various other cases. In simple pleurisy — from exposure 
to cold — we seldom have any hquids efl'used, except coagulable lymph and serous 
fluid. But if the inflammation has been caused by a punctured wound from without, 
or by laceration of the jMlmonary pleura by the sharp end of a fractured rib, or by 
a perforation of the pulmonar}'- pleura by the extension of a vomica in the lung — in 
all which cases air finds its way into the cavity of the pleura — then true empyema 
results — pus is formed. So also in pneumonia: at first the inflamed lung is rendered 
sohd by the effusion of coagulable lymph into the air cells ; but if the inflammation 
persists, the next thing that happens is what is called by Laennec gray hepatization 
— a puriform infiltration takes the place of the lymph. The same principle is exem- 
plified in the case of the urethra ; inflammation of the free surface of its mucous 
membrane leads rapidly to the formation of pus ; inflammation of its attached, surface 
occasions the pouring out of lymph, which produces stricture. And in general I 



ULCERATION. 



Ill 



think it may be said of surfaces that are open to the air, of tegumentary membranes, 
that either pus is formed upon them, under inflammation, without any previous 
effusion of plastic lymph, or the lymph is shght in amount, and transient in duration, 
and presently superseded by a puriform discharge. We have every-day examples 
of this, in inflammation of the conjunctiva, of the bronchi, and of the bladder. Per- 
haps it is in this principle that we may find an explanation of the fact that whereas 
in the inflamm^ation of the areolar tissue, of glandular organs, and of the parenchyma 
of the viscera generally, the pus which forms is collected into an abscess ; circum- 
scribed abscess in the substance of the lung, from common inflammation, such as we 
are now considering, is very rare indeed. This is a point which will of course 
come under our consideration again. 

There is, however, manifestly a close connection in many cases between the effu- 
sion of lymph and the effusion of pus ; although the progress and effects of adhesion, 
and suppuration are very different. When suppuration takes place, the pain belong- 
ing to the inflammation usually abates, or ceases, except when the pus is imprisoned 
so as to keep up the pre-existing tension. Certain remarkable constitutional pheno- 
mena also declare themselves, which I shall notice again hereafter. 

The effusion is longer continued in the case of suppuration ; and the quantity of 
pus is more copious generally than of lymph, especially in the serous and tegu- 
mentary membranes. When pus is diffused through the natural textures it tends to 
soften and separate them — to break them down : whereas the direct effect of the 
deposition of lymph in the same parts is to consolidate and harden. 

The time required for the formation of pus is extremely variable. Suppuration 
sometimes very quickly follows the commencement of the inflammation ; within a 
few hours, as in gonorrhosa. Sometimes it is postponed to a very distant period, 
even for weeks. 

The duration of the suppurative process is also uncertain, and seems to have no 
fixed relation to the intensity of the inflammation by which it has been preceded or 
accompanied. 

A. fifth event oi inflammation is ulceration. You may remember my telling you 
that Kaltenbrunner observed the progress of absorption in the inflamed tissues which 
he examined by the help of the microscope : how the stellated spots gradually 
vanished from the web of a frog's foot, and the fat from the mesentery of the rabbit. 

Independently of these microscopical observations, it is quite evident that absorp- 
tion goes on, often very actively, during the continuance of inflammation. The 
effused fluids, or products of inflammation, the serum, the lymph, the pus, are partly 
taken up again ; and not only are these products of inflammation hable to be so 
removed, but the original textures of the body are carried off by absorption. We 
cannot have a better proof of this than the progress that an abscess makes to the 
nearest surface at which the pus it contains may be discharged ; the intervening 
textures are gradually absorbed. Perhaps a great part of the principle concerned in 
this progressive approach to the surface is pressure. The harder tissues of the 
body, the bones themselves, yield and disappear before the increasing pressure of an 
aneurismal tumour. In this case the absorption appears to be independent of 
inflammation. 

But taking the process as one of the events of inflammation, we may say with. Dr. 
Alison that, whenever the absorption of the effused lymph, and of the surrounding 
textures, takes place in excess — in a greater degree, that is, and more irregularly 
than seems to be required for any useful purpose— the result is ulceration. The 
term is, however, commonly restricted to those cases in which the loss of substance 
occurs upon some surface, internal or external. 

Many circumstances influence the occurrence and progress of ulceration ; and 
great differences are observable between the different tissues, in respect to the facility 
with which they severally ulcerate. Ulceration is most common in the tegumentary 
membranes. It is frequently met with, also, in the inner coats of the arteries, in 
cartilages and in bones. But we are not always sure that it is in these cases an 
event of inflammation. Ulceration is rare in fibrous tissues of all kinds, in serous 
membranes, and in the outer coat of arteries. These differences have important 



I 



1] 2 INFLAMMATION. | 

pathological bearings. But I may not stop to consider these at present : they will 
be particularly noticed as the course proceeds. When I state that ulceration may 
lead to perforations of the alimentary canal— of the air-tubes — of the gall and urinary i 
bladders — of the blood-vessels ; and to the fatal escape of the natural contents of ' 
these organs ; I have said enough to convince you that ulceration, so frequently the | 
object of the surgeon's care, requires no less attention on the part of the physician. 

There are certain forms of ulceration that are specific in their nature : with these I 
I do not at present meddle. The process of ulceration is very clearly explained in I 
Dr. Ahson's admirable Outlines of Pathology. j 

There are three things generahy going on at the same time in an ulcerated sur- 
face. First, there is an effusion of plastic lymph, by which what are called granu- ; 
lations are formed. Granulations consist of coagulable lymph which has become 
organized; furnished with numerous delicate blood-vessels. Secondly, there is 
suppuration ; and, thirdly, there is absorption or the removal of parts. | 

Sometimes, apparently, there is no suppuration ; we see no pus in ulcers of the | 
cornea, nor in certain cases of absorption of articular cartilages. ! 

When the first of these three processes gets the better, if I may so speak, of the ! 
others, the lymph overspreads the surface of the ulcer, fills up the cavity, and the j 
ulcer heals : cicatrization takes place. ! 

When, on the other hand, the absorbing process predominates, the ulcer extends 
itself — the excavation grows larger, or deeper — or both larger and deeper: and 
when thfs excess of absorption is great, and the extension of the ulceration rapid, it 
is called phagedenic ulceration. When a part of the textures perishes during the 
process of the ulceration, and is separated in entire and sensible masses, the ulcer is 
said to be a sloughing ulcer. " When the process is slow, the lymph eifused at the 
base and round the edge of the ulcer is hardened, and the granulations on its surface 
are deficient, the ulcer is then said to be callous or indolent : and when the granu- 
lations are larger and softer, and more flabby than usual, and require to be repressed 
before the ulcer will heal : to this variety of ulcer the name of fungous ulcer is \ 
given :" and the coarse and too luxuriant granulations are called, by the vulgar, 
proud flesh. These several terms, in the senses now assigned to them, you will 
please to remember. 

It is by regulating the three processes now described — so far as they are capable | 
of being regulated by art — that the surgeon and the physician endeavour to obviate 
the threatened ill consequences of ulceration, and to promote the repair of the tex- \ 
tures which have been destroyed. \ 

I explained to you, in a former lecture, that inflammation may lead to a wasting ' 
of parts, although there is no suppuration or ulceration. The testis sometimes withers j 
as a consequence of inflammation : interstitial absorption takes place. Atrophy, in 
short. i 



LECTUHE XI. 

Mortification, as an event of Inflammation. Inflammatory Fever. Hectic j 
Fever. Typhoid Fever. Modification of Inflammation hy differences of 
Tissue; Areolar Tissue; substance of Glands and Solid Viscera; Serous 
Membranes; Synovial Membranes; Tegumentary Membranes — Skill — Mu' 
cous Membranes; Muscular Tissue; Arteries; Veins; substance of the | 
Brain. I 

We were occupied, when last we met, with what may be properly called the 
events of inflammation. We passed in review, 1st, resolution as an event of in- 
flammation ; 2dly, serous effusion; 8rdly, the pouring out of coagulable lymph, con- 
stituting the adhesive form or stage of inflammation ; 4thly, the formation of pus, or 
suppuration ; and Sthly, ulceration. The pathology of these several events, so far 
as it is understood, and the change of symptoms to which they may respectively lead, ; 



MORTIFICATION. 113 



were also treated of as fully as the limits of my course allow. At the close of the 
lecture I was about to speak of the sixth and last event of inflammation that requires 
to be noticed : viz. gangrene, sphacelus, mortification. 

When mortification thus succeeds to inflammation, the part dies ; it becomes cold ; 
all circulation through it is at an end ; all sensation in it is over. If it be an 
external part, its colour changes ; from being red, it becomes mottled, purplish, green 
or black ; decomposition takes , place ; vesications appear, filled with dark-coloured 
liquids ; air is extricated also. If there be a great accumulation of fluid in the 
part there will still remain tension ; but usually the mortified part is flaccid and 
^oggy ; and it emits a cadaverous smelJ. 

When internal parts mortify under inflammation, they do not always assume this 
black appearance ; often they are yellowish ; or the soft tissue of the dead part 
readily imbibes fluid, and takes the colour of the substances with which it has been 
in contact. We see sloughs of the mucous membrane of the intestines presenting 
the ochrey hue of the fgecal matters which had rested upon them. 

What I have described as mortification, occurring externally, and succeeding to 
inflammation, is such as the surgeon witnesses. Sometimes it spreads, and loses and 
confounds itself, insensibly, with the adjoining parts, which still retain life ; and 
which may continue actively inflamed, and subsequently perish also. Under more 
favourable circumstances, a distinct boundary line is formed between the dead an^ 
living parts ; and nature proceeds to amputate the portion which has lost its vitality. 
The process by which this is effected is extremely interesting. Adhesive inflam- 
mation constructs a barrier ^f lymph against any further advance of the mortifi- 
cation ; a furrow of ulceration marks out upon the surface the commencing 
separation, and (supposing a part of one limb to have become gangrenous, the foot 
for example) the furrow gradually deepens, until the dead part is completely cut olf. 
This very fact shows that all the textures of the body, skin, muscle, nerve, blood- 
vessel and bone, are capable of being removed by the ulcerative process. Mean- 
while very interesting changes occur in the part that lives : the large vessels are 
plugged up, to a certain distance, by the coagulation of the blood contained in them 
the coagulation of the blood following its stagnation. They are further sealed. up 
and the smaller vessels also are closed, by coagulable lymph. Were it not for these 
changes, fatal hemorrhage would follow the separation of the dead part. Now this 
is just what a surgeon rudely imitates when he amputates a hmb; he cuts through 
the parts with knife and saw, and he lies the larger blood-vessels as he goes along. 
He follows the path which the natural processes point out ; and, in truth, a great 
part of both physic and surgery consists in learning what are the expedients of repair 
and preservation for which provision has been made in the living body ; in exciting, 
or repressing, or directing, or imitating those natural actions which generally tend, 
and often suffi.ce, to restore health and to save life. 

Mortification is more common in some internal parts than in others. It is frequent 
in the areolar tissue ; and in the mucous and submucous tissues of the ahmentary 
canal ; in the throat, for example, in cynanche maligna ; and in the glandular parts 
of the intestines in fever. 

[The affection of the throat in cynanche mab'gna is not, strictly speaking, mortification. It 
has been shown by Bretonneau and others, to be a true pellicular inflammation. The false 
membranes, by which the fauces are covered, either in part or entirely, becoming tinged with 
blood, assume a dark or almost black appearance, and exhale an intolerable foetor — which 
circumstances have caused them to be mistaken for sloughs — but when they become de- 
tached the raucous membrane is found to be perfectly entire, and without any appearance 
of softening; the peculiar odour of gangrene, also, is alDsent. — C] 

Mortification seldom affects the other mucous systems — those which belong to the 
air-passages and the urinary organs. It occurs sometimes — but not very often — 
in the substance of the lungs. It is seldom met with in serous and fibrous tissues. 
It is not at all uncommon in bone : producing exfoliation when it is slight and su- 
perficial; necrosis when the entire shaft of a long bone dies. In these cases the 
process is slow, and we can watch its repair ; and a beautiful process it is : but I 
must not stop even to admire it. 

8 K% 



114 



INFLAMMATION. 



Now mortification is no certain or constant event of inflammation. It depends, 
more or less upon various causes and conditions. Sometimes, upon the naere in- 
tensity of the inflammation, as sloughing inflammation of the genitals ; the progress 
of the mortification being best checked by those measures which are calculated to 
abate the violence of the inflammation. The sloughing of the cornea in gonorrhoea! 
ophthalmia is another example to the same purpose. 

Again whatever tends to weaken the circulation in the part affected — or in the 
system at large — tends also to promote the perishing of the textures that are inflamed. 
In persons who are debilitated by fever, the mere pressure of the body against the 
bed is enough to produce sloughing of the integuments of the sabrum, hips, and 
elbows. The same phenomena are apt to occur in parts that are palsied. In drop- 
sical patients, with feeble and impeded circulation, we find that a blister on the 
extremities, where the circulation is the most feeble, will sometimes cause mortifi- 
cation ; while it might be applied to the chest without any risk of that event. Pro- 
bably, in each of these instances, the unheakhy condition of the blood conduces to 
the sloughing process. Inflammation of the stomach and intestines is marked by 
a strong disposition to run into gangrene — and this again is consistent with what 
I formerly mentioned, of the depressing influence of inflammation of these organs 
upon the heart. 

• It is necessary to remember that mortification is capable of being produced by 
other causes, as well as by inflammation. The death of frost-bitten parts is perhaps 
scarcely an exception — the phenomena of mortification occur in them after the re- 
application of a certain degree of heat — sufficient, probably, to give rise to more 
action than the frozen parts can bear without perishing. But the mere cutting off 
the supply of arterial blood, independenfly of any inflammation, will cause mortifi- 
cation. Ossification of the arterial trunks, and consequent stagnation and coagulation 
of the blood in them, is the commonest cause of the dry gangrene of old persons— 
gangrena senilis; which, by the way, is not always dry. In the majority, however, 
of these cases, the gangrenous part, not being preternaturally loaded with fluid, does 
not so rapidly putrefy ; but remains dry and shrinks up again. Again, whatever 
tends to prevent the return of the venous blood from a part (as a firm ligature placed 
round a limb — or the constriction of the gut in strangulated hernia), is favourable, 
also, to the production of mortification. Probably, here, too, the direct or indirect 
pressure made upon the arteries is chiefly concerned in occasioning the death of the 
part. We see limbs mortify sometimes after their principal artery has been tied for 
the cure of aneurism, when the collateral arterial circulation fails sufficiently to 
establish itself: we see the same thing when the passage of the blood through the 
main artery is stopped by external injuries. 

There is also a very curious form of chronic and dry gangrene, produced by the 
continued use of diseased grain as food — and particularly of the spurred rye ; and 
to this, as a distinct disease, I may perhaps have occasion to direct your attention 
hereafter. 



The different stages and events of inflammation that have now been described are 
accompanied by corresponding disturbances of the system at large. These were 
touched upon (barely mentioned, however) in that rough and general outhne which 
I attempted to sketch in the outset, of the various phenomena of inflammation ; and 
to which I have since referred as a type. They require, for many reasons, to be 
considered somewhat more minutely. 

When, as surgeons, you have to deal with external inflammation, you have no 
difficulty, in the first place, in ascertaining its actual existence : you see it ; and you 
know, besides, merely by looking at the part, and perhaps handling it, what changes 
it has undergone. You may perceive that the opposite lips of a wound have ad- 
hered : or that a phlegmon, in which you can also detect fluctuaUon, has assumed a 
pyramidal form, and begins to look white upon its summit; or you observe that the 
abscess has broken and left an ulcer behind it, which pours out pus, and which 
shows a tendency to contract, or to enlarge itself: or you may remark the alteration 
of colour and of temperature which denotes the approach of mortification, or the 
actual death of the part. The mere exercise of your external senses apprises you, 



INFLAMMATION. 



115 



hot merely that there is inflammation, but also whether it is of the adhesive kind ; 
or has reached the degree of suppuration^ or has produced gangrene. At the 
same time you do not fail to notice the nature of the constitutional disturbance that 
may be present ; and the knowledge thus obtained of the local and of the general 
symptoms determines your plan of treatment. 

But when, as physicians, we have to do with inflammation of internal parts of 
the body, and when the local changes attendant upon that process are concealed 
from our view, the case is very different. We should often be unable to make out 
the nature of the disease at all, if the presence of pyrexia did not instruct us. Some- 
times the constitutional disturbance is all that is apparent until after death. And, 
as the disease proceeds, we frequently are able to judge that this or that event of 
inflammation has taken place, only by observing the indirect symptoms which de- 
clare themselves through the medium of the system at large. Yet it is in many 
cases of the greatest importance to mark the transition from one stage or event of 
inflammation to another ; and to learn whether, and in what degree, the more urgent 
of the symptoms depend upon the inflammation itself; or upon the effects which it 
has produced. I do not mean to say that we have not, sometimes, as sure indica- 
tions afforded us by direct symptoms, cognizable by the sense of hearing or of touch, 
of the state of internal organs, as we could have if they were exposed to our view. 
To these direct symptoms I am not now about to refer ; they must be spoken of in 
connection with the diseases to which they belong. But the information which the 
physician gains from what may be called constitutional symptoms is always highly- 
valuable : and it is sometimes the only information that offers any guidance to the 
remedial measures he ought to adopt. 

Inflammation sufficiently extensive or intense to disturb the general system at ah, 
is attended with pyrexia ; and the presence of pyrexia, when the part affected is 
unseen, marks the nature of the disease. The most prominent of the symptoms 
that denote the existence of infiammatory fever are debihty and chilliness, followed 
by, or alternating with, increased heat of skin, and increased frequency and force, 
and often hardness o{ the pulse, with considerable derangement of most of the natural 
functions of the body. Commonly there is headache and confusion of thought, lan- 
guor, thirst, loss of appetite, a furred or white tongue. 

Among these leading symptoms, the chiUiness, often amounting to shivering, has 
this particular importance attached to it, that it marks the date of the febrile disturb- 
ance. And it is worth observing, that rigors more commonly attend the commence- 
ment of spontaneous inflammation than of inflammation caused by external injury. 

Now, without going more into detail — of this febrile condition belonging to the 
early stage of inflammation, I make the following remarks : 

1. That it generally succeeds the manifestation of the local symptoms of the inflam- 
mation : and that we cannot, therefore, help considering the fever as the natural 
effect of the inflammation. 

Kaltenbrunner describes an experiment of this kind. He says, if a drop of alcohol 
be apphed to the web of a frog's foot, the blood presently flows towards the part irri- 
tated, and the circulation in it is accelerated; congestion takes place, and follows its 
known march. 

If the dose of alcohol be augmented, the phenomena of congestion increase con- 
siderably, and extend over a larger space : at length points of stao-nation appearino^ 
in the focus of the affected part announce the establishment oi^ injiammation. 

If the dose of alcohol be still further increased, we observe that, on the one hand, 
the inflammatory points of stagnation become larger and more numerous ; and that, 
on the other, the circumferential disturbances of the circulation extend themselves, 
so as at length to imphcate the whole of the circulating system : they give rise to a 
fever which is added to the iriflammntion. The circulation in the web of the oppo- 
site foot is as much accelerated as in the vessels surrounding the inflamed part in the 
first foot. If the word congestion had not a local meaning, we might call fever (he 
says) a general congestion. • 

Perhaps the fever may be owing to the circulation of altered blood throughout the 
body. We know that the blood is altered in these cases, inasmuch as it is found to 



116 



INFLAMMATION. 



contain an unusually large proportion of fibrin ; and it has acquired the unnatural 
quality whereby, when withdrawn from the body, and allowed to coagulate, it exhi- 
bits the buffy coat. 

That the febrile state follows the local inflammation in point of time, is then the 
rule ; but this rule has frequent exceptions. Erysipelas, and all the febrile exanthe- 
mata, afford instances of exception ; the fever sets in before any manifestation at 
least of the local symptoms. These are indeed diseases of a specific kind : but the 
same is true sometimes of diseases that appear to be simply inflammatory ; such as 
inflammation of the lungs, and cynanche tonsillaris. There are other cases in which 
the local symptoms and the general febrile disturbance appear to burst forth simul- 
taneously : this is seen in certain instances of pleurisy, and of peritonitis. 

2. Again, it is a curious circumstance that the inflammatory fever is not always 
proportioned, in its degree of violence, to either the size or the importance of the 
part inflamed. The pyrexia is often very strongly marked in that common com- 
plaint, the quinsy, inflammatory sore-throat, cynanche tonsillaris — which can scarcely 
ever be said to imply much danger. 

3. The situation, the extent, and the degree, of the local inflammation being the 
same, the fever commonly runs higher in young, and in plethoric persons, and in 
those of sanguine temperament, than under the opposite conditions. 

4. The inflammatory fever may be modified in the outset, or very early indeed, 
by the nature of the part upon which the inflammation has seized. I have several 
times mentioned the peculiar depressing effect upon the action of the heart, pro- 
duced by inflammation of the stomach and bowels, and of some other of the abdo- 
minal organs ; and particularly by inflammation involving their peritoneal covering. 
This lowering influence (which is analogous to that of certain mechanical injuries 
to the abdomefi) has been supposed to depend upon the subduing and sickening kind 
of pain which is apt to accompany inflammation of these parts. Probably such, 
pain accompanies, rather than causes, the depression. However the latter may 
arise, it gives a pecuhar character to the inflammatory fever: lessens the amount of 
reaction, or abridges its duration ; affects especially the quality of the pulse ; and 
carries with it a strong tendency towards death by asthenia. 

5. There is no doubt either that the character of the inflammatory fever is liable 
to be considerably modified, from the first, by the previous habits of the patient. In 
persons who have been habitually intemperate — or who have been subject to long- 
continued excitement of the nervous system of any kind — the fever which attends 
inflammation approaches more or less to the typhoid form, from the very beginning. 
The febrile reaction is less strongly pronounced. The functions of animal hfe are 
sooner and more deeply involved in the train of morbid actions. Stupor and dehrium 
are apt to occur; with extreme debihty and irregular movements of the voluntary 
muscles. Still more conspicuous are these peculiarities in some cases of inflamed 
veins ; and whenever inflammation is produced or accompanied by the introduction 
of certain animal poisons into the system. 

6. The relative duration of the inflammatory fever is subject to some variety. It 
may persist for a little while, for a few days, even, after all the local signs of inflam- 
mation have disappeared : this happens chiefly in persons of an irritable habit. We 
watch such cases narrowly, not without some apprehensions of a relapse. On the 
other hand, a rapid abatement of the febrile symptoms sometimes takes place, while 
the local changes continue, or even for a time inci;"ease in extent. Nevertheless, we 
hail this change as a favourable augury of the ultimate result. 

When inflammation, external or internal, has gone on to the formation of pus, that 
event is frequently marked by the supervention of peculiar symptoms ; and the 
character of the fever undergoes, for the most part, a striking alteration. 

It is very important to ascertain the time when this event of inflammation takes 
place, or is at hand ; for the measures which might have been proper and necessary 
while any prospect remained of the resolution of the inflammation, may be useless, 
and even hurtful, if continued after that prospect is at an end. 

When the surgeon perceives any indication of the formation of pus in an external 
part, he mostly despairs of being able to bring about resolution : ceases to abstract 



HECTIC FEVER. 



117 



blood from the part, or from the system ; and applies perhaps warmth and moisture, 
by means of a linseed poultice, to promote the suppuration. And a corresponding 
change of plan is required in imernal inflammations. 

Now the commencement of suppuration is often marked by rigors ; and its con- 
tinucmce by hectic fever. 

If, after the symptoms of inflammation have lasted for a certain time, the patient 
■ is attacked by cold shiverings, fallowed by some increase of heat, that circumstance 
alone is enough to make us suspect that pus is formed, or is about to be formed : and 
to teach us that the measures employed to effect a resolution of the inflammation 
have not been successful. 

Rigors are very striking symptoms ; but they are by no means necessarily con- 
nected with suppuration. They usher in, as I presume you know, most forms of 
fever, appearing at the very outset of the disease. They recur, at regular intervals, 
in intermittent fevers. Slight causes will, sometimes, produce them. They often 
follow the introduction of a bougie into the urethra. But when they occur after 
symptoms of internal inflammation have been for some time present, they denote, 
in most cases, the production of pus in the part of the organ inflamed. Sometimes 
one such shaking fit only is observed : sometimes several take place. When they 
recur it is usually at irregular intervals ; but cases do happen in which the shiverings 
indicative of internal suppuration are so strictly periodic, that unless all the circum- 
stances be carefully taken into the account, they may be mistaken for signs of ague. 

The leading symptoms of hectic fever (by which, I say, the continuance of sup- 
puration is commonly marked) are an abiding frequency of pulse ; alternations of 
chilHness with heat and flushing, followed by perspiration ; a gradual wasting of the 
body ; and progressive debility. 

I shall hereafter have to speak of a very different kind of disease, in which, how- 
ever, there is a succession of symptoms resembhng more or less closely the series 
that characterizes hectic ; I mean remittent fever ; the succession of symptoms being 
chilliness, heat, perspiration. But these two disorders are in most cases discriminated 
from each other by the circumstances under which they occur. 

The symptoms of hectic fever often creep on, at the outset, insidiously, and almost 
imperceptibly. "A very slight degree of emaciation, a pulse a little quicker than 
ordinary, with a small increase of heat, especially after meals, are often the first 
symptoms which can lead us to suspect the formation of hectic." Cullen has de- 
scribed hectic fever as consisting of two exacerbations in the twenty-four hours — 
one about noon, the other towards evening ; but in many cases the latter alone is 
distinctly marked. The patient feels shivery and cold towards night ; then the skin 
becomes hot and dry, especially in the palms of the hands and the soles of the feet, 
and the pulse more frequent ; and in the middle of the night or towards morning, he 
wakes from short and uneasy sleep, in perspiration, which is often profuse. Some- 
times, however, there are two or three fits in a day. The paroxysms are shorter, 
and less regular, than those of intermittent or remittent fever. Each of the three 
phenomena constituting the series may, in its turn, be wanting : and even if the 
paroxysms are regular for two or three times together, they never continue to be so. 
^ Many circumstances connected with the paroxysm itself are very distinctive. " The 
hectic patient," says Dr. Heberden, who has left us a very good account of this 
affection in his Commentaries, " is very little or not at all relieved by the breaking 
out of the sweat ; but is often as restless and uneasy after he begins to perspire as 
he was while he shivered or burned. All the signs of fever are sometimes found 
■ the same after the perspiration is over: and during their height the chilhness will in 
some patients return, which is an infallible character of this disorder. Almost all 
other fevers begin with a sense of cold, but in them it is never known to return and 
to last twenty minutes or half an hour, while the fever seems at its height, which in 
hectic will sometimes happen." 

Hectic fever is one of the fearful accompaniments, and sometimes the most strongly 
marked symptom, of pulmonary consumption: and where the existence of that 
complaint is suspected, yet a matter of doubt, we look for indications of hectic fever 
with the greatest anxiety and dread. 



118 



INFLAMMATION. 



With relation to hectic fever, considered as an indirect symptom that suppuration 
has succeeded to inflammation, and is still going on, it will be worth your while to 
notice the strong contrast it offers, in many particulars, with the injiammatory fever 
that attends the earher stages of inflammation. 

The pulse loses much or all of its hardness and strength, but it remains perma- 
nently more frequent than the pulse of health : the appetite returns in great measure ; 
the thirst abates ; the tongue, instead of being cov,ered with a white fur, becomes 
clean and moist and towards the end is sometimes unnaturally red, or speckled with 
aphthfe : there is no longer headache or confusion of thought. 

A few more touches will suffice to fill up the picture of hectic fever. 

The face is usually pale ; but during the exacerbations it is partially flushed, and 
very often a characteristic circumscribed red spot appears upon either cheek. Besides 
the evident emaciation, various minor changes mark the want of proper nourishment: 
the skin, when not perspiring, is harsh and scurfy ; httle branny scales may be 
rubbed from the legs, merely by the friction produced in drawing ofT the stockings ; 
the hairs become fine and fall ofT; the finger-nails are incurvated into an adunque 
form ; and the sclerotic coat of the eye, as seen through the conjunctiva, becomes of 
a pearly white. As the disease advances (Edematous swellings of the ankles are 
very apt to come on. 

The connection between hectic fever and the formation of pus in some part or 
other of the body is so frequent, that it has been deemed, by persons of great expe- 
rience and sagacity, a universal fact. Dr. Cullen tells us, in his First Lines, that 
he had never seen hectic in any case, when there was not evidently, or when he had 
not ground to suppose there was, a permanent purulency or ulceration in some ex- 
ternal or internal part. And Dr. J. Thomson, speaking of the opinion that hectic 
might occur independently of suppuration, uses these words : " But till facts more 
decisive, and cases more accurately described than any which have yet appeared 
are produced in proof of that opinion, I shall think myself justified in adopting the 
common opinion ; and in believing that hectic fever is in every instance connected, 
if not with the absorption, at least with the formation of pus." 

The notion alluded to in the latter part of this quotation was at one time very 
commonly entertained, viz., that hectic fever resulted from the reabsorption of pus 
into the blood ; but there are many facts decidedly opposed to this behef. Consider- 
able collections of matter not unfrequently disappear, i. e., are taken up again into 
the blood, without occasioning the slightest approach to hectic. Again, hectic will 
accompany, and be kept up by, a scrofulous joint attended with an open sore, and it 
will sometimes cease at once, and completely, upon the removal of the diseased limb 
by amputation ; akhough a greater quantity of pus is secreted by the stump, than 
had been secreted in the diseased part previously to the operation. Facts hke these 
prove, I think, that hectic is not simply a consequence of the absorption of pus into 
the blood : and they seem to have suggested to Mr. Abernethy the notion (which 
was held indeed by John Hunter also) that sympathetic hectic fever is a teased 
action of the system, endeavouring to throw off what annoys it ; the cause of irrita- 
tion being removed, it ceases forthwith. t 

And there is another conclusive circumstance to be mentioned. Notwithstanding 
the opinions \ have just now quoted from Cullen and Dr. Thomson, I believe few 
persons who have attended to the subject, doubt, now, that there is such a thing as 
idiopathic hectic ; hectic unconnected at least with suppuration anywhere. We 
often see hectic, or a general state of the system not to be distinguished from hectic, 
in mothers who have suckled their infants too long ; we see it, too, sometimes, if I 
mistake not, in newly married husbands : and it may be noticed as occurring more 
or less distinctly in those who labour under diabetes. What is common to all these 
cases is, that there is an habitual drain upon the system beyond what the nutriment 
taken into it can supply and counterbalance. It is certain, too, that hectic fever 
sometimes happens in phthisis, not only before there has been any expectoration of 
puriform matter, but prior even to the softening and suppuration of a single tubercle. 
I call to mind one instance in particular of this. The hectic was distinctly marked, 
and continued Jong. The patient died, at last, comatose, after two attacks of convul- 



MORTIFICATION. 



119 



sion. Two or three large scrofulous tumours were found imbedded in the substance 
of his brain. Various other organs were infested with tubercles ; but the tubercles 
were all of them still hard and crude. 

However, setting aside these rarer cases of exception, there can be no doubt that 
hectic fever, considered as a constitutional symptom of mischief that may reveal 
itself by scarcely any other token, and especially as a sign of suppuration, deserves 
all the attention we can give it ; and for that reason have 1 spoken of it rather at 
large. Whenever I mention hectic fever in the progress of these lectures, you will 
know all that I wish to express by that term. 

I have very little to say at present respecting that modification of the general 
febrile disturbance, which sometimes attends mortification as an event of inflamma- 
tion. I stated before that the fever is apt in these cases to assume the typhoid forr^i ; 
and to be characterized by sinking of the pulse, shrunken features, coldness and 
clamminess of the skin, a dry and black tongue, low muttering delirium or stupor, 
tremors of the voluntary muscles, with spasmodi'^ startings of their tendons, and 
insensibility to the passage of fceces and of urine. I must, however, now inform you 
that these typhoid symptoms are no constant or necessary concomitants of mortifica- 
tion. The natural mode of death, under gangrene, is death by asthenia. But the 
typhoid state involves the nervous functions, and tends to death by coma. When- 
ever, therefore, typhoid symptoms supervene upon inflammation which ends in 
sphacelus, they may with much probability be attributed to some contamination of 
the blood by an animal poison ; and such contamination may have taken place pre- 
viously to the mortification, and have even helped to produce it, as when inflamma- 
tion arises during the progress of the contagious febrile disorders ; or it may occur 
as a consequence of the mortification itself, by the direct absorption into the system 
of some of the putrefying and poisonous elements, into which the dead part has been 
resolved. 

One circumstance, worth bearing in mind, as sometimes indicating the superven- 
tion of internal mortification, is the sudden cessation of pain : giving hope to the 
patient and his friends that the danger is over ; but not deceiving the experienced 
physician. 

So much, then, for the local and constitutional events of inflammation, considered 
generally. 

It remains for me to make some observations upon the modifications of inflamma- 
tion, according as it affects the different tissues of which the body is composed. 
Many of these observations T have, indeed, already anticipated ; but it will be useful 
to bring together, under one view, the most material facts ascertained on this matter. 

When inflammation affects the areolar tissue, all the events of inflammation 
which I have taken some pains to describe are apt to occur ; and for that reason, 
inflammation of this tissue, as it exists beneath the skin, was chosen by me as a 
convenient type, or general representative of the inflammatory process. It is, there- 
fore, the less needful that I should take up much of your time in speaking of the 
characters of inflammation exhibited in areolar tissue. There is a strong tendency 
to form circumscribed abscesses : the extension of the suppuration is prevented by a 
wall of lymph built up around it. The adhesive inflammation sets bounds to the 
suppurative. There is a good deal of pain when the areolar tissue is so situated 
that tension is occasioned by its swefling. 

But sometimes no such boundary waff is erected, and the inflammation spreads 
and diffuses itself, and becomes a very terrible disease, destroying the areolar tissue 
over a large and undefined space by a process compounded of sloughing and of bad 
suppuration. When the skin also is implicated in the inflammation, the disease is 
usually called erysipelas phlegmondides : when the skin is not involved, it has been 
called diffused inflammation of the cellular membrane. This difflised form of in- 
flammation frequently follows the introduction of animal poisons into the system ; 
and accompanies the inflammation of veins and of absorbent vessels. It is this 
disease which is so often fatal to members of our profession, when it results from 



120 



INFLAMMATION. 



wounds or punctures received in opening dead bodies. Dr. Craigie has recently put 
forth tlie opinion that in these cases of spreading inflammation it is the adipose 
tissue that is affected. 

The substance of the larger glands, and of the solid viscera of the body, suffers 
changes analogous to those observed in the areolar tissue : probably because areolar 
tissue enters largely into their composition. Acute inflammation of the Hver, when 
ii does not terminate in resolution, leads to abscess in that organ. Abscess is rare in 
the lungs, perhaps for the reasons mentioned in the last lecture. Gangrene is also 
uncommon in the pulmonary substance : and quite unknown, I believe, in the liver, 
and very rare in the kidney. Inflammation of the latter organ is not unfrequently 
attended by purulent collections. Inflammation of the substance of the viscera is 
not, in general, attended with much pain. 

The areolar tissue is hable to be rendered permanently thick and hardy by chro- 
7ih inflammation, as well in the parenchyma of internal organs as where it is spread 
out beneath the skin, or beneath serous or mucous membranes. Chronic induration 
and thickening of the areolar tissue which composes Glisson's capsule is no unfre- 
quent result of slow inflammation ; producing that particular change in the liver 
which the French pathoiogists denominate cirrhose ; but of which the Essence is 
atrophy of its lobules from compression of its nutrient arteries. 

The inflammation of serous membranes is characterized by sharp and severe pain ; 
by hardness of the pulse ; and by huffy blood ; by its tendency to spread ; by the • 
effusion of serous fluid, and of coagulable lymph ; and sometimes, when the inflam- 
mation is very violent, or air gets admitted to the inflamed surface, by the effusion 
of pus. Speaking generally, however, it is adhesive irtflammation which we most 
expect in this tissue. False membranes, consisting of organized lymph, belong to 
it : and the agglutination of contiguous surfaces. Sometimes the lymph, instead of 
being deposited in flakes or layers, appears in the form of numerous smaU granules : 
this is a phenomenon frequently observable in inflammation of the arachnoid, and 
of the peritoneum. Sometimes it has a villous or papillary or shaggy an'angement ; 
or is cellular Hke a honeycomb. This is common in the pericardium. The surface 
(to use the happy simile of Laennec) resembles that w^hich ipay be produced by 
separating two flat plates between which a layer of soft butter had been spread : and 
it probably depends upon a similar cause ; since in health a perpetual sliding mo- 
tion of the pericardium over the heart is going on. Ulceration of a seroiis membrane 
is very uncommon. I mean ulceration commencing in that tissue-; for these mem- 
branes are frequently perforated by ulcers which approach them on their attached 
side, and which begin in other tissues, especially the mucous. Neither does morti- 
fication occur in serous membranes, except sometimes by communication from other 
parts. The effect of chronic inflammation of the serous surfaces is to thicken, harden, 
and pucker them. We see this effect in the omentum frequently ; in the peritoneal 
cover of the liver; in the serous membrane which forms so large a portion of the 
valves of the heart. 

The synovial fnembranes have a strong analogy with the serous. Gendrin includes 
the two in the same category : yet their behaviour under inflammation offers, in 
some respects, a marked distinction between them. They are less liable to inflam- 
mation than the serous membranes: they rarely "throw out coagulable lymph, and, 
consequently, adhesion of their opposite surfaces is very uncommon. Joints do not 
become immovable, or what is called anch3?losed, in consequence of the agglutina- 
tion of their synovial surfaces ; but, generally, by means of granulations arising upon 
those surfaces after they have ulcerated. Very seldom, indeed, does pus form in 
the synovial sacs, except (again) the inflammation has been caused by mechanical 
injury, which has laid open the joint, and admitted air. When this is the case, very 
serious constitutional disturbance is apt to take place, and the existence of the sufferer 
is endangered. That this does not depend upon the mere violejice of the exciting 
cause is evident from the circumstance that the same acute inflammation, the same 
general affection of the system, and equal danger, often result from the careful inci- 
sion made into a joint by the surgeon, for the purpose of removing loose portions of 
cartilage. I have now at the hospital an out-patient who has, among other ills, a 



TEGUMENTARY MEMBRANES. 



121 



large cartilage floating about in fluid in one of his knee-joints : but I believe that Mr. 
ArnoU, whom I have consulted on the case, will be very slow to recommend its 
removal, until the inconvenience produced by it is so great as to incapacitate the 
patient from pursuing his employment, and until other methods of rehef have failed. 
Suppuration of the joints is also one of the occasional consequences of phlebitis. In- 
flammation of the synovial membrane speedily leads to a serous effusion into the 
joint, which often, especially in rheumatism, is as speedily taken up again. 

Let us next inquire into the modifications which inflammation undergoes when it 
aflects the tegumenfary membranes. 

Considering the skin as one membrane, and neglecting its subdivisions into epi- 
dermis, rete mucosum, and cutis vera, we find that inflammation assumes a variety 
of forms in this external covering of the body. Many of these belong to specific 
diseases, and do not fall within my present purpose, which is that of noting how 
common inflammation varies in the different tissues. 

When the inflammation is superficial, it frequently is denoted by a diffused red 
blush only, which may be banished for a moment by the pressure of the finger, and 
which, after a certain time, disappears of its own accord — terminates by resolution ; 
the only consequence of the inflammation being the separation of the cuticle in small 
branny fragments ; in one word, desquamation. We call the superficial inflamma- 
tion, in this case, erythema. If the inflammation has been a little more intense — as 
in some cases of erysipelas, in scalds, and in that which we are every day exciting 
by caatharides — a serous fluid is poured out, which elevates the cuticle in larger or 
smaller patches of vesication. Remove the cuticle and admit air, and the serous 
effusion becomes purulent effusion : and if the inflammation be pressed beyond a 
certain point by any otlier stimulus besides that of air, we may have pus poured 
out. Erysipelatous (which is also a specific) inflammation of the skin, is character- 
ized by its remarkable tendency to spread ; and a most singular circumstance attends 
several of the other specific inflammations of the skin, viz. : that having occurred 
once, they never occur again ; this peculiarity belongs, however, to the great consti- 
tutional diseases, of which the cutaneous affection forms merely a part. 

Inflammations of the internal tegumentary membranes — of the three internal sur- 
faces that communicate with the air, and are clothed with mucous membrane— 
very interesting to the physician : and the first thing which strikes our attention in 
respect to them is the indisposition they manifest to adhesive inflammation : and we 
are struck at the same time with the beauty of this provision. If the mucous mem- 
branes were as ready to throw out coagulable lymph, and to adhere to each other as 
the serous, almost every occurrence of inflammation in them would prove necessa- 
rily fatal ; by closing up the inlets of the air passages ; or the outlets of the urinary 
passages ; or any part of**that long mucous canal which, passing through the body, 
requires a free opening at both of its extremities. But the inflamed mucous mem- 
brane pours out serous fluid, or viscid mucus, or pus, or blood. Inflammation of 
these membranes is, however, sometimes [in children very frequently] attended 
with the exudation of something which is very like coagulable lymph, and which 
has been considered (but in my opinion erroneously considered) to be such lymph. 
The tracheal, bronchial, and pulmonary mucous membrane, the oesophageal, the 
intestinal, and that which lines the uterus, are all more or less subject to the forma- 
tion of adventitious membranes under inflammation. Casts of the smaller branches 
of the air-tubes have, in rare instances, been repeatedly coughed up in large quan- 
tity ; constituting what have been very inaptly called bronchial polypi. The mem- 
branous exudation of croup is well known : a tubular substance is formed in the 
trachea, and, sometimes, fortunately expelled : but too often it suffocates the patient. 
Similar concrete exudations, broken into irregular shreds, are occasionally voided by 
stool. It is said that a loj]g membranous mass of the same kind, in size and shape 
like an eartli-worm, has been discharged from the urethra ; having formed there in 
consequence of the injudicious use of stimulating substances, injected with the view 
of checking the more innocent effusion of pus. The films, or membrane-like flakes 
which are thus incidental to inflammation of the mucous surfaces, resemble, I say, 
in their general appearance and disposition, the strata or layers of coagulable lymph 

L 



122 



INFLAMMATION. 



which are the ordinary product of inflammation of the closed serous surfaces. But 
they differ from these in some remarkable points. They are softer. They never 
contract permanent or strong adhesions to the subjacent inflamed membrane ; but 
are partially separated from it by the intervention of thinner matters, serous or puri- 
form. Above all, they never become organized. They appear to consist of inspis- 
sated and altered mucus ; and are composed, in a great measure, of albumen. An 
opinion has been entertained that the want of apposition of the opposite surfaces 
has a great deal to do with their indisposition to cohere. The mucous air tubes are 
kept open and apart by iheir structure : the stomach and intestines by their con- 
tmts, or by the frequent passage of solids and fluids through them : and therefore 
(it has been supposed) they have no opportunity of adhering. But there can be no 
doubt that these mucous membranes are but little disposed to throw out true lymph 
at all : and when their opposite surfaces do grow together, I believe it will almost 
always be found that some abrasion or ulceration of the mucous surface had previ- 
ously happened. 

Inflammation affecting the mucous membranes has sometimes a strong tendency 
to spread and wander : sometimes, on the contrary, it is strictly confined to a small 
and definite space. In the former case it commonly restricts itself for a long time, 
or altogether, to the mucous tissue, leaving the neighbouring tissues untouched. In 
the latter it is apt to penetrate to the subjacent parts, and to produce obvious and en- 
during alterations of structure. The membrane becomes fastened to the parts which 
it should loosely clothe, and not unfrequently it ulcerates or sloughs. 

The sprea:ding form of inflammation is most often met with in the air-passages. 
Ulceration and sloughing, and circumscribed inflammation, are more common in the 
ahmentary canal. 

There is a remarkable contrast between the serous membranes and the mucous, 
in respect io pain which attends their inflammation. Very httle pain is experienced 
in many cases, when inflammation affects the mucous lining in any of the three 
systems, except towards their openings, where the membranes are about to become 
continuous with the external skin : in the mouth and throat, for example, the pha- 
rynx, the rectum, the vagina, the extremity of the urethra. And as inflammation 
of the mucous membranes is attended with less pain, so also it is accompanied by 
less fever than when the serous membranes are attacked ; and the blood more seldom 
exhibits the huffy coat. 

The muscular tissue appears to take on the actions of inflammation very reluc- 
tantly : and its vessels seldom, if ever, pour forth any of the products of inflammation. 
The chief effect of inflammation upon muscle, is the destruction of its contractile proper- 
ties. Serum and lymph, and even pus, are sometimes fw^d diffused through mus- 
cular parts ; but there is reason to believe that these effusions are rather the 
consequence of inflammation of the areolar tissue which enters into the composition 
of the muscle, and ties together its fleshy fibres, than of inflammation of those fibres 
themselves." 

I have rems.rked already that inflammation of an artery presently leads to the 
effusion of lymph, and the coagulation of the blood, within the artery. But arteries 
do not readily inflame, except under mechanical injury ; they do not often suppurate 
either: and they possess a singular power of resisting mortification. Dr. J. Thomp- 
son declares that he has seen cases of phlegmonous erysipelas, in which "several 
inches of the femoral artery were laid completely bare by the gangrene, ulceration 
and sphacelus of the parts covering it, without its giving way before death." 

Inflammation of the veins is much more common than that of the arteries : and it is 
a disease of fearful interest. In some cases it leads to a deposit of fibrin upon the inside 
of the vessel, " furring it over," as Mr. Hunter says. The blood soon coagulates, 
and blocks up the inflamed vein, or leaves, perhaps, a narrow passage in its centre. 
From this mechanical obstruction to the current of the blood new symptoms arise. 
The part from which the venous trunk receives its tributary branches becomes (Ede- 
matous or dropsical. Inflammation of the femoral vein, obliterating its cavity, is the 
essence of the complaint known to pathologists under the name of phlegmasia 



INFLAMMATION OF THE BRAIN. 



123 



dolens: a complaint which may happen to persons of any age, and of either sex; 
but which is most common, in women soon after parturition. 

This, which may be considered the adhesive form of phlebitis, is also its most 
innocent form. Too frequently the inflammation runs into suppuration : and then it 
proves a most terrible and almost hopeless disorder. The vein remains pervious: 
pus, of an unwholesome and poisonous quahty — or some morbid product of the in- 
flammation — is carried into the blood ; which thus scatters, in its course, the seeds of 
inflammation, and determines the rapid formation of purulent collections, in various 
and distant parts of the body, and especially in the lungs, the hver and the larger 
joints. Great constitutional disturbance ensues, and fever of a typhoid type is often 
estabhshed. To this, the destructive form of the disease, parturient women are also 
peculiarly liable. Phlebitis of the uterine veins constitutes the source of the most 
dangerous and deadly varieties of puerperal fever. It is the same disease which 
gives to a vast majority of those surgical operations that are followed by death, their 
iatal character. 

We hear continually of inflammation of the brain ; but what is so called is, most 
commonly, inflammation of the membranes which invest the brain. Inflammation of 
the cerebral substance itself is, however, not very uncommon ; but it is more fre- 
quently the result of injury than of spontaneous disease, and it is usually confined 
to a limited portion of the brain. Softening and suppuration are its ordinary events. 
Sometimes pus is met with, occupying a distinctly circumscribed space ; the pus is 
collected into an abscess. Sometimes, on the other hand, it lies loose, as it were, 
and surrounded by broken-down cerebral matter, or it is infiltrated into the cerebral 
pulp. Around tlie softened portions the inflamed substance of the brain is more 
dense and firm, sometimes, than is natural. Whether this be owing to the presence 
of coagulable lymph, has not (so far as I know) been clearly ascertained. Mortifi- 
cation must be very rare in the nervous substance. Dr. Baillie has described it as 
occurring after violent injury. Once or twice in my life, portions of brain have been 
shown to me, protruding through an aperture in the skull, dead, of a dark colour, 
and having an oflensive smell. Excepting in these cases of hernia cerebri-, I have 
never seen sphacelus of the brain from any cause. 

Perhaps, however, I am incorrect in saying this. I formerly told you that portions 
of the brain often become soft and diflluent, when there has been no inflammation ; 
but simply from atropliy, depending on a diseased state of the nutrient arteries of 
the brain. Now some persons call this, mortification of the cerebral substance. 
They consider it quite analogous to the gangrena senifis, which results from a similar 
cause, although it happens in another part of the body. 

The nature of the change, they say, is the same, although the physical cha- 
racters of it difl^er. If this be so, I have seen gangrene of the brain some scores of 
times ; but still I should be able to declare, that with, perhaps, the exception already 
mentioned, I have never seen unequivocal mortification of the cerebral substance 
as the result of hiflammaiion : which is what we have now been considering. 

This concludes, gentlemen, what I have to say concerning the phenomena of 
common inflammation, as they are perpetually witnessed in the various textures of 
the bod3^ I have not, indeed, gone through all the tissues ; I have said nothing of 
the peculiar effects of inflammation in cartilages, for example, and in bones ; but 
I have glanced at all those tissues in the inflammation of which the physician is 
chiefly concerned. Upon such points as I have purposely omitted, you will be 
amply instructed by my colleague, the professor of surgery. 



124 



INFLAMSIATION. 



LECTURE XII. 

Varieties of Inflammation : £cyte and Chronic^ Latent; Specific. Scrofulous 
Inflammation. Tubercles. Relative frequency of Scrofulous Disease in differ' 
ent Or gems. Signs of the Strumous Diathesis. 

We have now, gentlemen, considered the phenomena of inflammation, local and 
general ; its symptoms and its events ; and the intimation of those events which is 
afforded by the state of the system at large ; and we have surveyed the principal 
tissues of the body, and observed the modifications and peculiarities to which the 
process of inflammation is liable, according as it is situated in the one or the other 
of those tissues. 

There are still some varieties of inflammation ; and some epithets apphed to 
inflammation ; which require to be explained. 

Acute, and chronic, inflammation : these are words perpetually in our mouths. I 
have frequently employed them already. What do they mean ? Is acute inflam- 
mation different from chronic in kind? No : they differ only in degree. 

When the disease runs its course rapidly, and is attended with much general as 
well as local disturbance, it is said to be acute. When, on the other hand, the local 
and constitutional symptoms are less violent, and the inflammation runs a longer 
course, its phenomena following each other in slower succession, it is said to be chro- 
nic. The process is the same, but its features are less strongly expressed. The dis- 
ease passes through similar stages in both cases, but it travels at a different pace. 
The characters, then, of acute inflammation are intensity of symptoms and rapidity 
of progress : and the characters of chronic inflammation are mildness of symptoms 
and slowness of progress. Inflammation can scarcely be very violent, and at the 
same time of very long duration. When violent it has been likened (by Mr. Law- 
rence, whose language I have here adopted) to a blazing fire, which soon burns itself 
out. It may, however, be mild in its symptoms, and yet quickly over. The two 
terms acute and chronic are not directly opposed to each other : acute has more rela- 
tion to the intensity, chronic to the duration of the disease ; and some term is wanted. 
— althoug-h it is hardly worth seeking for — to denote such a degree of inflammation 
as exists in a pimple : which is neither severe nor long-continued. 

Now, in respect to intensity of duration, there are innumerable shades of differ- 
ence in different cases of inflammation ; and the same difficulty occurs here which 
always occurs when general terms are employed to express mere differences of 
degree. We feel no uncertainty or hesitation about those cases which occupy the 
two extremes of the scale ; but with regard to those which lie in the middle we are 
often at a loss. To meet this difficulty some pathologists have invented a third epi- 
thet, viz., sub-acute, intending to designate thereby cases which hold an equivocal 
rank ; which are neither decidedly acute nor plainly chronic ; in which the inflam- 
mation may run a brief course, and be attended with a certain degree of fever ; but 
attains no great intensity, works no profound changes, and does not require very 
energetic remedies to control it. 

You must not suppose that, because chronic inflammation is attended with less 
tumuh and disturbance, it is necessarily on that account less dangerous or less de- 
structive than acute. The latter is commonly more obedient to the influence of 
remedies than the former : it is usually soon brought to an end : whereas chronic 
inflammation is often obstinate and abiding, and leads to very serious changes in the 
part upon which it fastens. Speaking generally, it tends to thicken and indurate 
when it is situated in the interior of organs, and to the effusion of pus when it affects 
membranes, or surfaces. It is more common in weakly and debihtated persons than 
in others ; but you must not forget that such persons are also very liable to acute 
inflammation. 

Chronic inflammation is not unfrequently a sequel of acute inflammation. And 
that the two differ merely in degree, and not in kind, is evident from this ; that acute 



VARIETIES OF INFLAMMATION. 



125 



inflammation may sink or subside into chronic ; and that, on the other hand, chronic 
inflammation may readily be aggravated into acute. 

There is another, but less intelligible division of inflammation into active and 
passive. I beheve that they v^ho use the term passive inflammation intend to signify 
by it that languid and sluggish kind of inflammation which is apt to occur under the 
same circumstances, and in the same conditions, yviih passive congestion. When 
the granulations of an ulcer are in that state in which they may be made brighter, 
smaller, and healthier, by the application of a stimulus; when the blood-vessels of 
the eye are left, after acute inflammation, turgid and tortuous ; and that condition is 
improved, instead of being worsened, by the use of a stimulating lotion : in such 
cases as these, some persons would say there was passive inflammation. But I see 
little difference between this and chronic inflammation ; nor do I know any differ- 
ence between active and acute inflammation. 

The term latent inflammation is one of modern introduction. It is applicable to 
those cases in which internal inflammation runs its coarse silently, treacherously, 
and unperceived ; without the usual warning tokens of its presence ; without its 
more striking and prominent signs. Pneumonia, going on to disorganization of the 
lung, may arise, proceed, and even prove fatal, without any of the symptoms which 
ordinarily announce that disorder : without notable cough, or obvious dyspnoea, or 
complaint of pain, or the expectoration proper to pneumonia. And the same is true 
of other inflammations. We discover, with surprise and horror, the traces of their 
operation, when we come to examine our patient's dead body. 

This is a most important form of inflammation ; for though it does not declare 
itself to ordinary observation, neither does it occur absolutely without symptoms ; 
but it requires that the symptoms should be looked for. The auscultatory signs of 
pneumonia, all those symptoms which are furnished by the physical condition of the 
aflected organ, are present, and speak as clearly as in the more flagrant cases. 

Latent inflammation is apt to creep on during the progress of certain disorders, 
whereby it is modified and masked. It belongs to those states of the system in which 
the sensibility is dull, and the vital powers languid. In continued fever not only 
have I known the lung pass into suppuration, when the existence of pneumonia had 
been unsuspected: but I even have seen one case in which that usually torturing 
accident, perforation of the bowel, took place, with the escape of its contents into the 
cavity of the abdomen, and extensive peritonitis — yet the patient expressed no sense 
of pain, and the inflammation was revealed, while he continued to Hve, by no intel- 
ligible symptom. 

Inflammation of this insidious and lurking character is most to be apprehended in 
the aged, in those who are habitually intemperate, and in persons of sluggish tem- 
perament. It sometimes occurs during convalescence from acute diseases. 

Besides the varieties which have been mentioned in degree, there are also differ- 
ences in kind among inflammations. What I have been speaking of during the 
preceding lectures I have called common inflammation. It is the most common form 
in which that process displays itself. AH persons are liable to it ; and that again 
and again. None are at any time privileged from its attacks. But there are several 
forms of inflammation different from this, which are called specific. There are vari- 
ous forms of specific inflammation affecting the skin, discriminated from each other 
by the local appearances they exhibit, and by the constitutional disorder which 
attends them. The rash and the fever of measles, are very unlike the rash and the 
fever of scarlatina ; and both difl^er remarkably from those of small-pox, the eruption 
of which consists of little phlegmons. In each of these diseases the application of a 
specific poison is required for its production : and whereas common inflammation 
has a tendency, when once it has happened, to happen in the same part again — to 
recur — these forms of specific inflammation never, or almost never, occur more than 
once. 

There is again the gouty inflammation — differing from common inflammation in 
several signal respects ; in the production of chalk-stones ; in its attacking those 
who are descended from ancestors who have had the disease, and scarcely any 
others. Then there is rheumatic inflammation, cousin-german to the gouty, yet dis- 

l2 



126 INFLAMMATION. 

tinguisbable from it. And another variety of inflammation is that which arises from, 
the introduction of the syphilitic poison into the system. 

Of the specific forms of inflammation now adverted to I shall speak when I come 
to consider gout and rheumatism, and the contagious exanthemata, as distinct diseases. 
But there is one variety of inflammation — I mean the scrofulous — which meets us 
on every side ; and is apt to affect so many parts of the body, and so great a number 
of persons ; and has so fatal a tendency in most cases ; that it cannot be left out of 
the account that I have been desirous to give you of inflammation in general. 

Scrofulous or strumous inflammation (for struma and scrofula are convertible 
terms) is a slow process ; it falls therefore within the class of chronic inflammations. 
It is not attended with much pain, or heat, nor for some time with much change of 
colour; and the redness which does accompany it has often a hvid or purplish 
tinge. 

These, however, are the negative properties of merely chronic inflammation. But 
suppuration at length occurs, which also lasts long : and the pus formed is peculiar 
and characteristic ; and by no means laudable. It is not homogeneous or smooth, but 
consists partly of a thin serous whey-like fluid, and partly of fragments of a substance 
resembling curd : and the ulceration that ensues is marked by corresponding pecu- 
liarities. The ulcers are indolent ; show but httle disposition to heal. Scrofulous 
inflammation, compared with common, or what is called healthy inflammation, is in 
general but Httle influenced by remedies. 

Besides this scrofulous injiammation, it is necessary that I should now direct 
your attention to another form of disease, which is hkewise properly denominated 
scrofulous. It is marked by the appearance, in various parts of the body, of what 
are called tubercles. These tubercles are masses of unorganized matter — also 
resembling curd or nevv cheese, more or less ; but of various shapes and sizes. They 
suffer gradual changes ; soften or break down ; undergo a sort of suppuration ; and 
the softer matter into which they thus (as it were) melt, has the characters that dis- 
tinguish the pus of a scrofulous ulcer or abscess. 

Now tubercles and scrofulous inflammation occur very continually in the same 
individuals : and what is remarkable, although they affect a very large portion of 
the whole human race, and conduce more often and more surely than any one thing 
else to shorten the natural period of human hfe, yet they belong, almost exclusively, 
to certain classes of persons. We can tell, beforehand, that such and such persons 
are likely to become affected with scrofulous inflammation, or with tubercles : and 
we say of those persons that they have the scrofulous diathesis. I will not posi- 
tively affirm that these forms of disease cannot be produced in any or in all persons ; 
but thus much is certain — that some persons are particularly prone to them : fall 
into them as it were spontaneously : or on the operation of very sHght external 
causes ; and even when all possible care is taken to prevent the operation of every 
ascertained cause ; while other persons never show any tendency to scrofula, even 
when continually exposed in the same manner; or if they do become scrofulous at 
all, it is only when the external circumstances most favourable to the production of 
such disease have been extreme in degree, and protracted in their application. 

The occurrence of scrofulous inflammation in various parts constitutes distinct 
diseases ; and the occurrence of tubercles in various organs constitutes other 
diseases. It will facihtate our future inquiries into these several diseases, if I take 
this opportunity of stating to you what is known respecting the scrofulous diathesis 
generally ; and of the modifications of inflammation which are determined by its 
presence. 

A good deal of discrepancy, obscuring the whole subject, and puzzling the 
student, has existed-— and I believe [ may say still exists — among pathologists, as to 
the nature, and origin, and precise seat of tubercles, and as to the changes which 
they undergo. 

In general they have been loosely described as being round masses of firm but 
friable matter, deposited in various parts of the body. Laennec, who paid great 
attention to tubercles, states that they are, at first, small, firm, grayish, semi-transpa- 
rent bodies, which gradually enlarge and become opaque. In that condition he calls 



TUBERCLES. 



127 



them crude tubercles. At length, after an indefinite period, these crude tubercles 
begin to grow soft in their centres, and are by degrees converted each into a liquid 
mass, having the consistence of cream. There is much error in this description. 

Andral, another great authority, says that tubercles are, in the outset, small, round, 
opaque, yellowish bodies, unorganized, and of various degrees of consistence. He 
ascribes their softening (not to any spontaneous changes in their central parts, but) 
to the admixture of pus, poured out by the textures immediately surrounding the 
tubercle ; which has irritated and inflamed those textures as any other foreign body 
might. 

In some respects this statement is nearer the truth than Laennec's. 

But in the account which I am about to give you, I shall chiefly follow our coun- 
tryman, Dr. Carswell, the first Professor of Pathological Anatomy in University 
College ; who is one of the latest, and, as I think, most satisfactory writers on the 
subject. His opinions were formed after a long and careful examination, for himself, 
of the parts infested by these tubercles. He devoted several years to the study of 
morbid anatomy, in Paris, where he made a very large collection of drawings, in 
which various diseased appearances are beautifully, and doubtless faithfully deli- 
neated. Some of these he has since published. I show you enlarged copies of 
those which relate to tubercle. They bear out some novel opinions which are stated 
in the letter-press which accompanies them. 

After all, the points in question possess m.ore of curious interest than of practical 
importance. But as you cannot help forming some notions respecting them, I think 
myself bound to lay before you those which most recommend themselves to my own 
judgment. At the same time you are to understand that I do not vouch for their 
absolute correctness. 

Tubercles, then— or rather tubercular matter, is deposited from the blood. Whether 
it is something totally new, something foreign to the natural materials of the body, 
introduced into the blood from without— or whether, as seems more likely, it is the 
result of some defect or error in the due elaboration of the blood itself — I cannot 
satisfy you. If, as has been supposed, the deposit is at first fluid, it afterwards be- 
comes firmer, through the absorption of its more watery particles ; and there then 
remains a " pale yellow, or yellowish gray, opaque, unorganized substance." This 
tubercular matter, so deposited, does not always assume a round form : far from it ; 
the shape in which it appears depends upon the^ nature of the part wherein it is 
planted. It used to be held that the tubercular matter was always laid down in the 
areolar tissue. But Dr. Carswell asserts that its most favourite seat (if one may so 
speak) is the free surface of mucous membranes. In whatever organ it is met with, 
if mucous tissue enters into the composition of that organ, that particular tissue is 
either (he says) exclusively affected, or much more extensively afTected than any of 
the other component tissues. These remarks apply to the lungs, the ahmentary 
canal, the liver, the urinary organs, and the organs of generation ; but the presence 
of the tubercular matter is much more easily detected in the mucous tissue of some 
of these organs than in that of others. It is very conspicuous in the Fallopian tubes 
and uterus. 

But tubercular matter is often deposited on serous surfaces also; among which Dr. 
Carswell includes the plates of the areolar tissue. It is even to be seen sometimes 
in the blood itself : not indeed while it is retained in its proper vessels, but when it 
is collected in the celts of the spleen. You know that the spongy texture of that 
organ allows the blood to accumulate in it in considerable quantity : and the tuber- 
cular matter may be seen forming in the blood at some distance from the walls of the 
cells in which the blood is contained. In one cell, according to Dr. Carswell, you 
may perceive simply the blood coagulated : in another, it will be coagulated and 
deprived of its colouring matter ; and in another^ converted into a mass of solid 
fibrin, having in its centre a small module of tubercular matter. 

Now when a speck or morsel of tubercular matter has been deposited anywhere, 
it is liable to increase. It grows larger by continued accretion ; by additional deposits 
upon its surface. This being the case, we see plainly enough how it happens that 
tubercles assume different shapes, according as they occur in different parts. The 



128 



INFLAMMATION. 



round form which is so often observed is purely accidental. When a tubercle is 
deposited in the substance of the brain — and becomes larger by the repeated acces- 
sion of fresh tubercular matter upon and around it — it naturally takes a spherical 
form, because there is nothing to limit its enlargement, except the soft cerebral matter 
itself, which presses it with equal force on every side. For the same reason tuber- 
cles deposited in the areolar tissue are globular. In like manner, if tubercular 
matter be laid down in one of the pulmonary vesicles, so as to fill it up, it exhibits 
the roundish form of the vesicle. When it fills the cavity of a mucous follicle, it 
has a similar figure. But in the smaller bronchi it takes a more cylindrical arrange- 
ment. When (as often happens) it occupies one of these tubes, and also all the air- 
cells to which that tube leads, then we have twigs of tubercular matter, with cauli- 
flower terminations. You see this depicted in the drawings before you. In the 
cavity of the uterus, and the Fallopian tubes ; in the infundibula and pelvis of the 
Kidney, and in the ureters ; and in the lacteal and lymphatic vessels ; the tubercular 
matter is moulded to the forms of these parts respectively. We are more in the 
habit of examining tubercles in the lungs than anyw^here else ; and you will observe 
inat in making sections of these organs, and looking only at the surfaces of those 
sections, we may easily overlook the branch-like disposition of the tubercular matter 
in the smaller bronchial tubes. We see the transverse section only of the tubes, 
which is necessarily more or less circular. On the surfaces of serous membranes, 
whether natural or adventitious, the tubercular matter will ^sume a rounded, or a 
lamellated form, according as the morbid secretion in which it originates has taken 
place from separate points, or from a continuous surface. 

From w^iat has now been stated you will perceive that no alteration can be ex- 
pected to take place in the tubercular matter after once it has been deposited, except 
through the agency of the parts around it and in contact with it. It is never organ- 
ized, or capable of organization ; and, consequently^, no vital change in its consist- 
ence can originate in the tubercle itself. If any spontaneous change arises, it must 
be a chemical one : and of such we have no evidence at all. 

It may therefore seem odd, that so accurate an observer as Laennec should have 
persuaded himself that the softening of tubercles begins in their centre. 

Now Dr. Carswell has given what appears to me a sufficient explanation of this 
mistake. Take the lungs ; the morbid conditions of which were the most especial 
object of Laennec's investigations. The tubercular matter is effused (principally) 
upon the mucous surface ; upon 'the inner lining of the air-cells, and of the bronchial 
tubes communicating with them. Yet it need not so accumulate as to Jill these 
cavities ; and it often does not ; there is left a central vacuity, which contains mu- 
cus, or other secreted fluids : and if the lung be cut across under these circumstances, 
the divided air-vesicles will look like rings of tubercular matter grouped together ; 
and each divided bronchial tube will present also the appearance of a tubercle, with 
a central depression, or soft central point. On the other hand, when the tubercular 
matter has completely filled and blocked up these cavities, both vesicles and bron- 
chial tubes will look, when divided, like sections of round solid tubercles. These 
Laennec seems, in fact, to have regarded as crude tubercles : while he mistook the 
former appearances for tubercles which were beginning to soften in their centres. 

But you sometimes find large masses of tubercular matter in the lungs or else- 
where : and in these masses you see that the process of softening is going on at 
several points, within the mass, at the same time. How is this to be explained ? 
Why these large masses are formed, in fact, by the aggregation of many smaller 
masses, w^hich lying near each other, have coalesced as the deposit continued to 
increase : and the areolar and other tissues originally intervening between these 
coalescing masses at length suppurate, by reason of the augmenting pressure ; and 
by their suppuration, they soften, and gradually break down the tubercular matter 
which they enclose, and by which they are also enclosed. This is just the process 
by which tubercles are frequently expefled from the body. They increase till the 
surrounding parts take on inflammation, just as they might do if any foreign body 
exercised the same degree of pressure upon them. The inflammation thus excited 
is of the scrofulous kind ; the thin pus which is thrown out pervades and loosens 



TUBERCLES. 



129 



the tubercular matter ; a process of ulceration which goes on in the surrounding- tex- 
tures ; and at length (supposing the lung to have been the seat of disease) the detritus 
of the tubercle is brought up, gradually, by coughing. 

Both Laennec and Louis, the latter also being a very close observer, describe the 
nascent tubercle as a gray semitransparent corpuscle. I have frequently seen such ; 
but the appearance is rare, in comparison with the more opaque form of tubercle. 
Of this, too, Dr. Cars well offers what I think a very probable explanation. He says 
that the mucous membrane of the air-tubes separates from the blood, not only the 
matter of tubercle, but also its own proper secretion : and that, frequently, when the 
two have been poured out together, a dull yellow opaque point of tubercular matter 
becomes set, as it were, in a portion of gray, semitransparent, and, sometimes, in- 
spissated mucus. The same deceptive appearance is common on serous membranes : 
in tubercular peritonitis, coagulable lymph exudes, portions of which envelop Httle 
globular masses of tubercular matter. 

The account which I have now given you, and which I hope I have made intelh- 
gible, is, I think, extremely interesting — and much credit is due to Dr. Cars well for 
having so greatly simplified our views of a subject which had previously been 
wrapped in profound obscurity. In no other writer, that I know of, is there to be 
found so complete and credible an explanation of the origin of tubercles ; of the 
forms they assume, of the phenomena attending their enlargement and subsequent 
softening, and occasional expulsion. 

[According to Barthez and Rilliet, who have given the most complete and accurate 
description of tubercle, the various forms under which tubercle is found are the following : — 
the miliary or gray tubercle, the yellow or crude tubercle, the gray and yellow forms of infil- 
tration, tlie gelatinous infiltration, and tuberculous dust. There is no reason for ascribing 
these forms of tuberculous matter solely to tubercle of the lung. As M. Valleix remarks, 
incontestable proofs may be adduced to prove that the gray granulations of Laennec occur in 
all the organs, and as the researches in pathological anatomy have been more carefully con- 
ducted, these proofs have been multiplied. M. Papavoine, in his interesting memoir " On, 
Tubercle considered particularly in Children,^'' expresses himself thus: — "We cannot admit the 
seat of the gray granulations to be only in the pulmonary vesicles : forms of alteration 
exactly similar, are to be met with in the lymphatic glands, in the liver, the spleen, and on 
the' serous membranes, especially in certain cases of general and acute tuberculization.'' 
The statement of M. Nelaton leaves no doubt of the development of gray semitransparent 
granulations in the osseous tissue. He has been able, repeatedly, to determine that the 
tubercles of the bones, like those of the lungs, recognize for points of departure, the gray 
semitransparent granulations described by Laennec, Louis, and others (Recherches sur V affection 
tuberculeuse des os, 1836). Dr. Glover has observed, in granular meningitis, the forms of 
gray granulation, and yellow particles, answering very well to the yellow points which 
appear in the gray granulations of the lungs. The miliary tubercle may exist in all the 
organs, and it is in the form of gray infiltrated matter, granular to the microscope, more or 
less diff'used through the substance of a gland that we detect the first occurrence of mesen- 
teric tubercle ; afterwards we find a more crude or yellow appearance of the tubercle matter, 
as in the lungs. The appearance of infiltrated gray matter is especially marked in eff'usions 
organized between the tunics of the intestinal canal. Some of the illustrations presented 
by Dr. Glover (^Pathology and Treatment of Scrofula) show the tubercular eff'usion in a 
mesenteric gland : — Istly, in a diffused form throughout the hypertrophied tissue of the organ ; 
2dly, forming striae and patches, varying in hue from gray to yellow; 3dly, in cysts filled 
either with a tuberculous powder or with a curdy matter ; 4thly, in masses of lardaceous 
consistence, implicating either the whole gland, or more or less of its structure. We have 
specimens, likewise, remarks the same author, of bronchial glands, and bronchi sprinkled 
over, as it were, with a tuberculous powder, and studded with cretaceous particles. 

" The gray granulation," as Barthez and Rilliet observe, " exists in all the organs, not only 
in the intestines, peritoneum, and pleura, but in the spleen, the liver, the kidneys, the 
lymphatic glands and cerebral meninges." — (^Maladies des Enfans.) In fact all the forms of 
tubercle which occur in the different organs are brought about chiefly by mechanical causes, 
and differ very slightly in a physiological sense, never in their more minute anatomy. Thus, 
for example, the liver is an organ, in which tumours generally are of large size, and of 
various and irregular shapes ; in the lungs, the air-cells and the membranous character of 
the tissue tend much, if the effusion be not rapid, to surround it, while progressing and 
stiffening, with envelops of a membranous nature. The brain, from its structure, must 
oppose pressure in every direction in which the progress of a deposit in its interior can take 
place, and thus we find tubercles of the brain generally of small size and regularly circum- 

9 



f 



130 INFLAMMATION. 

scribed. Between layers of membrane we find the deposit stretched out in flakes. In the 
sub-cutaneous cellular tissue it forms irregular masses. On the free surfaces of mucous or 
serous membranes its figure is irregular, or it occurs in superficial layers. In the bones, in 
general, it is in little round granules, or in very circumscribed masses. — C] 

These processes — of softening, produced by surrounding inflammation, and of 
ultimate expulsion — may be regarded as a natural mode of cure. Such a cure is in 
truth occasionally accomplished. A scrofulous abscess forms in the glands of the 
neck; and pus and tubercular matter are discharged. At length the ulcer heals, 
and no trace of the diseased process remains, beyond a scar. The same thing takes 
place also in the lungs ; and, if there have been only one or two masses of tubercle 
deposited, the patient may thus get quite well: but unfortunately, as the scrofulous 
matter is extirpated from one part of the lung, it is apt to be multiplied in another, 
till at length we have death by hectic, and ah its melancholy accompaniments. 

But I am desirous of pointing out to you another way in which tubercular disease 
may be said to be cured by a natural process. And this also has been better described 
by Dr. Carsweil than by any other writer. One form of scrofulous disease, exceed- 
ingly common too, especially among children, is what is called tabes rnesenterica.^^ 
Tabes and phthisis, the one a Latin and the other a Greek word, signify, I need 
scarcely tell you, the same thing: a wasting away, or a consuming: and phthisis is 
apphed to the same disease in the chest, to which tabes is applied in the belly. The 
common English word is consumption ; and we might very well speak of thoracic 
consumption, and of abdominal consumption ; but the technical name of the latter 
complaint is tabes mesenterica. This is not only a very common but a very fatal 
disease in children and young persons. The glands of the mesentery enlarge and 
become charged with tubercular matter : but then they very rarely suppurate. Their 
enlargement is commonly connected with scrofulous disease and ulceration of the 
mucous follicles of the intestines,- and the little patients die, because the lacteals are 
no longer able to take up from the food a sufficient supply of nutriment : they die 
starved. But some few do recover from tabes mesenterica. Dr. Carsweil relates 
an interesting case in which such recovery took place, and in which he had an op- 
portunity of examining the glands at a subsequent period : it is the only case of the 
kind perhaps on record. He says, " the patiejit who when a child had been affected 
with tabes mesenterica, and also with swellings of the cervical glands, some of which 
ulcerated, died at the age of 21, of inflammation of the uterus, seven days after 
delivery. Several of the mesenteric glands contained a dry cheesy matter, mixed 
with a chalkjr-looking substance ; others were composed of a cretaceous substance ; 
and a tumour, as large as a hen's egg, included within the folds of the peritoneum, 
and which appeared to be the remains of a large agglomerated mass of glands, was 
filled with a substance resembling a mixture of putty and dried mortar, moistened 
with a small quantity of serosity. In the neck, and immediately beneath an old 
cicatrix in the skin, there were two glands containing in several points of their sub- 
stance (which was otherwise healthy), small masses of hard cretaceous matter." 

Now what Dr. Carsweil here saw in the mesentery and in the neck, is what 
sometimes occurs in other parts of the body ; in the lungs ; and particularly in the 
bronchial glands at their root, and about the bifurcation of the trachea. From these 
situations, the hard chalky matter left by the absorption of all the more watery part 
of the morbid deposit, and by the concretion of its earthy salts, is often coughed up. 
But it may remain, when the tubercles are few, and there is no tendency to their 
increase, for years, as an inert, and almost harmless mass. 

I mentioned just now that the secretion or separation of the matter of tubercle 
from the blood, takes place, by preference, upon the free surface of mucous mem- 
branes, and very frequently also upon the surface of serous tissues, including the 
areolar. 

It may not be uninteresting to inquire into the relative frequency of scrofulous 
disease in different organs, or in different parts of the same organ. The facts 
which we possess on this head afford us very valuable assistance sometimes in 
respect of diagnosis. 

During the periods of childhood and youth the lymphatic glands are exceedingly 



TUBERCLES. 



131 



prone to scrofulous inflammation ; especially the mesenteric and the cervical glands. 
But in adult age tubercles are, beyond all comparison, most frequent in the respira- 
tory organs ^ and they occupy the summit of the lung much more commonly and 
thickly than any other part. The superior and posterior portion of the upper lobe 
is the spot in which, if any tubercles at all exist in the lung, they are almost sure to 
be found. It is here also that they first begin to suppurate or soften. This law has 
long been well known : and so constant is it, that Dr. Carswell holds the formation 
of tubercles in any other portions of the lung to be always of secondary occurrence. 
He declares it to be the result of his experience (and few persons can have had 
more opportunities of examining diseased lungs), that there is no deviation from this 
rule, except when some other portion of the lung may have been the seat of an in- 
flammatory attack, which has determined the priority of tubercular disease in that 
portion. We shall see hereafter what a very important bearing a knowledge of 
this law has, in settling the mature of a complaint which might, without it, be 
doubtful. 

Scrofulous ulceration of the larynx and trachea, when they occur, are usually 
concomitants of tubercular deposits in the lungs. 

Next, tubercular or strumous disease is exceedingly common in the digestive 
organs : most of all in the mucous follicles of the small intestines ; both in those 
follicles which are separate, and are called glandulse sohtaria^ ; and in those which 
are collected into roundish or oblong groups, the glandute agminatas. It is second- 
arily to these affections of the follicles, in many cases at least, that the glands of the 
mesentery become implicated. Tubercular deposits are frequent also in the solitary 
glands belonging to the csecum. The ulceration which follows the evacuation of the 
strumous matter from these parts gives the interior of the bowel an appearance 
somewhat resembling that of a moth-eaten garment. Tubercular matter is seldom 
deposited in any other parts of the intestines, great or small, than those which I have 
mentioned. Dr. Carswell supposes that it may often be secreted upon the free sur- 
face of the membrane, but that, not being entangled or confined in any mucous 
crypt, it is removed as soon as it forms. It is not often that scrofulous tubercles are 
found in the liver of adults : they are not very uncommon in that organ in children, 
but even then they are few in number and small in size. It is a curious fact that 
they are much more frequently seen in the spleen also in children, than in grown 
up persons. The uterus, the testicle, the prostate gland, are all liable to them : they 
are common enough upon the surface of the peritoneum. 

In the nervous system, tubercles are by no means unfrequent : they are met with 
oftener in the brain than in the spinal cord. That fearful disorder of childhood, 
known by the name of hydrocephalus, occurs principally, if not altogether, in con- 
nection with the scrofulous diathesis. 

Strumous d'eposits are rare in the organs of circulation. Tubercles have been seen, 
1 believe, in the muscular substance of the heart : but this must be a very uncom- 
mon thing. Scrofulous disease is not at all unfrequent in bone, especially in the 
bodies of the vertebrje, and in the spongy extremities of the long bones. 

It is very seldom, indeed, that scrofulous tubercles occur in any one organ only. 
Almost always they are met with in at least two, and frequently-; in all the parts at 
once Vv'^hich are hable to be infested by them. Sometimes the lungs alone are affected ; 
but generally both the lungs and the intestines are occupied by the disease. It has 
been affirmed, by a great \Wmg pathologist, M. Louis, that if you find tubercles in 
any other organ, you are sure to find them also, and in greater number, and further 
advanced in the lungs. But this, though true as a general rule, is not without ex- 
ceptions. I have seen the peritoneum crowded with myriads of these tubercles, 
when the most careful examination could not detect a single one in the lungs. And 
similar examples have fallen under Dr. Carswell's observation. 

[The genera] diffusion of tubercular matter is much more common in children than in 
adults. Thus, in 358 cases where tubercles existed in the lungs in adults, M. Louis notices 
the existence of tubercular matter in the brain or its membranes only once ; ia the bronchial 
glands it was detected in about one-fifth of the cases ; in the mesenteric glands, in one-fifth; in 
the liver, only twice ; in the kidneys, yz^;e times in one hundred and seventy cases j on the other 



132 



INFLAMMATION. 



hand ulceration of the larynx, existed in. one-fourth ; ulceration of the bowels, in five-sixths of 
the cases. In 180 cases in which tubercles of the lungs existed in children, Dr. Green found the 
brain to be atfectetl with tiibercles in one-ninth of the eases ; the bronchial glands, in 100 out 
of 112 ; the mesenteric glands were tuberculous, in one-half: the liver, in one-ninth ; the kidneys 
in one eighteenth of the cases ; but ulceration of the larynx occurred only once, and ulceration 
of the bowels, sixteen times in 112 cases. 

M. Cless, of Stuttgard, has also published the results obtained from the examination of up- 
wards of 180 bodies affected with tubercular disease. In 152 examinations of adults, M. 
Cless found the lungs free from tubercles six times. In 21 examinations of children, he only 
found the lungs free from tubercles once. This was in a boy eleven years of age, who. besides 
a considerable serous effusion into the ventricles of the brain, had two large masses of tubercle 
in the cerebellum, many small ones on the surace of the liver, and caries of the vertebrae. 

In 146 adults affected with tubercles in the lungs, there were only thirty-five in whom the 
disease was confined exclusively to the lungs. In children there were only three cases out 
of twenty in which all the other organs were free. M. Cless never found the bronchial glands 
in children affected with tubercular deposit without the existence of tubercles in the lungs 
also. In thirteen adults and one child there were tubercles in the pleura. In sixty-one adults^ 
and four children, the tubercles were limited to the peritoneum eight times. The four chil- 
dren were between six months and ten years of age. In 152 adults affected with tubercles, 
tire small intestines were affected eighty-three times, and the large intestines thirty-seven times, 
and in twenty-one children, the small intestines were affected seven times, the large ones only 
once. Among 152 adults, thirty-two had tubercles of the mesenteric glands, while they occurred 
in these glands in seven out of twenty -one dhWdir en. In all the cases tubercles were found in the 
other organs. Tubercles of the liver occurred once in an adult, twice in children, while other 
organs were also affected. In four adults, and twelve children, the spleen was affected with 
tubercles, these at the same time existing in other parts of the body. In children M. Cless 
remarks, the parenchyma of the spleen is often completely invaded by tubercles. In the 
kidneys, tubercles were met with four times in adults, and three times in children; of five 
children, aged from eight months to eleven years, in whom the membranes of the brain pre- 
sented tubercles, four died of acute hydrocephalus. In all these there were tubercles in the 
lungs and other organs also. The tubercular granulations had always their seat on the ex- 
ternal surface of the arachnoid, between this membrane and the pia mater, never within the 
cavity of the arachnoid. In twenty-seven children who died from tubercles, four had tubercles 
of the brain, as also in other organs; M. Cless never found any in the brain of adults. Be- 
sides their existence in the mesenteric and bronchial glands, M. Cless found tubercles in the 
glands of the neck in five adults, and one child. See Condie on Diseases of Children, 2d 
edition. — C] 

The question has been much and eagerly discussed, whether the deposition of 
tubercular matter be not, what I should call, an event of inflammation. Some persons 
have strenuously argued that the curd-like substance is nothing more than a parti- 
cular kind of vitiated lymph, and that it is never poured out except as a consequence 
of inflammation ; and they cite cases of persons who aKvays had enjoyed good 
health, until inflammation was accidentally excited in their lungs, immediately after 
which the well-known signs of phthisis began to display themselves ; and, after 
death, the lungs were found full of tubercles. But they forget to take imo the 
account another fact equally well established, viz. : that tubercles are found, in great 
abundance, in the lungs of persons who were never known, in their lives, to have 
any functional disturbance of those organs ; and whose lungs present, after death, no 
other traces of having been inflamed. We even find tubercles in the lungs of unborn 
children. Not th'at this is conclusive ; for inflammation does sometimes attack the 
foetus in utero, aud leave permanent and unequivocal traces of its action. 

Moreover, inflammation continually happens, in all the component textures of the 
lung, in the forms of bronchitis, pneumonia, and pleurisy, without the subsequent 
development of tubercles, I admit that this fact, to be of weight, should be proved 
of persons who possess the scrofulous diathesis ; and I believe the proof might be 
found ; but the search for it would require much carefulness and candour. 

In my own opinion, there is not a shadow of evidence to show that the deposit of 
tubercular matter is always and necessarily preceded by inflammation. Yet 
an undoubted and most important connection obtains between the occurrence of in- 
flammation and the occurrence of tubercles. Tubercles will cause inflammation, and 
jnflamnaation will determine the development of tubercles. The enlarging tubercles 
excite inflammation in the surrounding textures by the pressure they exert upon 
them ; and pri?bably in other ways ; by mechanically interfering with the healthy 



TUBERCLES. 



133 



circulation of the blood, for example : and the inflammation lit up is usually of the 
scrofulous kind ; it is slow, and partial, and easily quieted by treatment, though 
scarcely to be cured. On the other hand, there are numerous facts to prove that, 
in a person having the scrofulous diathesis, the occurrence of inflammation with the 
chest may rouse that previously dormant tendency into action, and become the ex- 
citing cause of the secretion or separation of tubercular matter from the blood. The 
cases in which other parts of the lung than the apex are found exclusively occupied 
with tubercles, are also cases in which, apparently, the same parts had been the seat 
of inflammatory action : of which we sometimes see other traces in adhesions of the 
neighbouring pleura. 

The connection between tubercles and inflammation is shown also by their occur- 
rence in the substance of false membranes. And the same phenomenon marks the 
fact that they are something distinct and different from coagulable lymph. 

You must not suppose, from any thing I have said, that persons of the scrofulous 
habit are not susceptible of common inflammation ; we know that they are, by the 
readiness with which slight injuries often heal in such persons ; but there is always 
much reason to apprehend that inflammation occurring in them will take on the 
scrofulous form; become chronic, if it was not so at first, suppurate tardily, and pro- 
duce that unhealthy kind of puriform secretion which is characteristic of strumous 
disease. 

Another question relating to tubercular diseases is, whether they are contagious :■ 
capable, i. e., of being communicated from one individual to another. The general 
belief, in this country, is that they are not. Indeed their very dependence upon a 
pecuhar diathesis would seem to disprove the supposition. Yet some practitioners, 
even here, have, I know, misgivings on the subject : and in some parts of the con- 
tinent, in Italy particularly, consumptive patients are shunned, from the persuasion 
that their complaint is infectious. I shall revive this question when I speak of 
phthisis hereafter. 

I have stated that scrofulous disease appears, almost exclusively, in certain classes 
of persons, of whom, therefore, we say, that they have the scrofulous diathesis. 

It is both interesting and useful to be able to distinguish those in whom the scro- 
fulous habit of body, or the predisposition to strumous disease, exists. 

Now there are certain physical and moral characters which teach us to apprehend 
the existence of a tendency to scrofulous disease, even when there has not, hitherto, 
been any local manifestation of such disease. 

Again, we infer the scrofulous diathesis, in many persons, from knowing that 
scrofula has existed among their progenitors. 

On these two points I have a few observations to make : and first, on what may 
be considered the external tokens of a scrofulous constitution. 

The persons, in whom scrofulous disease is most apt to declare itself, are marked, 
during childhood, by pale and pasty complexions, large heads, narrow chests, pro- 
tuberant bellies, soft and flabby muscles, and a languid and feeble circulation. They 
present many of the features belonging to that pattern of body which is denominated 
the leucophlegmatic. But the strumous disposition very often, indeed, accompanies 
a variety of the sanguine temperament also ; and is indicated by light or red hair, 
gray or blue eyes, with large and sluggish pupils, and long silky lashes, a fair trans- 
parent brilliancy of skin, and rosy cheeks. This red colour, which is well defined 
in general, is easily changed, however, by cold, to purple or livid ; the skin is thin 
and readily irritated ; the sclerotic has often a peculiar pearly lustre ; and the extre- 
mities are subject to chilblains. Such children are, many of them, extremely clever 
and ready of apprehension, of eager tempers, and warm afl(-'Ction?, lively, ardent, 
imaginative, and susceptible. This precocity of mind and intellect, while it delights 
the fondness of the parent, awakens the fears of the more far-seeing physician. 

But the disposition to scrofula is by no means confined to persons of the serous or 
of the sanguine temperament. It is frequent, though less common, in what has been 
called the melancholic or bilious temperament ; in persons of dark muddy com- 
plexion, and h^rsh skin ; in whom the mental and bodily energies are more sluggish 



INFLAMMATION. 



and dull. And it is remarked that in persons of this cast, scrofula, when it does 
occur, is even more than usually obstinate and intractable. 

Scrofula does often, indeed, appear in persons who exhibit none of those signs of a 
strumous disposition which I have been enumerating ; but is more likely to appear, 
ceteris paribus, where those signs are observed. 

There are several alleged marks of a scrofulous diathesis which are, in fact, in- 
stances of scrofulous disease. Such, for example, is that chronic lippitudo, which 
so frequently disfigures strumous cliildren, rendering them what is called blear-e5^ed ; 
and chronic inflammation of the conjunctiva, lasting long, wdthout much redness or 
heat, and with extreme impatience of light, and a tendency to forai httle pustules 
near the edge of the cornea. The tumid and chapped upper lips, the redness and 
sweUing of the columna nasi, and lower parts of the nostrils, so common in children, 
especial] V during winter, are early fruits of the strumous taint. Certain maladies 
of the joints, what are popularly called white swellings, are instances of scrofulous 
disease. So may, perhaps, rickets be considered : at any rate, rickety children are 
very often affected with scrofula also. Moist eruptions behind the ears ; chronic en- 
largement of the glands of the neck ; that slow, eating ulceration of the nares, termed 
lupus ; may all be included within the class of strumous disorders. 

When any one of these scrofulous affections has once shown itself in any person, 
we know, by that circumstance, that he possesses the strumous constitution ; 
and we look for the recurrence of his complaint in the same part, or in other 
parts. 

In a former lecture I mentioned scrofula as one of those distempers the hereditary 
tendency to which is indisputable. The scrofulous diathesis is hereditary : and 
som-etimes scrofulous disease is so too. I have seen lungs, taken from the body of a 
foetus, stuffed with tubercles. There were some fine examples of this in Mr. Lang- 
staff's museum in the cit}". We have, therefore, in respect to scrofula, the rare con- 
junction of congenital disease, and hereditary disposition. I need not repeat here 
the remarks I made before respecting hereditary diseases in general. No one, of 
the least observation, can doubt that the disposition to consumption is very often 
transmitted from parent to child. We see whole famihes swept away b}^ its ravages. 
Like other hereditar}^ tendencies, it ma}' skip over one or two generations, and re- 
appear in the next, just as family-hkenesses are known to do. There are other 
famihes in which you can trace no such predisposition ; but such families are per- 
haps few. A httle leaven is sufficient, sometimes, effectually to taint a whole pedi- 
gree. The tendency, however, exists in various degrees. It may be so strong that 
no care, no favourable combination of circumstances, will prevent its local manifes- 
tation ; and it may be so faint that it would never break out into actual mischief if 
the exciting causes of scrofulous diseases could be warded off. It is important, 
therefore, to know what these exciting causes are. 

" They may all be ranked together (to use the language of Dr. Alison) as causes 
of debility, acting permanently, or habitually for §i length of time, although not so 
powerfully as lo produce sudden or violent effects." 

The circumstances to which, acting separate!}-, or in combination, we most con- 
fidently ascribe the power of developing scrofula, are insufficient nutriment, exposure 
to wet and cold, impurity of the atmosphere, the want of natural exercise, and mental 
disquietude. To estimate the separate effect of each of these causes may be diffi- 
cult ; but their combined influence is unquestionable. 

There can be no doubt that improper diet, or rather- imperfect nourishment, is 
one main exciting cause of scrofulous disease. Yet of this it is not an easy thing 
to obtain evidence, which shall be entirely free from fallacy. The disease occurs 
very often among the poor; but then it very often occurs also in the families of the 
rich. There is one fact which has always struck me as very instructive and con- 
vincing on this point. Infants at the breast, having good milk and plenty of it, 
seldom show an}^ signs of scrofulous disorder : whereas, as soon as they are weaned, 
the}' become subject to various complaints of a strumous kind. When an unweaned 
child is brought to us with ophthalmia, we expect ahnost always to discover inflam- 
mation of the common and acute kind ; the purulent eye. In nine children out of 



SCROFULOUS DISEASE. 



135 



ten who come after weaning, we look for and find some form of scrofulous inflam- 
mation, such as pustular ophthalmia. 

[Mr. Phillips (^Scrofula, its nature and causes), has succeeded in establishing very conclu- 
sively the influence of bad and deficiexit food, and "of an excess of vegetable food, in the 
production of scrofula. — C] 

The greater prevalence of scrofulous disease among the poor may be ascribed, in 
great measure, to their frequent exposure to wet and cold. 

[Earth ez and Rilliet were only able to find two cases out of 314 tuberculous children, 
where exposure to humidity appeared to be the sole cause of the tubercles. The researches 
of Mr. Phillips would tend also to prove that the influence of humidity has been much over- 
rated. — C] 

Scrofula seldom breaks out in the mild and dry weather of summer. The influ- 
ence of climate in fostering or repressing the disease is notorious. There is no cli- 
mate in which it flourishes more than in our own. Consumption is called, in some 
parts of the continent, the English disease. Persons who migrate from this country 
to warmer and more equable climates, seldom become scrofulous ; nay, it very often 
happens that the* incipient indications of strumous disease are completely arrested or 
quieted by the change. Phthisical patients, much troubled by symptoms here, are 
sometimes so thoroughly freed from them soon after their arrival in Madeira, as to 
be deceived into a belief that their case had been mistaken. They think themselves 
well. A return to this country undeceives them. The native inhabitants of hot 
regions are by no means, however, exempt from struma, in any of its forms. When 
they come into these latitudes they are more subject to scrofula than we ourselves 
are. And the same effect of climate is very distinctly visible in the lower animals. 
The physicians in ordinary to the inmates of the Zoological Gardens will tell you 
that the beasts and birds which are brought hither from warm latitudes perish in 
great numbers from scrofulous diseases. John Hunter observed this long ago in 
respect to monkeys. 

Of the debilitating influence of impure air I spoke in a previous lecture. That it 
promotes the evolution of scrofulous disorders we have proof, on a large scale, in 
the great mortality produced by such disorders among the lower classes in large 
cities as compared with agricultural districts. The per-centage of deaths from con- 
sumption, hydrocephalus, and various other diseases which spring from a strumous 
habit, is much greater in London than in the country. Even in individual cases this 
influence is too manifest to be overlooked or mistaken. It is impossible to question 
the beneficial effect, upon children afflicted witk scrofula, of a removal from London 
to the sea-coast. ' 

I said, when I first began to speak to you of inflammation, that it was the only 
disease which v/e were able to excite at will : that we could cause inflamma- 
tion, in various ways, whenever we desired to do so ; but that to make a cancer or 
a tubercle was beyond our, power. Now in strictness of language, and in the prac- 
tical meaning of these words, the assertion is quite true. But it is not so exact if 
we extend it to all the predisposing causes of disease. We are able to bring about 
the formation of tubercles, in the lower animals at least, by so arranging external 
influences as to concentrate their prejudicial effects. By shutting rabbits up in a 
cold, damp, dark, and narrow place — and feeding them on food not natural or suited 
to them — we can produce or evolve in them tubercular disease. Of course no ex- 
periment of that kind can be purposely made upon a healthy man ; but accidental 
opportunities arise of witnessing an approach to a similar trial of the human species. 
Instances are recorded of persons, previously well (but having probably the strumous 
diathesis), becoming affected with scrofula after being confined in the dungeons of a 
prison, and there scantily fed. 

Something of this kind I have, very recently, had the opportunity of seeing. 

A number of male prisoners, chiefly young men, became affected with glandular 
swelhngp of the neck, after incarceration for some length of time in the Penitentiary 
at Milbank. The circumstances of their health led to a relaxation of their punish- 
ment. Instead of being kept in sohtary confinement in a coldish cell, and on the 



INFLAMMATION. 



prison diet, they were permitted to work, for several hours daily, in each others^ 
company in the garden of the establishment. Some porter was at the same time 
given them, and their allowance of meat was increased. The improvement in their 
condition was rapid and striking. Here we have the disorder germinating under 
one state of external circumstances, and checked immediately under the opposite 
state. 

If you consider the way of life of the children of the poorer classes in this me- 
tropolis, and in our large manufacturing towns, you will find that they are much 
exposed (though in a less degree) to the same injurious influences, the combination 
of which appears to generate tubercles in the rabbit. They live, for the most part, 
in an atmosphere made stagnant by narrow streets ; and in small, crowded, ill-ven- 
tilated and dark rooms in those narrow streets ; the stagnant atmosphere is contami- 
nated in a thousand ways ; they are very insufficiently protected from transitions of 
temperature, against cold and wet, by their clothing; they are commonly ill-fed — 
their diet being frequently scanty, and generally of a kind quite unsuited to their 
growing years. We need not be surprised, therefore, at the ravages Avhich scrofula, 
in its manifold shapes, makes among the children of the poor in large and populous 
towns. If ever scrofula be generated, in this country, independently of any heredi- 
tary strumous taint in the constitution, it is in them. But in most cases I beheve it 
is the latent disposition that is called into action. Moderate exercise, in pure air, and 
in the open daylight, with suitable nourishment, sufficient clothing, and attention 
to the state of the bowels: these circumstances comprise nearly all that we can 
attempt, in a given climate, tov>^ards preventing the development of struma: and 
from each and all of them many of these poor children are habitually debarred. 



LECTURE XIII. 

Cancer; its Species or Varieties. Scirrhus; Encephaloid Cancer ; Colloid Cancer. 

Its mode of Growth and Dissemination. Habitudes of the several Varieties. 
Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting. 

I HAVE more than once coupled cancer and tubercle in the same sentence. 
Though very different in many respects, they are alike in their intractable cha- 
racter and destructive tendencies. Of the two, cancer, M'hile it is happily much the 
more rare, is also much the more painful, loathsome, and hideous in its consequences. 
It is to cancerous diseases that the epithet malignant especially belongs. Not re- 
sulting from any change in the natural textures of the body, but constituting an 
addition to them, and therefore assuming, usually, the shape of tumours, they are 
commonly and correctly spoken of as cancerous growths. But there are other 
growths which, by comparison, are innocent; which do not imply any necessary 
destruction of contiguous parts, nor any inevitable danger to life, nor even any 
marked deterioration of the general health. Such are certain fatty tumours, and 
fibrous tumours, and osseous tumours. All these last, as their names denote, re- 
setnble in their sensible qualities some of the healthy and natural textures. They 
have accordingly been styled analogous, or homologous growths ; while cancer 
and tubercle, which find no counterparts in the sound body, are said to be hetero- 
logous.' Some varieties of cancer are, however, very similar in outward appearance 
to the substance of the brain ; and microscopic observers say that in their minute 
and original structure there is no perceptible distinction between the most innocent 
and the most malignant growths ; nay, that both agree in their primary corpuscular 
elements with the healthy tissues of animals, and even of plants. 

[This statement is not perfectly accurate. The microscope has not, it is true, thrown much 
light upon the nature and causes of morbid growths 5 it has, however, shown that in many 



CANCER. 



137 



of the particulars of their intimate structure, they not only differ from the healthy tissues of 
the body, but that they differ in this respect from each other. 

That such is tlie case, is rendered evident by the result of all the xnore recent researches 
into the intimate structure' of cancerous formations. 

By Miiller and other pathologists, cancerous formations have been arranged in two great 
families or groups — the encephaloid and the scirrhous. — .Of the first there are three sub- 
divisions. 

1. Medullary Carcinoma; in which there is a predominance in the medullary mass, of 
round globules over loose fibrous tissue. The globules are of various sizes; but the smallest 
are larger than pus-corpuscules. Each contains a granular substance or nucleus within. 
They are very similar, in many respects, to those of common cancer, and of reticulated car- 
cinoma or scirrhus. 

2. Medullary Carcinoma^ consisting of pale, elliptic.^ non-elongated corpuscles., and of a funda- 
mental cevebriform mass. These corpuscles are usually twice or three times as large as the 
globules of the blood. There is never any appearance of fibres proceeding from their sur- 
face, and they rarely exhibit any traces of nuclei within them. 

3. Medullary Carcinoma., with, fibrated or puriform corpuscles. This species of encephaloid 
structure has, at times, on laceration, a sort of fibrous aspect, when the puriform corpuscles 
are arranged in a somewhat determinate direction; according to which the morbid mass 
will present a radiated or a tufted appearance. In many cases their directions are so various 
that the lacerated surface exhibits no traces of fibres anywhere. The puriform corpuscles 
are sometimes nucleated, at others they contain granular points, but without distinct nuclei. 
They are elongated, on one or two sides, into fibres of different lengths. They may be con- 
sidered as cells that are arrested at the period of transition from the cellular to the fibrous 
condition. 

The three forms of disease now described, may, most probably, be regarded as so many 
degrees or stages in the develojiment of the same tissue; these successive stages being cha- 
racterized, 1, by rounded nucleated globules ; 2, by elongated oviform globules, which are 
either non-nucleated or indistinctly so; and 3, by puriform globules. 

These several kinds of globules may be regarded as so inany successive epochs of evolu- 
tion through which a cell must pass before it can become a fibre. Thus we find, it is true, 
that in an encephaloid mass there is the same transforiiiation of the primitive elements, as 
occurs in many normal tissues — with this difference only, that the process of evolution is 
not complete — being arrested before the fibrin is perfectly formed. 

The essential element of an encephaloid tumour is the presence of cells. In some cases 
the entire mass is composed of them, placed one alongside of the other, but without hav- 
ing any perceptible bond of union, while in others there is a network of fibrous or cellular 
tissue interposed between the cells. When the fibrous tissue prevails, the encephaloid then 
approaches in character to the scirrhous structure. In the latter die existence of the two 
elements, cells and fibres, is always more distinctly marked than in the former. The fibres 
are often quite perceptible to the naked eye. Sometimes they are lengthened, and run 
parallel to each other ; at others, they form rounded capsules, within which the globules are 
contained. As in the case of the newly formed fibres of the cellular tissue, so those of a 
scirrhous formation are destroyed by acetic acid, leaving nuclei or nucleated fibres behind. 
Tlie fibres sometimes exhibit, at different points, a sort of varicose enlargement, within each 
of whiph a nucleus is found. This appearance is often observed in fibrous tumours — not 
genuine scirrhus — of the uterus and other parts. 

In the reticular carcinoma oi Miiller, the white network which encloses the scirrhous glo- 
bules in its meshes, is formed of round, opaque gratmlations, three or four times as large as 
the blood globules; they are, occasionally, agglomerated into rounded masses. The genuine 
scirrhous tissue, of a pale grayish colour, is composed of globules that, on the whole, resem- 
ble those of the first stage of an encephaloid formation. These globules are either round or 
somewhat oval ; along with them, according to Vogel, we find free nuclei with their nucleoli. 

From a variety of observations, it may be reasonably concluded that the cells of scirrhus 
are formed around the nuclei of which M. Vogel speaks ; their contents are at first granular 
and almost opaque. When the process of softening commences, the granulations disappear, 
the globules become transparent, and within them are formed new cells, which at first are 
few in number, and gradually multiply, until they entirely fill the parent cell. M. Valentin, 
who, in part at least, admits this account of the progress of the cell, declares, that the parent 
cells eventually burst and discharge their cellules; we may thus account for the presence 
of young free cells in scirrhous formations that have become softened. 

The inter-cellular substance seems to undergo certain modifications corresponding with 
the evolution of the cells; the granulations or granular points which it often contains, 
usually dis?,ppear, and it becomes limpid, while, at the same time, the space which it occu- 
pies is diminished by the enlargement and^multiplication of the cells. 

The fibrous network does not appear to follow, in its alterations, the development of the 
cells; it may remain firm and resisting while the cells are far advanced in their evolution. 

m2 



138 



INFLAMMATION. 



Even when a scirrhous tumour has become completely softened, this tissue sometimes forms 
shreds that retain their original character. 

In alveolar cancer^ the basis of the morbid tissue consists of white fibres and lamellae, 
which cross and intercross with each other, containing, between "the meshes thus formed, 
limpid cells, either closed or communicating with each other, of various sizes, from that of 
a grain of sand to that of a large pea, and filled with a transparent, gelatinous substance. 
In this substance there are cells, which contain other cells more minute. The smallest of 
these cells exhibit, at one point of their parietes, a distinct dark yellowish nucleus, and 
sometimes, also, many free and unattached granules floating within them. To this sj)ecies 
Miiller refers the gelatiniform and areolar cancers of Laennec and Cruveilhier. The ceils of 
this species of the disease appear to be only an advanced or more mature degree of the 
cells of scirrhus. — C] 

This very agreement, if it really be so complete, shows that in classifying morbid 
growths we must reject the aid of the microscope, and attend to their grosser and 
more palpable features. And, inasmuch as cancerous formations have, by some 
pathologists, been ascribed (very erroneously, in my opinion) to inflammation as 
their cause, I shall scarcely be going out of my way if I state here some of the 
broad facts which have been ascertained upon this very interesting subject. 

Cancer, or carcinoma, considered as a genus of disease, comprehends two or three 
species, ■which present among themselves very striking differences, and of which the 
varieties have received a puzzling multiplicity of names ; scirrhus, stone cancer, 
medullar}^ sarcoma, encephaloid or cerebriform disease, soft cancer, fungus hsma- 
todes, colloid or gum cancer, and several more. The simplest division, founded 
upon the consistence of the morbid growth, is into hard and soft cancer. But the 
most modern and scientific system recognizes three species, viz., scirrhus ; encepha- 
loid, or brain- like cancer ; and colloid, or gum-like cancer. The physical characters 
of these three species offer, strong points, not merely of difference, but even of 
contrast. 

Scirrhus, as that word implies, is remarkable in its earh^ stages, for its hardness. 
It is as firm as cartilage, and creaks when divided by a sharp knife. The surfaces 
exposed by its division present a glistening, satiny appearance, and a white, or gray, 
or bluish-vvhite colour. Athwart this grayish and serai-transparent substance run. 
opaque intersecting bands, having a fibrous aspect. By strong pressure a thin juice 
mo-j be made to ooze from a shce of the scirrhous tumour. 

Encephaloid cancer is also well named. It is composed, in great measure, of a 
soft, white, opaque pulpy substance, very closely resembling, both in colour and in 
consistence, that of the healthy brain. This cerebriform pulp is traversed and cir- 
cumscribed by fibrous septa, which are sometimes extremel}" thin and dehcate. In 
both these species of cancerous growth, therefore, there is a contained and a containing 
element. 

The same feature is still more distinctly marked in the third species, the colloid 
cancer, which exhibits the appearance of small portions of a greenish-yellow trans- 
parent gum, or jelly, arranged in regular cells. Hence it is sometimes denominated 
alveolar cancer. 

You may ask upon what principle stractures so dissimilar in their physical ap- 
pearance have been assigned to the same genus ? Why, for these reasons. They 
are all strictly destructive or mahgnant forms of disease. Although in any shape 
the}^ are of somewhat rare occurrence, yet when they do occur, two, or all three 
of the species are often found to coexist in different organs of the same individual ; 
. nay, in contiguous parts of the same organ. More than this : if a tumour consisting 
of one species be amputated, and a fresh growth springs (as too often it does) from 
the same spot,, this secondary growth is frequentl}^ of another species. There can 
be no doubt that all are connected by some very intimate bond of union ; and the 
facts I hav^e just stated suggest the question, whether instead of being different spe- 
cies of the same genus, they ought not rather to be regarded as mere varieties of the 
same species. 

Of ail three it has been ascertained, by much and fatal experience, that occurring 
in any one part of the body they are prone to mukipiy in various other parts ; that 
they are commonly attended, during some part at least of their progress, wdth very 



CANCER. 



139 



severe pain ; that they are incontrollable by any known remedy ; and tend always, 
sometimes slowly, sometimes with frightful rapidity, to augment in bulk ; eating 
away contiguous parts by their invasion and pressure ; breaking out, when near the 
surface, into foul and repulsive ulceration; producing often the most ghastly disfi- 
gurement ; and ultimately destroying life. Sometimes vital parts are slowly disor- 
ganized by the corroding extension of these tumours ; sometimes large blood-vessels 
are laid open, and death is suddenly brought about by hemorrhage ; and sometimes 
the powers of hfe sink gradually under the wearing influence of the disease, and 
that degeneracy of the blood which it causes or accompanies. 

There is scarcely an organ or a texture of the body which is not liable to be 
attacked by this terrible foe : the brain, the eye, the hp and face, the lungs, the 
stomach, the intestines, the hver, the kidneys, the breast, the womb, the testicle, the 
bones. But some parts are more often the seat of cancer than others. Among 
these may be reckoned the female mamma, the uterus, the stomach, the liver, and 
the testicle. 

The mode in which cancer originates is uncertain ; the modes in which it spreads 
and multiplies are better understood. An individual tumour may enlarge by the 
progressive insinuation of the cancerous matter into the interstices of the neighbour- 
ing tissues, w^hich, thus fastening upon, it consolidates. The disease may be com- 
municated, by imbibition, from one organ to another which is in mere contact with 
it. But how does it come to occupy at the same time, or in quick succession, several 
separate and distant organs ? This is a question of the greatest interest and im- 
portance, and it admits of a distinct reply. 

Cancer often makes its appearance in a single spot on the surface of the body ; in 
the female breast, for instance. We see and feel it there while it is yet small, and 
while the general health of the patient seems to be otherwise perfect. By degrees 
the tumour increases, and at length it softens in some places'; the glands of the axilla 
become swollen, hard, painful, and filled sometimes with cancerous matter; the 
•tumour breaks perhaps through the skin, and presents the shocking spectacle of 
" open cancer ;" the general health gives way, and the skin assumes a straw-coloured 
tint. During this process, unless the patient dies prematurely, or the original disease 
is removed by a surgical operation, cancerous jptumours form in one or in several of 
the internal organs, and give notice of their presence by appropriate symptoms. There 
is an original morbid growth, and there are subsequent morbid growths ; a primary 
tumour, and secondary tumours ; and the latter are caused by the former. This is 
a most important fact, if indeed it be true. 

Now Miiller has discovered, by means of the microscope, and the discovery has 
been confirmed by other observers, that the contained matter, in the several species 
or varieties of cancer, consists of very minute cells, with nuclei attached to their 
walls, and of granules still more minute, which are supposed to be the rudiments of 
new cells. It is (apparently) by the amplification of these granules into cells, and 
by the development of the nuclei into other cells, and by the growth and evolution 
of young cells, which in some instances are included generation after generation 
within parent cells, that the original tumours enlarge and extend themselves ; and it 
is by the transference of certain of these cells and granules from the original tumour 
that a crop of secondary tumours is sown in remote f^arts of the body. The cells, 
and probably the granules also, are endowed with the power of self-increase and 
propagation, whenever they find a fitting nidus. Possessing, like the seeds of plants, 
an inherent vitality of their own, they merely require, in order to germinate, to be 
placed in contact with some living tissue, wherewith they may form vascular con- 
nections, and wherefrom they may draw the materials of their nourishment. Co- 
hering together, for the most part, with but httle force, they are easily detached from 
the parent mass. It is matter of fact that the secondary tumours form most surely 
and most rapidly when the primary tumour is of a soft kind ; and that vA'hen they 
succeed to scirrhus, it is after the process of softening has commenced in that origin- 
ally hard structure. These germs — which present, in their forms and mode of 
generation, striking analogies to those of some of the lower animals, as well as to 
those of plants — these germs are probably carried sometimes through the lymphatic 



140 



INFLAMMATION. 



vessels to absorbent glands in the vicinity of the primarj^ growth ; but there can 
scarcely be a doubt that the blood is the main channel by which the seeds of this 
dreadful maiad}" are conveyed from its first to its subsequent sites, and thence per- 
haps, if life continues long enough, to tertiar}" locations. The gross matter of cancer 
is often to be found in the veins that proceed from the primary tumour — nay, in large 
venous trunks at a distance : so that some distinguished pathologists have too hastily 
conjectured that it m^.y originate in the veins. You are probably aware that foreign 
substances, circulating with the blood, stop or are entangled more often in some 
organs than in others. Minute globules of mercur}", where that metal has been 
introduced into the veins, are found strewed through the substance of the lungs, and 
of the liver. Pus, received into the blood in phlebitis, is arrested, and forms scat- 
tered points of inflammation and abscess, in the same organs ; and it is in the hver 
and the lungs that separate tumours of secondary cancer are most commonlj^ met 
with. If this be the true theory of secondary cancerous formations, I need scarcely 
point out to you the urgent importance of the rule which prescribes to the surgeon 
the most complete extirpation of the primary tumour, at the earliest possible period 
of its existence. 

Of these primar}^ formations the origin is involved in much obscurity. It seems, 
however (and this, after what has just been stated, you might expect) that the germs 
of the disease are capable of being transferred from one human being to another ; 
and even to an animal of a different species. Langenbeck injected cancerous matter, 
just taken from a living body, into the veins of a dog. After some weeks the dog 
began to pine away, and w-as then killed, and cancerous growths were found in its 
lungs. Several instances have occurred — I have m5^self known of two — of cancer 
of the penis in men whose wives laboured under cancer of the uterus. Here it is 
presumable that the cancerous germs, received upon a delicate and vascular surface, 
and suffered perhaps to lodge there through neglect of clean Uness, might fasten upon 
the part, take root there as it were, and grow. One ver}^ curious circumstance con- 
nected with this subject is, that the frequent contact of common soot seems to have 
the power of producing cancer. There is a form of carcinoma, affecting chiefly the 
sciotum, and famih^r to surgeons as the chimney-sweeper's cancer. A case is 
recorded of cancer of the same variety occurring in the right hand of a gardener, 
^vho for years had been in the habit ol sprinkling soot over his flower-beds wdih his 
hands. 

There are not wanting, then, plausible grounds for the hypothesis, that the seeds 
of cancer may be introduced, in some way which eludes observation, from without ; 
that cancerous growths are strictly parasitic, and independent of the body, excepting 
so far as they derive their pabulum from its juices. The difficulties involved in 
this supposition are -not greater (as we shall see hereafter) than those which hang 
over the source and origin of certain entozoa, whereby the body is hable to be 
infested. But whether this hypothesis be true, or whether the cancer cells and gerais 
are merely morbid elements of the native tissues of the body, developed by some 
perverted energy of the formative process, remains yet to be determined. 

From the tables contained in the Reports of the Registrar-General, it would 
appear that women are more subject to this fearful disorder than men, in the large 
ratio of five to two. It fixes i^hiefly upon the female organs of reproduction ; the 
mammas and the uterus. 

The mortality from cancer, estimated with due reference to the whole number of 
persons existing at different ages, increases steadily as hfe advances. 

There are still some general habitudes of the different varieties of cancer, with 
which I should wish you to be acquainted. 

The secondary formations are most commonly of the encephaloid kind, whatever 
the primary form may have been. 

Encephaloid cancer, as compared with scirrhus, is abundantly furnished with 
blood-vessels ; and upon this difference in their degree of vascularity other remark- 
able differences between the two varieties seem to depend. First, encephaloid 
tumours generally augment with much greater rapidity, and attain a much larger 
size, than scirrhous tumours. Occasionally their magnitude comes to be enormous. 



ENCEPHALOID CANCER. 



141 



Again, cerebriform growths seldom happen singly, but occupy several organs of the 
body at once. Scirrhus, increasing slowly, occurs also in fewer sites ; it is some- 
times even solitary. More tissues, too, appear to be obnoxious to the soft than to the 
hard variety. 

Now (as Dr. William Budd has well remarked) a large apparatus of blood-vessels, 
bringing a proportionally plentiful supply of nourishment to the parasitic tumour, 
accounts suffi^ciently for its rank and rapid growth ; and the same condition, espe- 
cially when conjoined with softness of the parent mass, affords obvious facilities for 
the hberal dissemination of its germs through numerous returning channels. In 
fact, the soft varieties alone have, as yet, been found in the veins. 

The same multitude of its blood-vessels, and slender cohesion of its component 
parts, serve to explain another pecuharity of the cerebriform species. Intermixed 
with, or diffused through, the brain-like substance, there is often to be seen a quan- 
tity of extravasated blood ; and when the disease breaks out into ulceration, red, 
ragged, and bleeding growths, of fungous aspect, sprout rapidly from the open sur- 
face. To these accidents of cancer the term fungus hfsmatodes is to be traced. We 
do not find scirrhus to be the seat of similar interstitial hemorrhages. 

Encephaloid cancer has less tendency to contract adhesions with contiguous parts 
than scirrhus has. 

Of the alveolar variety, which has been more lately discriminated from the others, 
and less studied, less is known. It occurs principally in the abdomen, affecting the 
pyloric orifice of the stomach, and the omentum. It appears also occasionally in 
the bones, and the breast and testicle. Although sometimes combined with the two 
other species in the same person, it is often alone, and limited to a single organ. I 
beheve it has not been met with except in adults. 

For more minute information upon this subject, so interesting and important both 
in its pathological relations and in its practical bearings, I must refer you to a very 
able and elaborate article on cancer, in the Cyclopedia of Surgery, by Professor 
Walshe, and to a shorter but admirable essay on the same topic, by Dr. William 
Budd, pubhshed in the Lancet. From these sources has been derived much of 
what I have now been stating. [We may also refer the reader to the full and excel- 
lent paper of Dr. Carswell, on Scirrhus, in the Cyclopaedia of Practical Medi- 
cine. — C.] 

Returning to our current theme, I proceed, in the next place, to speak, in a gene- 
ral manner, of the measures to be adopted when we are called upon to administer to 
the relief of a person labouring under inflammation : of what is sometimes called 
the cure; but, more correctly, of the treatment of inflammation. 

In describing the phenornena and progress of inflammation, I took external inflam- 
mation as a type, and I shall keep that type principally in view in what I have to 
say respecting its treatment: making, however, such reference to the inflammation 
of internal parts as the subject wiU permit. You v/ill bear in niind that my design 
at present is merely to explain the principles of treatment, generally: I shall point 
out, by and by, the application of those principles, and the modifications they may 
require, in respect to particular cases. I speak also, now, of common inflammation, 
occurring in a previously healthy person. There are many observations that con- 
cern all inflammations alike, whether external or internal, and by despatching these 
in the outset, I hope to avoid much repetition hereafter. 

In all cases of inflammation, our first object is, if possible, to obtain resolution : 
and if that . be not possible, we next aim at securing that event of inflammation 
which would be the most fortunate in the particular case before us. In external 
inflammations good suppuration will generally, next to resolution, be the most 
desirable event : in internal inflammations it will be: sometimes suppuration, some- 
times adhesion. • 

It is necessary to keep in view the distinction between the treatment proper for 
the inflammation itself, and the treatment that may be required for the effects of 
the inflammation. At present we are concerned only with the inflammation itself. 

I stated to you in a former lecture, that a knowledge of the cause of a disease 



142 



TREATMENT OF TNFLAMMATIO?r. 



might help us in its treatment. Knowing the cause, our first care must be to ' 
remove it, if we can. In the case formerly supposed, we should extract from the ; 
inflamed arm the fragment of glass. If the inflammation has been excited by the ■ 
extremit}^ of ?l fractured bone, of a broken rib, for example, we take measures for | 
bringing the separated bones into their proper places, and for keeping them there : | 
if the mere displacement of a part has occasioned the infiam.mation, as the disloca- 
tion of a joint, the protrusion of the bowel in hernia, the first thing to be attended to ' 
is the restoration of the part to its natural situation : if there be any chemical source j 
of 'irritation (in the stomach, for instance, threatening or producing inflammation i 
there,) we eject, neutralize, or dilute it. 

I know of but one exception to this rule, and it belongs to surgery : to 2vit, when ; 
a bullet or sphnter is so lodged in the interior of the body, that its extraction would 
be more hurtful or hazardous than its remaining where it is. I 

A knowledge of the cause of an inflammatory disease may help us in another ! 
way. We do not treat a joint that is inflamed in consequence of external violence , 
as we should treat the same joint when inflamed in rheumatism. ; 

But it is very seldom, except when the inflammation is external, that we can ' 
accomplish the removal of its cause. In most internal cases, either it cannot be got ' 
at, or it has already ceased to be applied; as when the inflammation has been excited | 
by exposure to cold. But it may be possible, and it is of the utmost importance i 
when possible, to prevent any re-application or repetition of the same cause, which ) 
would be hkely to frustrate our endeavours to bring about .resolution. j 

Next in importance to the removal and avoidance of the exciting cause, must be 
placed in most instances, the observance of what is called the antiphlogistic regi- . 
men. This may seem an old-fashioned phrase, but it is a very convenient one ; i 
being a brief form of expressing the sum of several distinct provisions for the wel- 
fare of the sick, and for the conduct of their attendants. The word antiphlogistic is 
derived, indeed, from an obsolete theory ; but we retain it as a useful arbitrary term, 
without reference to its etymology, or to its original meaning. 

The object of the antiphlogistic regimen is to put and keep the patient in that 1 
state which is most favourable for the spontaneous subsidence of the disease, or for ' 
the sanative influence of remedies. This regimen consists in the avoidance of every j 
stimulus that can be avoided, whether external or internal. Common sense w^ill j 
suggest to you the details. It impKes a total abstinence from animal food, and from j 
strong drink of all kinds. It prescribes the exclusion of all that might excite or i 
exercise the mind, or produce a strong impression upon the senses : noise ; bright '< 
light ; great heat or cold. The patient should be kept in a temperature of about 62°, ' 
and in a well-ventilated apartment. He must not be allowed to converse, nor to , 
attend to matters of business ; unless, indeed, his mind happens to be disturbed and ' 
anxious about some point which one short interview with a friend msLj effectually 
settle. All causes of strong emotion, and mental agitation, should be strictly guarded \ 
against. Whatever tends to quicken the circulation is to be shunned ; and therefore i 
not only those influences which operate through the nervous system, but also all i 
needless bodily effort and exertion, must be prohibited. The patient (in the serious 
cases I am now contemplating) must remain in bed : and in a position which facili- 
tates, or at least does not impede, the free return of blood by the veins from the suf- 
fering organ. If the inflammation is seated in or about the head, that part should j 
be elevated by pillows. If one of the lower extremities is affected, even when the : 
disease is not so intense as to require confinement to bed, the limb must be sustained ■ 
horizontally, or be even still more raised up. On the same principle it is that we i 
suspend an inflamed hand or fore-arm in a sling. In some cases of internal inflam- 
mation — in pleuris}^ for example — the patient will choose his own position. He is I 
admonished, by the pain and distress they occasion, that certain postures would be j 
hur^ul or dangerous, and he carefully avoids them. We often derive much informa- j 
tion from this instinctive caution on the part of our patient. j 

The function of the organ inflamed should also be spared its exercise, whenever j 
and in as great a degree as that can be done. As you would not allow a patient to ' 
move an inflamed joint, so you must not permit him to use an inflamed eye ; to | 

\ 
I 

,i 



ANTIPHLOGISTIC REGIMEN. 



143 



speak more than may be absolutely necessary with inflamed lungs ; to exert by 
thinking, and by attention to external excitements, an inflamed brain. This last rule 
is essential, even when the brain is not the seat of the inflammation: it is to be 
observed in all febrile disorders. 

The adoption of this antiphlogistic regimen is not, indeed, necessary, nor even 
proper, in all cases and stages of inflammation. The inflammation may be so slight 
as not to require it ; particularly in external cases, of which the causes and the extent 
are known ; as shght contusions, trifling wounds, and some kinds of eruption. But 
this exception must always be applied with great caution to cases of internal inflam- 
mation, about the causes and extent, and tendencies of which we may be less sure. 
In chronic forms of inflammation again, as in scrofulous inflammation of the lympha- 
tic glands, or of the eyes, attended with but little pain or heat, the antiphlogistic regi- 
men would often fail to be beneficial : the state of the general system being such as 
to require support and strengthening measures, more than the local symptoms call 
for an opposite treatment. So also when suppuration or gangrene have supervened, 
the antiphlogistic regimen must generally be modified, or abandoned. 

But in the outset of all cases of serious inflammation, when the strength is entire, 
and the inflammation intense enough to produce pyrexia, all the particulars of the 
antiphlogistic regimen may require to be observed. 

Of all the direct remedies of inflammation, the abstraction of blood, bleeding, or 
hlood.-letiing, as it is called, is by much the most eflfectual and important. We 
should, I think, be prepared to expect this, prior to any experience of it. Blood 
being the natural stimulus of the heart, we should deem it probable that the removal 
of a portion of that fluid would diminish the force with which the heart contracts : 
and as an inflamed part contains a preternatural quantity of blood, and as (with the 
exception of resolution and mortification, which really are terminations of inflamma- 
tion — as with these exceptions) all the events of inflammation depend upon the effu- 
sion of certain parts of the blood from its containing blood-vessels, we should be 
inclined, a priori, io believe that the amount of those effusions would be checked and 
limited by lessening the supply of blood to the inflamed organ, as well as by abating 
the force with which the blood reaches it. And we find it in fact to be so. The 
results of experience confirm, in this matter, the suggestions of our reason. Blood 
forms the pabulum of the whole process. "If," (says Mr. Lawrence,) "we may be 
allowed to use figurative language, the obvious increase of heat in the part is analo- 
gous to that of fire ; and blood is the fuel by which the flame is kept up : in fact, 
if we could completely take away its blood from the part, we should be able entirely 
to control or arrest the increased action." 

But it is not every case of inflammation that requires or warrants the abstraction 
of blood : and when blood-letting is requisite, the mode of taking away the blood, 
the proper quantity to be taken, and the propriety of repeating the bleeding, all vary 
greatly in different cases. It is obviously of vast importance that you should learn 
so to use this valuable remedy as not to abuse it. Its power is great for evil as well 
as for good ; and in rash or inexperienced hands it too often becomes an instrument 
of fatal mischief. 

There are, as you are all aware, several modes of abstracting blood : phlebotomy, 
arteriotomy, scarification, cupping (which is merely a variety of scarification), the 
apphcation of leeches. Bleeding performed in either of the first two of these me- 
thods is called general bleeding. The rest are, in most instances, topical or local: 
but they are not merely topical in all cases. The main object of general bleeding 
is to diminish the whole quantity of blood in the system, and thus to lessen the force 
of the heart's action. The object of local bleeding is, in most instances, that of emp- 
tying the gorged and loaded capillaries of the inflamed part. Sometimes the blood 
is thus taken directly from the turgid vessels themselves ; more often, I fancy, topi- 
cal blood-letting produces its effect by diverting the flow of blood from the affected 
part, and giving it a new direction, and so indirectly relieving the inflammatory con- 
gestion. General bleeding has also incidentally a similar tendency to deplete the 
vessels concerned in the diseased process : and, on the other hand, a dexterous cup- 
per, under favourable circumstances, will take away blood from a part as copiously 



144 



INFLAMMATION. 



and rapidly as if it were made to flow from an opened vein : and then tiie effect 
upon the system will be alike in the one case and in the other. The same may 
be said of leeches, when they are applied in the enormous numbers which our 
neighbours, the French, are fond of using. In whatever way the blood is drawn, 
whether from a vein or from an artery, or by the pressure of a cupping-glass around 
a surface previously scarified, or by the suction of leeches, the general effect upon 
the system will be in proportion to the quantity of blood abstracted in a given time. 
The most convenient and effectual mode of general bleeding, upon the whole, is 
certainly the common one, from the veins at the bend of the arm. But sometimes 
those veins are small or deep, especially in fat people ; and w^e fail in our efforts to 
get the blood to flow from them in a full stream : and then we may open some other 
vein or an artery, or call in the cupper to our assistance, or cover the neighbouring 
surface with leeches ; according to the situation of the part inflamed, and other cir- 
cumstances. 

Let us now briefly consider what the indications are by which we judge of the 
expediency of taking away blood. We are guided very much by the degree of 
pyrexia ; by the quahty of the pulse ; by the importance of the organ affected ; by 
the intensity of the inflammation, in what manner soever that may be measured ; by 
the period or stage of the disease ; by the age, and sex, and general condition of the 
patient; and frequently also by the ordinary character and course of the disease, 
when inflammation happens to be, or to accompany, an epidemic disorder. It is not 
one of these circumstances alone, but several of them, that we have to take into the 
account, in most cases : and what I have now to say in reference to them must needs 
be very general. 

The presence of pyrexia, especially when the febrile disturbance is well marked, 
admonishes us, indeed, to search after other indications of the propriety of blood- 
letting, and confirms them if they are found ; but is not, of itself, a sufficient reason 
for resorting to that remedy. There may be high febrile symptoms without any 
inflammation at all ; as in the hot stage of an ague fit : and a smart attack of fever 
may spring out of local inflammation, and yet the known course of the disease, or 
the nature of the part affected, may render the abstraction of blood unnecessary, and 
therefore improper. 

Our judgment is more often determined by the quality of the pulse, although we 
are by no means to be wholly directed by this. The quality of the pulse which — 
other things being the same — bespeak the necessity of blood-letting, is hardness, I 
described this quality to you in a former lecture : it may coexist with a large or a 
small, a slow or a frequent pulse. Most commonly (and yet the exceptions are nu- 
merous) in acute inflammations the pulse is full and frequent as well as hard. The 
hardness is ascertained and measured by the resistance which the throb of the artery 
makes to the pressure of your finger. The pulse is sometimes said to be incom- 
pressible ; which means that, although you apply your finger with considerable firm- 
ness, the blood stiff forces its way through the vessel beneath it. 

Now this hardness of the pulse is sometimes our best warrant for active depletion 
by means of the lancet : yet I say we must not trust to this alone ; for a hard pulse 
may habitually exist, where there is no inflammation. Certain chronic diseased 
conditions of the heart may occasion it; and it probably results also sometimes 
from some unnatural state, which is not inflammation, of the whole of the circulating 
system. When you happen to know your patient, and have ascertained what kind 
of pulse he has when he is well, and are previously aware that his pulse during 
health is not a hard pulse, you learn from that circumstance that the new quahty it 
has now acquired denotes the presence of inflammation ; and usually of active inflam- 
mation, likely to go on, if not controlled, to the destruction of the part it has seized 
upon. 

Many persons, and young practitioners in particular, are apt to look to the fre- 
quency of the pulse, when they wish to ascertain the expediency of blood-letting: 
but really its frequency is very subordinate in importance to its hardness or softness: 
and this is very unlucky, because any body with his stop-watch in his hand can 
count a pulse : but it is not every one who can tell a hard pulse when he feels it. 



BLOOD-LETTING. 



145 



The finger requires a certain education for that purpose ; and there are some persons 
who seem never to attain the tadus eruditus. I should advise you to attend par- 
ticularly to this quaUty of the pulse, and to compare your perceptions to the hardness 
or softness of the pulse in individual cases, with those of other medical men. 

The frequency of an inflammatory pulse ranges for the most part between 90 and 
120. When the hard pulse is much more frequent than this, it commonly occurs 
either in young children, or in persons who are more than usually nervous and sus- 
ceptible ; or in persons who w^ere previously labouring under some chronic and 
wasting complaint, in which the pulse was already frequent, though not hard : as, 
for example, in phthisical patients, when acute pleurisy supervenes upon tubercular 
disease of the lungs. 

As the hardness of the pulse is, with certain exceptions at which I have just 
glanced, our lawful warrant for general bleeding, so the disappearance of that hard- 
ness is a token that the blood-letting has been carried far enough. 

Again, the nature and importance of the organ affected will influence our judg- 
ment in respect to the question of abstracting blood. If the organ inflamed be a vital 
organ ; or if we are not sure about that, but have any reason to suspect that it may 
be a vital organ ; I need scarcely say that we must act upon the w^orst supposition, 
and bleed. But if the part be of less importance in the economy of the body; or if 
inflammation is known ordinarily to run its course in that part without producing 
any abiding damage ; it may not be worth while, even though the fever be high and 
the pulse hard, to have recourse to this potent remedy, for the sake of subduing 
inflammation w^hich is attended with so httle danger. In this predicament may be 
placed many instances of cynanche tonsillaris, and of acute rheumatism. The sub- 
sequent debihtating effects of the loss of blood upon the system may be more certain 
and more hurtful than the effect of the bleeding upon the local inflammation is likely 
to be beneficial. 

[Without pretending to advocate the employment of blood-letting in every case of cynanche 
tonsillaris and of acute rheumatism, we must dissent from the correctness of Dr. Watson's 
position, that " even though the fever be high and the pulse hard," it may not be worth 
while to bleed "for the sake of subduing inflammation which, in these aJfections, is attended 
with so little danger." When acute rheumatism occurs in young, robust, and plethoric habits, 
and is attended with considerable fever and a hard and accelerated pulse, we know of no 
remedy from which such decided advantage is to be obtained as from a well-timed resort 
to the lancet. The extent to which the bleeding is to be carried and the propriety of its 
repetition, must be determined by the circumstances of each case, and the effects produced 
by the first oiseration. We are no advocate, under any circumstances, for the profuse and 
repeated bleedings recommended by M. Bouillaud as a means of cutting short an attack of 
acute rheumatism ; we have had, however, ample experience of the very decided relief 
obtained by a prudent and well-timed use of the lancet in this disease. 

In many cases of cynanche tonsillaris, also, an early and full bleeding will have the effect 
of arresting the inflammation, and thus of saving the patient from much suffering, if not 
danger. Even when the arrest of the disease is not aifected by it, the inflammation is 
reduced in violence and shortened in duration. — C] 

The period or stage of the disease forms a most important element in the question 
before us. It is of inflammation while yet in its early progress, that blood-letting 
may emphatically be pronounced the cure ; while the disease is still within the pos- 
sibility of resolution ; before there is any great amount of effusion, or any serious 
disorganization of structure. The sooner we bleed, the more surely will the inflam- 
matory process be moderated and limited, even when it cannot be wholly quenched. 
In no case within the range of medical practice is the maxim " principiis obsta" 
more imperative. Those among you who happen to be attending the wards of the 
Middlesex Hospital may wonder, indeed, after hearing my estimate of the power of 
blood-letting over inflammation, that I so seldom prescribe venesection there. The 
truth is, not that I undervalue the remedy, but that the time for its employment 
has generally gone by. The poor are unwilling to rehnquish the occupations by 
which they subsist : they struggle on as long as they can, and resort to hospitals 
only when they are compelled to do so by the exigency of their malady. Many of 
them labouring under inflammation, have been freely bled before admission. It is 

10 N 



146 



INFLAMMATION. 



commonly too iate, when they present themselves, to expect that the course of the 
disease can be so arrested. The first effect of blood-letting is to deplete and reheve 
the labouring circulation. But when it is again and again repeated, it becomes (as 
the French say) spoliative; it robs the vital fluid of its nutrient and plastic materials. 
Pushed still further, it produces a peculiar state of the nervous system, marked by 
great weakness and irritability. Now akhough blood-letting is the summum remedium 
for inflammation at its commencement, there is a point beyond which it not only 
does no good, but is positively injurious. And this point it is not always easy to 
hit. On one side is the danger that the inflammatory action may continue and 
extend : on the other the danger that the strength of the system may be so reduced 
as to prove unequal to the process of restoration ; for, to remove the interstitial extra- 
vasations, and to repair the damage that has accrued, a certain degree of vital power 
is requisite, and a sufficient quantity of healthy blood. Bleeding will cure inflam- 
mation, but it will not always cure the effects of inflammation ; nay, it may render 
them Angering in their departure, or even determine their fatality. I cannot too 
often, or too strongly inculcate the precept, that in order to check and extinguish 
acute inflammation, you must, above all, bleed early. 

We judge that the bleeding has been carried far enough when the inflammatory 
fever subsides, or changes its character; when the pulse regains its softness, or 
undergoes some marked alteration ;.when any of the signs (already specified) of sup- 
puration appear. Upon these points I hope to give you more explicit instruction 
when we come to special instances of inflammation. 

Whenever inflammation supervenes on other chronic disease : whenever it arises 
in the progress of idiopathic fever, or whilst the constitution is contaminated by some 
specific poison : whenever suppuration is inevitable, or even probable : in all these 
cases general bloodletting may be necessary, but it must be employed with great 
caution. 

Kor can we, safely, neglect the age, and sex, and general condition, of the sick 
person, when we are turning in our minds the propriety of bleeding. The very 
young, the old and the feeble, do not bear well the loss of much blood. This con- 
sideration is not to deter you from bleeding such persons when they are attacked by 
dangerous inflammation ; but it especially enforces, with respect to them, the gene- 
ral rule, that no more blood should be abstracted than is absolutely required to con- 
trol the disease. 

It is also very necessary to study the character and tendency of the reigning epi- 
demic : whether that may depend upon some predisposition silently and gradually 
produced in men's bodies by the agency of causes that are but httle understood : or 
whether it may result from some peculiarity in the exciting cause of a particular 
epidemic disease. I have been long enough in practice in London to have learned, 
in common with others, how much the character of continued fever may aker. Since 
about the time when the virulent form of cholera made its first appearance among 
us, continued fever has neither required nor borne the abstraction of blood as it did 
bear and require it for some years prior to that period. Perhaps some variation in 
the intensity of the poison may partly explain the comparative mahgnity — the 
greater tendency, I mean, to the typhoid type — which marks certain epidemics of 
scarlet fever, small-pox and measles. The influenza, or epidemic catarrh, w^hich 
was almost universal in this town and kingdom in the years 1833 and 1837, afforded 
a striking illustration of the point I am endeavouring to set before you. The inflam- 
matory symptoms — the bronchitis, and sometimes pneumonia — were in many cases 
strongly marked, and it was necessary to abstract blood ; but persons suffering under 
influenza bore bleeding exceedingly ill, and where the use of the lancet could not be 
avoided, it was never resorted to without reluctance and misgiving. 

When we bleed in acute inflammation of an important organ, we endeavour, I 
say, to effect our purpose as speedily as possible, and w^ith as little expenditure of 
the vital fluid as possible. It would be quite ridiculous to pretend to give any precise 
direction as to the number of ounces of blood that should be taken. You must stay 
by the patient, and bleed, in such cases as I am now contemplating, until you pro- 
duce some distinct impression by the bleeding ; and one of the best guides in this 



BLOOD-LETTING. 



147 



I matter is the state of the pulse. If you find, as you sometimes will do, that the most 
pressing symptoms give way while the blood is still flowing— that the pain, for 
instance, is mitigated — that the respiration (when the lungs are concerned) becomes 
, easier and deeper — that (in affections of the brain) the patient emerges from a state 
j of stupor or delirium — you may be sure that you are doing right in bleeding ; but 
you must keep your finger upon your patient's wrist, and suffer the blood to flow, 
until the hard pulse is sensibly softer, or until symptoms of impending syncope 
appear ; and then you had better tie up the arm, and wait a few hours, and repeat the 
bleeding if the symptoms which at first demanded it again become urgent. 

As it is desirable to produce the necessary effect upon the system as quickly as 
may be, the blood should be taken pleno rivo ; i. e., a sufficiently large orifice should 
be made in the vein : and sometimes it may be right to open a vein in both arms : 
and the patient should be bled in the upright position. Faintness and syncope 
depend upon a defective supply of blood to the brain ; and therefore will be likely 
to occur the sooner when the force of gravity facihtates the descent of ihe blood from 
the head through the veins, and retards its ascent towards the head through the 
arteries. And conversely, the first thing to be done towards remedying syncope 
is to lay the person flat in a horizontal posture, or even with his head lower than 
his trunk. 

If you neglect these smaller matters, and make an insignificant sht in the vein, 
and suffer your patient to lay down whilst you are bleeding him, you will be obliged 
to take much more blood in the end ; or you may drain him of his blood and of 
his strength by repeated bleedings of this sort, and make no impression after all 
upon the disease. It is one of the numerous cases in which parsimony is not true 
economy. 

The quantity of blood requisite to be taken in order to produce the due effect is 
exceedingly various. It is a remarkable circumstance, well worth attending to, and 
much insisted upon of late years, especially by Dr. Marshall Hall, that a patient 
under the influence of mere inflammation will bear to lose a far greater quantity of 
blood without becoming faint, than he could bear in health : that the state of the 
system produced by the presence of inflammation protects it from the ordinary con- 
sequences of loss of blood. The amount of the bleeding necessary to occasion syn- 
cope will be in proportion to the exigency of the case. This fact — if it be really a 
fact, as, indeed, I believe it is — is evidently one of the highest value and importance, 
for it furnishes, what is always so desirable, especially in an uncertain art hke ours, 
a simple rule of practice. Yet it is not a rule so firmly estabhshed as not to- admit 
of exceptions. If the mere state of syncope was the curative influence required, 
w^e should have no difficulty. That the faintness does constitute a part of that influ- 
ence I fuhy beheve. Dr. M. Solon even relates a case in which it sufficed to the 
cure of erysipelas of the head and face, attended with high fever. The patient 
fainted from alarm, before the vein was opened. The inflammatory symptoms there- 
upon ceased : but with returning animation they presently recurred. Again, prepa- 
ration was made for venesection ; and again the young lady lapsed into syncope : 
and this time the inflammation and fever disappeared, never to return. She is 
described as having been quite well the next day. I cannot, however, entertain a 
doubt that the withdrawal of a certain quantity of blood is, in almost every case, 
essential to the permanent control of common acute inflammation, attended with 
pyrexia : and it may be advisable to keep persons who, like M. Solon's patient, are 
of a timid disposition, and hable to syncope from shght causes, in a recumbent 
posture, in order that the requisite discharge of blood from the system may be 
obtained. 

In equivocal cases (and there are many such), where it is questionable whether 
the symptoms proceed from inflammation or not, the diagnosis may often be settled 
by observing the quantity of blood which, taken in the upright posture, suffices to 
bring on incipient syncope. 

Dr. Hall's book. On the Effects of Loss of Blood, is well worth your attentive 
perusal. He suggests that a scale of diseases might be formed, representing the 
protective influence of some maladies against the effects of blood-letting ; and the 



INFLAMMATION. 



opposite irxfluence of some others in producing preternatural susceptibility of those 
effects. " It would begin (he says) with congestion of the head, or tendency to apo- 
plexy ; inflammation of the serous membranes, and of the parenchymatous substance 
of various organs, would follow ; then acute anasarca ; and lastly, inflammation of 
the mucous membranes. This part of the scale would be divided from the next by 
the condition of the system in health. Below this would be arranged fever ; the 
effects of intestinal irritation ; some cases of deUrium ; reaction from loss of blood ; 
and disorders of the same class with hysteria, dyspepsia, chlorosis, and cholera 
morbus." 

With respect to the propriety of repeating venesection, it is his remark, that if, at 
the first blood-letting, much blood flowed before any tendency to syncope manifested 
itself, an early repetition of that remedy will probably be required — and at any rate 
an early repetition of our visit to the patient will be proper. But this last precept 
is of universal obhgation in all cases of serious inflammation. 

I am almost afraid to tell you how much blood I have seen taken at one bleeding, 
lest I should seem to encourage you to imitate such heroic practice. I once stood 
by and saw, not without trembling — although I was quite free from responsibihty 
in the matter — a vein in the arm kept open until seventy-two ounces (four pints and 
a half) of blood had issued from it: and then, and not till then, did the patient 
become faint. The event of the case quite justified the bleeding in that instance, for 
the man got perfectly well. It was a case of general dropsy, which had come on 
suddenly, in a young and robust man. It occurred in the chnical wards of the 
Infirmary at Edinburgh ; the physician had desired the chnical clerk to bleed the 
patient in the erect posture, until some sensible effect was produced upon his pulse : 
and no such effect could be perceived until the enormous quantity I have mentioned 
had been abstracted. It is very seldom that such large bleedings are required ; you 
will generally find that five-and-twenty or thirty ounces, taken properly, will be suffi- 
cient to accomplish the purpose of the measure. Sometimes one such bleeding wiU 
extinguish, as it were, the inflammation ; sometimes two or three, or half-a-dozen 
may be necessary : and we judge of the propriety of repeating the venesection by 
the effect of the former bleeding ; by the character of the pulse ; by the appearance 
of the blood already drawn. It would be impossible, in a general account hke the 
present, to lay down any minute directions on this head. 

I have hitherto been speaking of bleeding as we perform it for the cure of active 
inflammation, occurring in a person previously heakhy, affecting an important organ, 
and attended with febrile disturbance of the system. But the abstraction of blood 
is scarcely less valuable as a remedial measure in chronic inflammation, when the 
system at large scarcely sympathizes at all with the local disease. And here it is 
that what is properly called local bleeding is so useful — by cupping glasses, or a 
moderate number of leeches. The object is always the same, viz. : to unload and 
reheve the turgid capillary vessels of the part : and this we could not do by general 
bleeding without carrying it to an extent which would be dangerous to our patient's 
existence. These local bleedings for chronic inflammation usually require to be often 
repeated. Considered as a remedy, blood-letting resembles some other remedies in 
this, that it must be proportioned and adjusted to the rate of progress, and the dura- 
tion of the disease. The remedy must be used chronically when the malady is 
chronic. A patient may lose, on the whole, much more blood for the cure of a 
chronic inflammation, than for the cure of one that is violent and acute ; but then 
the bleeding must be spread over a larger space of time. 

With respect to the relative merits and advantages of cupping and of leeches, as 
topical remedies for local inflammation ; it may be said in favour of cupping, that 
the precise quantity of blood taken away is more accurately determined in that 
manner, and the operation is sooner over, and is less fatiguing, than the suction of 
leeches. But on the other hand, the leeches seldom bungle in the operation, while 
the surgeon often does. It requires a good deal of practice to become handy and 
dexterous in the apphcation of the glasses — to avoid torturing and burning the patient 
—and therefore it is that in large towns, as in this metropolis, cupping is an art car- 



^1 

11 



! BLOOD-LETTING. 149^ 

I ried on by a distinct class of persons. You may apply leeches also to parts where 
! the cupping-glasses could scarcely be used. 

General bleeding, then, is best adapted to acute inflammation ; and topical bleed- 
ing is most appropriate in that which is chronic and slow. But a combination of 
the two is often highly proper and us.eful. You may lessen the force of the general 
circulation by venesection : but the small vessels of the inflamed part may remain 
' unable to rid themselves of their excess of blood, and continue dilated and full. 

Such, at least, we may reasonably suppose to be sometimes the case ; and certainly 
i we often act successfully upon that theory ; that is, we bleed from the arm, and at 
I the same time, or presently after, we empty the capillaries of the labouring organ, 
I or the neighbouring vessels, by the help of leeches, or by the scarificator and ex- 
I hausted cup. The good effect of local bleeding, after the general febrile disturbance 
I has abated under venesection, is often very marked in the relief of pain. 
I I have recommended blood-letting to you when, among other circumstances, the 
pulse is full and hard ; and have stated that the blood should be suffered to flow 
until some distinct impression is made upon the system. But I wish also to apprise 
I you, that you ought not to be deterred from bleeding merely because the pulse is 
j small. It is very apt to be so in dangerous inflammations within the abdomen ; and 
it is a very curious thing that the pulse will often rise, and the artery develop or 
expand itself, during the time the blood is flowing. Now you must look upon that 
circumstance as a distinct impression made upon the system, although it is one of a 
rather different kind from what I spoke of before.* You had better, in my opinion, 
pause when this eflect is fairly obtained : for so great is the tendency to death by 
syncope in abdominal inflammation that it would not be prudent to urge the influence 
of the blood-letting further, at one time, than the change I have just mentioned. 
Wait, therefore, and repeat the venesection if the circumstances should again render 
it necessary. 



LECTURE XIV. 

Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. 

Mercury. Antimony. Digitalis. Colchicum. Opium. 
Local Remedies. External Cold. External warmth. Counter-Irritation. 

After pointing out to you, yesterday, the necessity of guarding your patient, as 
much as possible, from all stimulants or sources of irritation, both internal and ex- 
ternal, the avoidance of which constitutes what is called the antiphlogistic regimen., 
I began to speak of the remedies of inflammation. 

Now the great remedy in acute and dangerous inflammation is blood-letting; and 
when this remedy is used at all, it should be used freely, and so as to produce a 
decided impression : and its efficacy will always be the greater, in proportion as it 
is applied in the earlier stages of the inflammation. The objects of the abstraction 
of blood are two-fold : to lessen the force of the heart's action is one object : to empty 
the gorged capillaries of the part inflamed is the other. We effect the first of these 
objects, or both of them at once it may be, by making an orifice with a lancet, in the 
trunk of some convenient vein or artery, and allowing the blood to escape ; we ac- 
complish the second by making little incisions with a scarifier through the skin as 
near the inflamed part as we can, and forcing the blood through these little wounds 
by the pressure of the atmosphere : i. e., we take off" the pressure from the part sca- 
rified, by placing over it a glass cup, from which the air has been in great measure 
exhausted, and then the unbalanced weight of the atmosphere upon the surrounding 
surface forces out the blood : or we suffer leeches to scarify the skin, and to suck 
out the blood. These two modes of drawing blood, from the trunks of the blood- 
vessels on the one hand, and from the capillaries on the other, we call, respectively, 
general bleeding, and topical bleeding. 

I say the main point to be achieved in general bleeding is so to manage the opera- 

n3 



150 



INFLAMMATION. 



tion as to make a decided impression, as quickly as possible, upon the pulse or the 
heart : and to do this we place our patient in an upright position, and make a free 
orifice in the vein of one or both arms. 

And when the force of the general circulation has been thus abated, it will" in 
many cases be proper and necessary to take away blood from the capillaries also, in 
the neighbourhood of the suffering organ ; this is almost always safe and good prac- 
tice : there can seldom be any reason for abstaining from it, except when the general 
bleeding has brought the patient so low that the abstraction of a few more ounces in 
any way might be hazardous. But the employment of local depletion presently 
after general is ihen especially indicated, when the /oca/ symptoms remain unrelieved ; 
when, although the indirect symptoms which manifest themselves through the 
medium of the system at large have been moderated by the general blood-letting, 
yet the direct symptoms belonging to the part, and disturbing its functions, the pain 
for example, or the labouring breath, or the stupor, have not undergone a propor- 
tional improvement. Under such circumstances, the unloading the oppressed capil- 
laries by means of leeches or cupping-glasses will often be attended with the hap- 
piest effects. 

I mentioned that the most common way of performing general blood-letting in 
this country is by venesection ; and that the veins chosen, as the most suitable for 
that purpose, are the cephalic and basilic veins at the bend of the arm : but that 
when, from accidental circumstances, blood cannot be obtained easily and abundantly 
from those veins, any other large" and superficial blood-vessel may be opened. It 
matters little which, in my opinion, so far as regards the effect of the abstraction of 
blood upon the disease. Some persons are fond of opening the temporal artery when 
the inflammatory disease is situated in or about the head : and certainly, when we 
see this vessel starting from the surface like a cord, and tortuous from its fullness, and 
visibly throbbing, we feel tempted to give vent to the blood which is distending it. 
But arteriotomy is not so easily managed as phlebotomy. It is sometimes difficult 
to get the blood to flow properly ; and it is sometimes difficult to stop its egress when 
we wish to do so ; and sometimes there are after-consequences which are far from 
being pleasant : little aneurismal tumours are apt to arise. It is, besides, desirable 
to avoid the necessity of bandaging the head, in order to restrain the further efflux 
of blood from the artery. Other practitioners recommend opening the external 
jugular vein in head cases, especially in children, whose veins in the arm are small. 
This is a plan which I have very seldom adopted, and which, I am bound to tell 
you, I do not much like : first, because I think it is seldom necessary ; secondly, 
because I think it is often unsafe. 

It is seldom necessary : for in children we can always get as much blood by topi- 
cal bleeding as will be equivalent to a general blood-letting. And it is unsafe in 
two ways. In the first place, it is not always an easy matter to stop the bleeding 
from the jugular vein, especially in a struggling and unmanageable child ; and the 
difference of a few ounces of blood may be a fatal difference. Here also anjr com- 
pression of the neck, to stay the hemorrhage, might affect injuriously the cerebral 
circulation. Again, there is a distinct and peculiar danger attending the incision of 
this vein, that, namely, of admitting air into it. You perhaps are aware that if air 
enters a large vein near the heart, and passes on to that organ, it kills outright. If 
you open the jugular vein of a horse, and blow forcibly into it towards the heart, 
the animal drops down dead. The celebrated Dupuytren was performing some ope- 
ration about the neck, in the course of which he cut across one of the veins there 
situate : some bubbles of air rushed in at its open mouth, with an audible clucking 
noise, and, in an instant, his patient expired. The same frightful accident has 
occurred in operations performed in this country, and in America. I was told very 
lately that in one of our metropolitan hospitals it Avas thought right, for some reason 
or other, to bleed an adult patient by opening his jusiular vein : the opening was 
made very near the clavicle, so that pressure between the orifice and the heart was 
difficult to effect. Of course the blood soon leaves the portion of the vein nearest the 
heart ; and whether by some suction power of the heart itself upon the veins, or how, 
one scarcely knows, but air rushed in, and the patient was presently a dead man. 



BLEEDING. 



151 



Perhaps misadventures of this kind may be capable of being prevented by using 
great caution in such cases ; but as it is the etiquette for physicians to direct but not 
to perform these manual services towards the sick, and as, therefore, I should incur 
all the responsibihty, and at the same time be able to ensure none of the necessary 
care, I confess that I am shy of recommending venesection to be made in that parti- 
cular place. 

Whether, all other things being the same, the abstraction of arterial blood may be 
more or less effectual in restraining inflammation than the abstraction of venous, is 
more than I can tell you. 

When topical bleeding is employed with the view of disburdening the turgid 
capillaries, either in chroriic intianamation, or in acute inflammation as an auxiliary 
to general bleeding, it would seem most expedient to get as near to the part affected 
as we can. To apply, for example, our cupping-glasses or our leeches to the tem- 
ples, or behind the ears, or just below the occiput in inflammatory affections of the 
head; to the chest or the precordia, when the lungs or heart are the seat of the dis- 
ease ; to the surface of the abdomen, in inflammation of the liver, or stomach, or 
intestines, and so on. And this is the plan which I have almost always adopted ; 
and with such satisfactory results that I have felt little inclination to try any other. 
But many persons do beheve that local bleeding is more useful when it is performed 
at some distance from the affected part : they would put leeches, for instance, on the 
insteps, to reheve an inflamed throat ; and they attribute the benefit that ensues to 
what is called revulsion: they suppose that the suction of the leeches solicits the 
blood, as it were, to that quarter, and diverts it from the vessels of the part that is 
inflamed. It seems to me that the revulsive influence of topical bleeding would be 
greater in the neighbourhood of the inflamed part than far from it. I know, how- 
ever, some very practical men who have been much struck with the results of this 
distant blood-letting, which they had seen practised in the Parisian hospitals. 
Leeches are also sometimes apphed at a distance from the seat of the inflammation, 
on another principle — that of drawing the blood directly from the veins which com- 
municate with the diseased part. In abdominal affections, in inflammation of the 
liver or intestines, the French are in the habit of applying leeches in great numbers 
to the verge of the anus : because, they say, the blood is then abstracted from the 
very veins through which it is returning towards the alread}^ overloaded organs. It 
is right that you should be aware of these opinions, and of this practice. I can say 
but httle of it from my own knowledge. I can well believe, however, that it is good 
and useful practice : but in this country we should find it difficult to persuade many 
of our patients to submit to have leeches planted round the anus ; and I have seldom 
been. disappointed of the benefit I expected from topical bleeding, when it has been 
employed at the surface, as near the part inflamed as possible. 

The evacuation next in importance to blood-lettinq-, is purging. This is an expe- 
dient which in cases of violent inflammation, or hig^h general fever, should scarcely 
ever be omitted. To keep the bowels what is called open, forms indeed a part of 
the antiphlogistic regimen; but in acute inflammatory diseases, active purging is 
of very great service. These two points are gained by it. The stomach and intes- 
tines are freed from accumulated fseces, or other matters which, by their bulk or 
their acrimony, might prove irritating : and at the same time depletion is carried on 
by means of the serous discharge which is produced from that large extent of mucous 
membrane. There are some cases of inflammation in which the operation of purga- 
tive medicines is of especial benefit ; as in inflammatory affections of the head, either 
external or internal, of which part these medicines assist or cause the depletion in a 
very sensible manner. We have an illustration of this in the paleness of the face, 
which often, during health, accompanies the action of a brisk cathartic. The use- 
fulness of repeated purgatives is less distinctly seen in inflammations situated be- 
tween the thorax ; although in these cases also they are often highly beneficial. 
They are efficient remedies, too, in all inflammatory conditions of the Hver. But 
when inflammation has fastened upon the stomach or bowels themselves, although 
it may be indispensable that they should be unloaded of their contents, which are 
often composed of irritating, ill-digested food, and of morbid secretions no less teasing 



152 



INFLAM]VrATION. 



and hurtful, the propriety of going beyond this point is extremely questionable. I 
believe that much harm is often done hj pressing the inflamed ahmentary canal 
with active purgatives. But to all those points I shall have occasion to return. 

Next to blood-letting, as a remedy, and of vastly superior value upon the whole, 
to purgation, in serious inflammations of various kinds, is mercury. This mineral 
is really a ver}^ powerful agent in controlling inflammation ; especially acute, 
phlegmonous, adhesive inflammation ; such as glues parts together, and spoils the 
texture of organs. It is of the greatest importance that you should accurately inform 
yourselves concerning the various effects of mercury upon the system : the changes 
jt produces ; the changes it arrests or prevents ; the cases in which it does good ; 
the cases in which it does harm ; that you should learn, in short, how to wield a 
very potent, but a two-edged weapon. 

If we inquire what mercury does when it is administered to a person in health, 
we find three very marked effects following its internal use. They vary, indeed, in 
different cases, and under different circumstances : but we know that the employ- 
ment of mercury under any of its usual forms of exhibition is often followed by 
increased watery evacuations from the intestines ; or by an increased discharge of 
bile ; or by an increased flow of saliva ; that is to say, it determines (as the phrase 
is) to certain secreting organs — the mucous membrane of the bowels, the liver, the 
salivary glands ; it augments their natural secretion ; and in this augmentation of 
secretion is implied an increased afflux of blood to the secreting part. It is probable 
that mercury has a similar influence on most or all the secreting surfaces of the body, 
altering the condition of the capillary circulation throughout. And an explanation 
of its curative power in inflammation has been drawn from this fact : it has been 
supposed that mercury thus tends to equalize the circulation ; that by causing the 
blood to be distributed in larger quantity than common upon several surfaces at the 
same time, it obviates, pro tanto, its excessive congestion or accumulation in any one 
organ. Whether this hypothesis in respect to the modus operandi of mercury be 
true or not, I will not pretend to say ; but it certainly is not an unreasonable hypo- 
thesis. 

If you push this remedy in healthy persons, other effects ensue : inflammation is 
actually produced ; the gums become tender, and red, and swollen, and at length 
they ulcerate; and in extreme cases, and in young children especially, the inflamed 
parts may perish : the cheeks, for example, sometimes slough internally. Not only 
the gums, but the throat and fauces, grow red, and sore and sloughy. 

Now you will do well to observe what is the character of the inflammation thus 
produced. It is superficial, spreading, erysipelatous : it leads to ulceration without 
any distinct occurrence of suppuration ; the ulcers enlarge. Of the three processes 
which I formerly pointed out as going on in different degrees, at the same time, in 
an ulcerated surface, that of absorption is vastly predominant ; and you will find that 
persons in whoui this local affection, this condition of the parts within the mouth, 
has been produced, get rapidly thin ; their fat disappears ; they become emaciated. 
That is, the absorption of the old materials throughout the body exceeds the deposit 
of new matter. Patients who are kept under the influence of mercury grow pale 
as well as thin : and Dr. Farre, who has paid great attention to the effects, remedial 
and injurious, of this drug, holds that it quickly destroys red blood : as effectually 
as it may be destroyed by venesection. As an example of this he was in the habit 
of relating in his lectures the case of a lady who was attacked with hematemesis : 
and whose gastric system and liver were gorged with blood. " Her complexion,'* 
said the doctor, "was compounded of the rose and the violet. Under a course of 
mercury she was blanched, in six weeks, as white as a lily." 

There are still other, occasional, effects of the continued introduction of mercury 
into the system : a peculiar eruptive disease ; a peculiar condition of the nervous 
system : but with these I do not now meddle ; they will come under our more parti- 
cular consideratiou hereafter. At present I am desirous to place such facts before 
you as may help you to determine in what cases mercury is a fit remedy for inflam- 
mation ; in what cases it would be improper to give it. The factg I have already 



mehcury. 



153 



mentioned show that it has a loosening effect upon certain textures ; that it works by- 
pulling down parts of the building. 

But the great remedial property of mercury is that of stopping, controlling, or 
altogether preventing the effusion of coagulable lymph ; of bridling adhesive injiam- 
mation ; and if we, in our turn, could always bridle and hmit the influence of 
mercury itself, it would be a still more valuable resource. 

From the httle I have now said you will readily understand in what description 
of cases mercury is likely to be useful. In common adhesive inflammation, whether 
of the serous or the areolar tissues ; whenever, in fact, you have reason to suppose 
that coagulable lymph is effused, or about to be effused, and mischief is Hkely to 
resuk from its presence, then you may expect much benefit from the proper admi- 
nistration of mercury ; as an auxiliary, however, to blood-letting, not as a substitute 
for it. 

On the other hand, mercury is hkely to be hurtful in those forms of disease 
" where the morbid action approximates to its own action." In cases of erysipela- 
tous inflammation having a disposition to gangrene ; in scrofulous diseases ; in 
inflammatory complaints attended with general debility, and an irritable condition of 
the nervous system, or a manifest tendency to take on a typhoid character. 

When we have to contend with acute inflammation, and desire to prevent or arrest 
the deposition of coagulable lymph, our object is, after such bleeding as may have 
been proper, to bring the system as speedily as possible under the specific influence 
of mercury. How may this best be done ? and how are we to know that it has been 
achieved ? 

I will answer the last of these questions first. We know that the whole system 
has been brought under the specific influence of mercury, as soon as its effects 
become even slightly perceptible in the gums and breath of the patient ; and in 
adults we cannot be sure of it before. The gums grow red and spongy ; the patient 
complains that his gums are sore : and that he has a melalhc taste, a taste hke that 
of copper, in his mouth ; and an unpleasant and very peculiar foetor, easily recog- 
nized again when it has been once perceived, is smek in his breath. These symp- 
toms are enough : you need not in general look for any more decided affection of 
the mouth, such as ulceration of the gums, swelling of the glands beneath the jaw, 
and of the tongue, and a profuse flow of saliva. Formerly, when it was believed 
that the material cause of the disease was carried out of the body with the saliva, 
the mercurial treatment was continued with a view of producing the discharge of 
many ounces, and even of a pint or two, in the twenty-four hours : but all that is 
requisite is that the gums should become distinctly tender, and that the mercurial 
fostor should be unequivocally manifest, and that these symptoms should be kept up 
for a certain time. 

Now this is best effected, usually, by giving some form of mercury in equal arid 
repeated doses, by the mouth. For urgent cases calomel is the best form in which 
it can be administered : two or three grains, given every four or six hours, will 
generally suffice to touch the gums in the course of thirty-six or forty-eight hours. 
If it acts as a purgative its specific effect upon the whole system will be postponed 
by that circumstance ; and it then becomes expedient to combine with it just so 
much opium as will prevent its passing off by the bowels. A quarter of a grain of 
opium with two grains of calomel — or a third of a grain of opium with three or four 
grains of calomel — will generally be sufficient to restrain the purgative operation of 
the latter. When a speedier effect is desirable we give larger doses ; such as five 
or ten grains every three, or even every two hours: or we combine mercurial 
inunction with the exhibition of calomel by the mouth. It is impossible to lay down 
any precise rule that will fit all cases. 

Blue pill, or the hydrargyrum cum crefa, may, in certain cases, be preferable to 
calomel; but they must be given in greater quantity. 'Some practitioners beheve 
that a combination of blue pill and calomel acts sooner, and answers better, than a 
proportional dose of either, given alone. 

This mode of administering mercury, so as to affect the system at large, is emi- 
nently useful in many instances of acute phlegmonous inflammation, after bleeding 



154 



INFLAMMATION. 



has been carried as far as the circumstances of the case may warrant. I repeat that 
it must not be allowed to supersede blood-letting. Previous bleeding renders the 
body more readily susceptible of the influence of mercury ; and the operation of 
the mercury comes in aid of the salutary effect of the abstraction of blood. The 
two remedies accomphsh by their joint power what neither of them could accom- 
phsh singty. 

It is important to know that different persons admit of, or resist, the specific agency 
of mercury, in very different degrees ; so that in some patients the remedy becomes 
unmanageable and hazardous ; while in others it is inert and useless. It is most 
grievously disappointing to watch a patient labouring under inflammation which is 
hkely to spoil some important organ, and to find, after bleeding has been pushed 
as far as we dare push it, that no impression is made upon his gums by the 
freest use of mercury. Such cases are not uncommon ; and unfortunately they 
seem most apt to occur when the controlhng agency of mercury is most urgently 
required. On the other hand, there are persons in whom very smafl quantities of 
mercury act as a violent poison ; a single dose producing the severest sahvation and 
bringing the patient's existence into jeopardy. This history was told to Dr. Farre 
by a medical man, under whose notice it fell. A lady, whom he attended, said to 
him, at his first professional visit to her, " Now, without asking why, or speculating 
about it, never give me mercury, for it poisons me." Some time afterwards she met 
with the late Mr. Chevalier, and spoke to him about her complaints ; and he pre- 
scribed for her, as a purgative, once^ two grains of calomel, with some cathartic 
extract. She took the dose ; and the next morning showed the prescription to her 
ordinary attendant. " Why (said he) you have done the very thing you were so 
anxious to avoid ; you- have taken mercury." She rephed, " I thought as much, 
from the sensations I have in my mouth." Furious salivation came on in a few 
hours ; and she died, at the end of two years, worn out by the effects of the mercury, 
and having lost portions of the jaw-bone by necrosis. 

Another medical man informed me that he knew a person so susceptible of the 
influence of mercury, that when his wife had rubbed a very small quantity of white 
precipitate ointment upon her neck for some cutaneous affection, after sleeping with 
her his gums were tender for three or four days, and shght salivation took place. 
This did not happen once only, but three several times. On one occasion this same 
man took two blue pills, as preliminary to a common purge, and he was salivated 
profusely for six weeks. Cases similar to these occur now and then to most medical 
men : we cannot tefl beforehand in whom such effects are to be looked for ; but it is 
never prudent to neglect any warning which the patient gives of his own previous 
experience on this point. You will generally find that where the affection of the 
gums and salivary organs goes on to a troublesome or distressing extent, it has super- 
vened upon the employment of a very moderate quantity of mercury. 

So distressing sometimes are these effects of mercury upon the mouth, that I may 
pause a moment to tell you what I know about the means of remedying them. You 
will constantly be called upon to do something for the rehef of this disease (for so^ 
we must call it), which you yourselves, or some of your brethren, have with the best 
intentions inflicted. I have tried all sorts of expedients ; and I have asked a great 
number of my friends what is the best plan to adopt in such cases : but I never 
could get much satisfactory information from them. Some thought purging was the 
best thing. Others recommended alum gargles ; or gargles made with the chloride 
of soda; and these last certainly have one good effect, that of correcting the fcetor. 
A- dilute solution of chlorine in water, much used at the Middlesex Hospital, is better 
still. Others believed that sulphur, which has long been prescribed in such emer- 
gencies, was really of service ; and some advised that the patient should be as much 
as possible in the open air : a few commended iodine. All admitted that they knew 
of no certain remedy. Neither do I. But there are two or three expedients which 
I am confident are often of very great use in checking the violence of the salivation, 
and in removing the most distressing of its accompaniments. If there be much 
external swelling, treat the case as being, what it really is, a case of local inflamma- 
tion: apply eight or ten leeches beneath the edge of the jaw bones, and wrap a soft 



MERCURY. 



155 



poultice round the neck, into which the orifices made by the leeches may bleed ; 
, and I can promise you that, in nine cases out of ten, you will receive the thanks of 
your patient for the great comfort this measure has afforded him. Pure tannin, 
moistened and smeared upon the spongy gums, is remarkably efficacious in render- 
ing them firmer and more comfortable. But this is not always to be procured : and 
when the flow of saliva, and the soreness of the gums, formed the chief part of the 
grievance, I have found nothing more generally useful than a gargle made of brandy 
and water ; in the proportion of one part of brandy to four or five of water. This 
last piece of practice I learned from the present apothecary to the Middlesex Hos- 
pital ; I have tried it over and over again ; and I tell it to you as a thing worth 
remembering. These little points are by no means to be despised. A very fashion- 
able and successful physician, now dead, used sometimes to sslj when he met others 
of his brethren in consultation, " It is all very well to speculate about the exact situa- 
tion, and the precise nature of the disorder, but the question with me is, ' what is 
good for this, that, or t'other thing ?' " A wise physician will seek to combine with an 
accurate knowledge of disease, and settled principles of treatment, those practical 
expedients and minor appliances which are picked up by casual experience ; which 
could never have been reasoned out : and which sometimes constitute nearly all that 
we can do for our patient's benefit. 

But to return to mercury as a remedy against inflammation. Tt is of great service 
in many cases of chronic inflammation ; and I may repeat here the observation I 
formerly made when speaking of blood-letting — ^that the treatment must keep pace^ 
as it were, with the disease. When textures have been slowly altered by a gradual 
deposition of coagulabie lymph, we should gain but little by suddenly or speedily 
salivating our patient. The lymph, if it can be dispersed at all, must be gradi(ally 
taken up again : and mercury, given with the view of promoting its absorption, 
must be slowly and gradually introduced into the system ; and its specific influence, 
when at length it is felt, must be sustained for a considerable length of time. 

You must not expect any good, but the contrary, frOm the exhibition of mercury 
in scrofulous inflammations ; and where the scrofulous diathesis is well marked, you 
should be cautious in giving mercury at any time. But I am certain that many 
men are too scrupulous in this respect; and that, through over tenderness of your 
patient's constitution, you may risk his life, by withholding mercury because he 
shows tokens of scrofula. You may recollect my stating that scrofulous persons are 
not exempt from attacks of common inflammation ; and in some such cases the pos- 
sible aggravation of their general ill health, by mercury, is not to be put in competi- 
tion with the immediate danger from the local inflammation. I have again and 
again seen scrofulous patients benefited by moderate salivation ; which, if it proved 
injurious at all to their general condition, was certainly less injurious than the 
unchecked local complaint would have been. 

There are some other remedies for acute inflammation which, in this general 
account of its treatment, I must briefly notice. Antimony is one of them ; and a 
very valuable remedy it is in some forms of inflammatory disease. Antimony, 
properly administered, subdues the action of the heart and arteries, producing nausea, 
paleness, and sinking of the pulse, and frequently great rehef to the local symptoms. 
You bring the circulation into that state into which it may be brought by free blood- 
letting. But when the violence of the inflammatory symptoms recurs again and 
again, you cannot again and again employ the lancet : or if you do so employ it as 
at length to extinguish the inflammation, you reduce your patient to a state of pitiable, 
and even perilous, debihty. Now you may continue or repeat the depression of the 
circulation by means of antimony, without any dread of such subsequent weakness. 
Antimony, so far as my own observation goes, is admirably suited to cases of active 
inflammation, in which mercury would either be not so useful, or could not be 
brought to bear. It is in inflammation of the mucous membrane of the air passages 
that antimony is so signally beneficial. You will see a patient labouring for breath, 
unable perhaps to he down, with a turgid and livid countenance from imperfect 
arterialization of the blood. He has been ifl but a short time ; it is an acute affec- 
tion ; and upon hstening at his chest you hear that peculiar wheezing sound which 



156 



INFLAMMATION. 



we call sibilus, in every part of his lungs. I shall have to describe this sound, and 
its causes, and its meaning, in a future part of the course. You give such a patient 
repeated doses of antimony ; he becomes sick, vomits perhaps, but he feels nausea : 
his pulse becomes less forcible, his face grows pale, and he can breathe again. The 
nausea is not a pleasant sensation ; but the want of breath is a far more distressing 
one : and that is greatly mitigated. Perhaps free secretion takes place from the 
congested membrane, and then the patient is easy and safe. Now 3^ou could not 
effect this change so quickly and readily, or so conveniently, by mercury, and per- 
haps not at all. Bronchitic affections are very common in children, in whom it is 
usually difficult to induce the specific influence of mercury. 

On the other hand, antimony does not appear to be nearly so valuable a remedy 
as mercury, when serous membranes are inflamed. 

The French and Italian physicians place much reliance upon antimony for the 
cure of inflammation ; and they seem to know httle or nothing of the remarkable 
agency of mercury upon that disease. For my own part I do not see how any 
useful comparison can be made between these two substances in respect to inflam- 
mation, considered generally, as we are now considering it. There are some par- 
ticular forms of inflammation to which the one remedy is better suited, and there are 
others in which the other is most effectual. I must content myself for the present 
with having adverted to these distinctions. 

As to the form in which the antimony should be exhibited, I apprehend that we 
shall all come at last to freshly dissolved tartar emetic. The antimonial powder is 
of very uncertain strength ; and the antimonial wine contains too much spirit to allow 
of its being given in large and frequently repeated doses. It is a curious circum- 
stance, that although vomiting and purging are apt to be produced by the first two 
or three doses, they usually cease when the same quantity is persevered with. 
Tolerance of the remedy is estabhshed. But although these unpleasant primary 
effects cease, the curative agency of the antimony appears to continue. When you 
desire to obtain its full influence in a short time, you may dissolve a grain of the 
tartar emetic in two ounces of hot water, and give a fourth part of the solution every 
half hour. If the patient becomes pale and sick, you pause awhile and allow him 
to recover himself ; and if the inflammatory symptoms return, you repeat the medi- 
cine. It sometimes acts violently upon the bowels, and then it is necessary to add a 
few drops of laudanum to each dose. 

[The remarks of Dr. Watson upon the remedial effects of tartar emetic in inflammatory- 
affections, are perfectly correct in reference to these diseases as they occur in the adult; in 
the inflammatory diseases of infants and. young children, however, the tartar emetic is not a 
remedy that can be safely employed ; it produces in them always very considerable and 
enduring disturbance of the stomach, and in many cases a state of extreme and, as remarked 
by a late writer — Dr. Wilton, (Prou, Med. and Surg. Journ.) — even fatal depression of the 
vital powers. — C] 

Digitalis is another powerful medicine, from which, as a remedy for active inflam- 
mation, much was at one time hoped ; but this hope has been in a great measure 
disappointed. It is not a manageable remedy in such cases. Its singular property 
of retarding the circulation, of bringing down the number of the heart's pulsations, 
and abating its force, led to the expectation that it might render the use of the lancet 
unnecessary ; that it might check the inflammatory process without permanently 
reducing the strength of the patient. But if you give moderate doses of digitalis, 
its pecuhar effect upon the pulse comes on at very uncertain periods, and may be 
postponed until it is too laie to be of any service. If, on the other hand, you give it 
in such quantity as speedily to affect the heart's action (which is what we want in 
acute and serous inflammation), then you are never secure against what may bf 
called its poisonous effects ; deadly faintness, frightful syncope, and even death itself. 
Most practitioners can tell of cases in which patients, who were taking full doses of 
digitalis, have suddenly expired; and when the remedy has appeared to have had 
more to do with the fatal event than the disease. There are practitioners, however, 
and I knovi^ one of them, who affirm that digitahs may be given, after due depletion, 
and in acute inflammation, in very large, and I should say startling doses, with the 



COLCHICUM, OPIUM. 



157 



very best effects — doses which range from half a drachm to half an ounce, and even 
six drachms, of the officinal tincture. I confess to you that I should be very unwill- 
ing to sanction this mode of using digitahs. I never attempt to employ it with the 
view of knocking down acute inflammation — to which alone you will observe that 
my present remarks apply. Digitalis is often of great service in other complaints ; 
but I am not at present discussing the remedial virtues of digitahs, or of any other 
drug, except so far as they relate to the cure of recent and active inflammation. 

Colchicum is a drug which is often prescribed in inflammation. It is a most valu- 
able remedy in certain specific forms of inflammation. But for repressing common 
phlegmonous inflammation we have much more certain and better remedies. For 
this purpose colchicum is, I beheve a very unimportant medicine. 

I have formerly been asked, by students attending here — and therefore I antici 
pate the question now — respecting the ntihty of opium as a remedy in inflammation. 
Certainly opium, like most of our powerful medicines, may do much good, as it may 
do much harm, in different inflammatory diseases ; and it is not very easy to point 
out clearly, in a general view of the treatment of inflammation, the rules for its 
administration by which we must be guided in different cases. Yet there are a few 
general observations which I may make now on this subject. 

The administration of a full dose of opium has been strongly recommended after 
that free and effective bleeding which I have already described. It prevents the 
rekindling of the inflammation which is apt to result from irritation of the nervous 
system — a kind of irritation, you will remark, which the copious abstraction of 
blood is calculated to produce ; or to augment, if it finds it already existing. The 
opium soothes this nervous irritabihty, and it must be given, when given at all, in 
doses which will have that efl?ect. It is best adapted to those cases in which a 
natural irritabihty is inherent in the constitution of the patient — to those in which 
such irritability has been acquired by bad habits of life — and to those in which the 
local disease is attended with much pain, which is in all constitutions a source of 
irritation. 

However, this is a remedy which requires to be used, in inflammation, with great 
caution and discrimination. In cases of active inflammation within the cranium, its 
propriety is very questionable. It is apt to confuse both the patient and his ph37-si- 
cian, who is unable to say, after a full dose of opium has been given, how much of 
the stupor that follows is owing to the disease, and how much to the drug. It is a 
very ticklish remedy in pectoral inflammations. I believe that by the free use of 
opium I saved the life of a relation of my own, an old lady, who was in danger of 
being worn out by the cough and bronchial affection which attended the influenza. 
On the other hand I certainly have known more than one person, labouring under 
extensive and severe bronchitis, so effectually quieted by a dose of the same medi- 
cine, that they never woke again. As a general rule I should say that you must be 
very careful how you venture upon opium in inflammatory diseases that tend to pro- 
duce death by coma, or apncea. If there be any unnatural duskiness of the face, if 
ever so shght a tinge of purple mingles itself with the red colour of the lips, this is 
an appearance which (with certain exceptions, to be specified hereafter) should warn 
you against opium. It shows that the blood is imperfectly arterialized : and imper- 
fect arteriahzation of the blood, as I hope you all know, either results from, or con- 
duces to, a state of coma. 

On the other hand, it is, cseteris paribus, in cases where the tendency is towards 
death by asthenia, that the use of opium, as a remedy for inflammation, is most 
serviceable. It has a capital effect often, after free bleeding, in cases of peritonitis, 
and of enteritis. It probably does, good in various ways : by quieting the nerves — 
by sustaining the faltering action of the heart — ^by keeping the inflamed parts at 
rest. There are some frightful accidents in which we can expect little from blood- 
letting, but in which the judicious employment of opium affords some glimmering 
of hope. I allude to those cases of intense and general peritonitis which arise upon 
the escape of irritating substances into the cavity of the belly ; the contents of the 
intestines, from ulceration or from external injury; urine from rupture of the blad- 
der; and so on. If there be any hope in such cases, it is to be found in the con 

o 



158 



INFLAMMATION. 



tinued exMbition of opium in considerable doses. But upon all these points I shall 
go more into detail when we come to consider individual diseases. 

A very few remarks, in respect to external remedies in cases of inflammation, 
will terminate both this lecture and what I have to sa}^, thus generally, of the 
treatment of inflammatory complaints. 

The application of external cold will aid us very powerfully, in certain serious 
cases of inflammation; and especially in cases of inflammation within the cranium. 
It is really wonderful what a sedative and soothing effect this expedient frequently 
has in allaying delirium, the result of active inflammation of the brain and its 
membranes. Thin folds of linen, kept constantly moist and cold by cold water, are 
placed upon and around the shaven head. We often apply ice in the same way. 
But I need not go at present into any detail on this subject ; I will only observe, 
that we have a most excellent and simple guide as to the probable usefulness of cold 
application to the head, in the sensations of our patients. It is very lucky that it 
is so. As long as the cold cloths, or the bags of ice, are pleasant and grateful to the 
patient, so long we sedulously continue to apply and renew them ; as soon as the 
patient dishkes them, they had better be intermitted. 

Cold apphcations to the chest, and to the helly, in active inflammation of parts 
situated within those cavities, have been praised by some practitioners ; but I believe 
are very seldom employed. I have no personal experience either of their utility, 
or of their hurtfulness. I confess that I should not hke to use them. I should think 
that the effect of the cold, in driving the blood from the cutaneous vessels, and accu- 
mulating it in internal parts, would be likely to be injurious. We shall see, by and 
by, that the contents of the skull are somewhat differently circumstanced, in this 
respect, from those of the thorax and abdomen. 

The totally opposite measure, applying warmth to the surface, is of very great 
service in many cases of internal inflammation ; especially in inflammations of the 
abdominal organs. • We speak of cold lotions, and of hot fomentations. These 
last are managed in various ways, into which I do not at present enter. They seem 
to do good by determining to the surface ; they promote perspiration ; they mitigate 
pain, and persuade to sleep. 

In cases of external inflammation, sometimes cold applications are found to be of 
use, and sometimes warm. In this matter, also, the sensations of the patient afford 
the best criterion. Both of them tend, in different circumstances, to promote reso- 
lution. We have an illustration of the beneficial agency of cold applications for 
this purpose in the treatment of recent burns and scalds, particularly when the injury 
is superficial, and the skin has not been destroyed. Probably there is scarcely any 
one present who has not experienced the relief given to the pain of a burned finger, 
by dipping it in cold water ; and the return of the pain upon taking the finger out 
again. The cold may be so constantly applied that the pain will cease to recur 
when the application is at length suspended. Dr. John Thomson relates a case in 
which a burned arm was kept immersed in cold water for two days and two nights 
incessantly ; and inflammation was thereby wholty prevented. I have known this 
expedient fail, however. A nurse in the Middlesex Hospital fell as she was car- 
rying a pail of hot water upstairs, and in her fall thrust one of her arms into the 
scalding liquid. Without loss of time she plunged the same arm into cold water; 
but after a while was obliged to desist; the cold immersion bringing on severe 
rigors. 

In er3'-sipelas I am persuaded that warm fomentations not only afford more 
comfort, but are more effectual and safer than cold lotions. 

Independently of their occasional influence in promoting resolution, warm appli- 
cations — warm soft poultices for instance — are often used with the view of forward- 
mg suppuration. Hence this rule. Whenever resolution of the inflammation is 
possible — but suppuration is likely to ensue — warm applications are the most proper: 
because, under their use, we have an equal chance of obtaining resolution, with less 
iiazard of retarding or rendering untoward the process of suppuration, I'n case 
resolution does not take place. 

Counter-irritation, by means of blisters, sinapisms, irritating ointments, setons. 



HEMORRHAGE. 



159 



issues, or moxas, is often very beneficial. It probably operates by attracting blood 
into the neighbouring parts, and in the same degree diverting it from the inflamed 
part. It is most serviceable in chronic inflammations, and towards the decline of 
those which are acute. It is particularly adapted to scrofulous affections. There 
is an objection to the use of counter-irritation during the height of the inflammatory 
fever, on account of the increase of general irritation which it would then occasion. 
Neither in local inflammation should counter-irritation be apphed very near to the 
inflamed part. Blisters upon the head or neck, are not proper, therefore, at least 
in the early stages of the disease, in acute inflammation within the cranium ; but 
they are sometimes apphed in such cases, with Idvantage, to the lower extremities. 
To the chest, however, in thoracic inflammation, and to the belly in abdominal, 
bhsters are often not only perfectly safe, but of the greatest use, as will, I trust, be 
apparent as we go on. 



LECTURE XV. 

Hemorrhage : — most commonly by Exhalation. Habitual Hemorrhages. Vica- 
rious Hemorrhages. Idiopathic Hemorrhages. Active and Passive. Symp- 
tomatic Hemorrhages. Usual Situations of Hemorrhage. Symptoms and 
Diagnosis. Principles of Treatment. 

In the course of that somewhat cursory account which I have been endeavouring 
to give you of the general facts and doctrines of pathology, as a preparation for the 
better understanding of special forms of disease, we reached, some lectures back, 
the subject of local plethora or congestion. From that point our road branched off 
in three several directions. We have pursued the first and main branch to its ter- 
mination ; that which led to the discussion of inflammation. We must now go back 
to the same point again, and follow first the one and then the other of the two 
remaining branches, which conduct respectively to the consideration of hemorrhage 
and of dropsy. These branches are shorter than that along which we were last 
travelhng ; but they are not uninviting ; they will open to us, if I mistake not, some 
interesting views of the country of which we purpose, in the end, to make a more 
particular survey. 

You are to observe that I treat of hemorrhage only so far as it falls to the care of 
the physician. The subject is exceedingly full of interest in its relation to surgery : 
and it will receive at the hands of my colleague all the attention which its great 
importance, as a surgical accident, demands. 

But we, also, as physicians, have much to do with hemorrhage ; with what, for 
distinction's sake, I may call medical hemorrhage ; which differs in kind, in cause, 
in its cons^uences, and in the treatment it requires, from that which surgery con- 
templates. 

In surgical or traumatic hemorrhage the blood flows from some considerable 
vessel, which has been cut or torn, or somehow ruptured. You would greatly 
mistake, if you inferred from that circumstance (as you naturally might), that it is 
nsually so — the only difference being in the situation of the vessel — in medical 
hemorrhage also. 

Yet that is the popular notion. When blood gushes out from internal parts, 
through any of the natural apertures of the body, the person is said and supposed 
to have broken a blood-vessel. But this is rarely, though it is sometimes, the case. 

I In nine cases out of ten, if there be any rupture at all, it is rupture of numerous 

j capillaries only : but even of this there is often no evidence. 

I Whence, then, and how, does the blood escape from its natural channels? Why, 
j it exudes from the unbroken surfaces of organs, without any appreciable lesion of 
arteries, veins, or capillaries ; just in the same manner as sweat oozes from the 
skin, mucus from the inner surface of the bowels, and serum or synovia from the 



160 



HEMORRHAGE. 



membranes that respectively furnish those fluids ; and probably by the very same 
outlets. 

This certainly is a very remarkable circumstance, if it be true ; and you will na- 
turally ask what proof we have of its truth. 

The proof is simple, and, I think, conclusive. We examine the surface from 
which the blood must have proceeded, and we find it entire : we wash and even 
macerate it : we employ the microscope to assist our powers of vision : yet we fail, 
after this careful inspection, to discover the slightest breach of substance, or any 
appearance of erosion. 

When, for example, hemorrhage has occurred so profusely from the stomach or 
bowels, that the death which ensued could be sufficiently accounted for by the mere 
loss of blood, the whole tract of the ahmentary canal has been diligently scrutinized, 
and has exhibited no ruptured blood-vessel, no abrasion even of its surface, nor any 
perceptible alteration of texture. Sometimes its mucous membrane appears, here 
and there, of a red colour, and, as it were, charged with blood. Sometimes it is pale 
and transparent, while the vascular net-work visible immediately beneath it is gorged 
and turgid. Sometimes the whole is colourless ; the same net-work of vessels hav- 
ing been completely emptied by the previous hemorrhage ; and sometimes, again 
(and this is very illustrative of the mode by which the blood has issued), vast num- 
bers of small dark-coloured masses, hke grains of fine sand, can be made to start 
from the surface of the membrane by slight pressure. There can be no doubt that 
these are minute portions of blood which had remained and coagulated in the vessels 
or apertures forming the uhimate channels of the hemorrhage. 

We have absolute proof, therefore, that hemorrhage may transude through an 
uninjured surface : nay, in some rare cases, the process has been actually witnessed. 
There are well-authenticated instances on record of cutaneous hemorrhage ; where 
a dew of blood has appeared upon some portion of the skin, has been wiped away, 
and has reappeared ; and that, again and again, without any perceptible alteration of 
the afTected surface, beyond some occasional variation in its colour. So, again, the 
menstrual discharge has been seen to issue guttatim from the healthy surface of a 
living but inverted uterus. I confess, however, that, although this analogical fact 
helps our conception of the manner in which blood may be exhaled from an un- 
broken membrane, I should not lay much stress upon it for any other purpose. It is 
not exactly a case in point. The process of menstruation cannot be looked upon as 
a morbid process. During a certain portion of the life of an unpregnant female, it 
is not only consistent with perfect health, but even essential to it ; and the fluid poured 
out is not strictly blood. 

That the blood proceeds from the same vessels or apertures, which, in health, pour 
out the fluids natural to the part, is rendered the more probable by this fact : — that 
certain hemorrhages are ushered in and succeeded by an increased efflux of the fluids 
which belong to the surface concerned. In hemorrhages from ttie mucous mem- 
branes the following succession of events is, in some persons, habitual. First, there 
is an augmented flow of mucus alone ; then of mucus tinged with blood ; then of 
pure blood : and the hemorrhage recedes by a similar but inverse gradation, towards 
a mucous drain, which itself at length decreases or disappears. 

When blood thus exudes, we say that the hemorrhage takes place by exhalation. 
It is a convenient word, and will spare circumlocution. What the vessels or out- 
lets to which we give the name of exhalants really are ; whether they be branches 
from the capillaries not large enough in the natural state to admit the red particles, 
or whether they be mere pores in the sides of the capillaries ; these are points con- 
cerning which we have no positive knowledge. We know, indeed, that such chan- 
nels must exist, though we cannot demonstrate or see them ; and we know that while 
every part of the body is in a state of health and integrity, they do not allow the 
blood, as such, to pass through them. 

I am aware that my learned colleague Dr. Todd objects to this doctrine of hemor- 
rhage without rupture^ even of capillary vessels : arguing that, if the red corpus- 
cles of the blood, which measure from 4 oVo 3 oVo^^ ^^^^ diameter, could 
pass through lateral pores in those vessels, such pores must be large enough to be- 



BY EXHALATION. 



161 



come visible under the microscope. But on the other band, Mr. Wharton Jones, 

who also is well versed in the use of that instrument, declares that the red corpuscles 
" can readily accommodate themselves to vessels of a diameter less than their own." 
However this may be, the distinction is broad enough between hemorrhage from a 
palpable leak in a large vein or artery, and hemorrhage from innumerable capillaries 
in which no rent can be demonstrated. Treating, then, this question of rupture 
according to the old maxim, that de non apparentibus et de non existendibus eadem 
est ratio, 1 shall venture to adhere to the term exhalation. 

Now, although internal hemorrhage may happen in other ways ; as from the 
bursting of an aneurism, or from an opening made in a large vessel by progressive 
ulceration; yet in by far the greater number of cases it takes place by exhala- 
tion. Exhalation is the rule — other modes of hemorrhage furnish the occasional 
exception. 

I must exclude, however, from this general statement one very important hemor- 
rhage. In the brain, the former exception becomes the rule. In almost all cases 
cerebral hemorrhage results from the rupture of a blood-vessel. 

There are various kinds of hemorrhage by exhalation. I will bring them before 
you, in succession, as clearly and concisely as I can. 

In the first place there are hemorrhages which, although they do not belong to the 
state of health, if we take mankind in general, yet when they do occur, cannot pro- 
perly be called diseases. There are some persons — I believe I may say there are 
many persons — who are subject, during the greater part of their lives, to discharges 
of blood ; which happen again and again, commonly at regular intervals, without 
any perceptible detriment to the general health, independently of any obvious ex- 
citing cause, and (as it would seem) from some inherent property or necessity of the 
system. 

Hemorrhages thus occurring, I will call habitual hemorrhages. They proceed 
more commonly from the rectum, and from the nares, than from any other parts; 
although instances are recorded of their taking place from the bladder, and from the 
bronchi. Appertaining to the original constitution of the body, this disposition to 
periodic hemorrhage has been sometimes observed to be hereditary. 

You will at once be struck with the analogy which obtains between these habitual 
hemorrhages occurring in either sex, and the monthly discharge which is peculiar to 
the female. The analogy is even closer than it may at first sight appear : but it is 
more distinctly marked in some individuals, liable to habitual hemorrhage, than in 
others. It was one of the singular notions of the celebrated phrenologist M. Gall, 
founded upon his analogy, that there is such a thing as male menstruation. The 
points of resemblance between the two phenomena will be manifest in the following 
summary of the characters belonging to habitual hemorrhage. 

Like the catamenia, these hemorrhages do not ordinarily prevail throughout the 
whole course of life. In most cases they do not commence before the period of 
adolescence ; and they cease altogether, or recur at distant intervals only, in declin- 
ing age. Their first eruption is sometimes preceded by a state of general indisposition, 
more mrely by slight febrile disturbance, and even (according to some observers) by 
a sort of chlorosis similar to that which affects young girls in whom the menstrual 
evacuation is delayed or suspended. The hemorrhage sometimes recurs at precisely 
regular intervals, and by monthly periods more commonly than any other : being 
announced, on each occasion, by the same preludes, proceeding from the same part, 
continuing for the same space of time, and furnishing always about the same quan- 
tity of blood. Its accidental interruption is almost uniformly the cause or the conse- 
quence of some derangement of the health: and when it becomes excessive, it 
becomes, like too profuse menstruation, a disease. 

It forms a very curious part of the general history of hemorrhages that they are 
not unfrequently vicarious, or supplemental, sometimes of each other, but more often 
of the monthly discharge from the uterus. Females are hable to perverted men- 
struation (so to call it) through other channels than the natural one : and here again 
the analogy between the catamenia and habitual hemorrhage comes into view. The 
hemorrhages wliich belong to the constitution are apt to wander in their seat. As 
11 o2 



162 HEMORRHAGE. 

"bleeding from the lungs, stomach, rectum, or skin, sometimes follows upon the sus- 
pension of the menses, so bleeding from the bladder, from the mouth, and from other 
parts, has been occasionally observed to succeed the suppression of habitual hemor- 
rhois. 

These hemorrhagic deviations take place commonly by the same organ on each 
occasion ; more seldom by different organs in succession. It is almost aKvays in 
this supplementary manner that the rarer forms of hemorrhage occur, and those of 
the skin in particular. 

This singular migration, this interchange of place between certain hemorrhages, 
seems calculated to throw some light upon the obscure doctrine of revulsion: a 
doctrine to which 1 have already more than once referred, and which, though it is 
very imperfectly understood, is of frequent avail in the practice of physic. 

Vicarious hemorrhage always denotes a disordered state of the general health : 
and must be considered, in itself, as a malady. 

Again, there are certain forms of hemorrhage, not habitual, which may be deno- 
minated idiopathic : inasmuch as they are apt to arise without any perceptible con- 
nection with antecedent local disease. 

In other respects, however, they differ considerably, and require to be further 
distinguished : and the terms active and passive, which are in common use, will 
sufficiently express the two forms of idiopathic hemorrhage that I wish to bring 
under your notice. 

Active hemorrhage is preceded by active congestion, and therefore is akin to 
inflamaiation ; and it often requires the treatment of inflammation. 

Passive hemorrhage often occurs without any apparent previous congestion of any 
kind. Hemorrhage of this passive character has been ascribed to some change—- 
different from that which we conceive to be produced by the distension of plethora — 
in the vessels or apertures through which the healthy exhalations are transmitted. 
The change is considered as being of the nature of morbid debility or relaxation. 
That such a state may sometimes exist is not impossible, nor even unlikely : but as 
we are altogether ignorant of the natural condition of these outlets, it is difficult to 
reason about the alterations to which they may be subject in disease. This hypo- 
thesis derives its chief support from the occasional efficacy of astringent substances 
(either apphed locally, or taken into the system) in checking the effusion of blood, 
when other remedies have failed. 

A more probable hypothesis perhaps is that which supposes some alteration in the 
consistence or composition of the blood itself; which thus becomes attenuated, and 
capable of passing through channels or orifices that healthy blood, under ordinary 
circumstances, cannot penetrate. In support of this supposition are adduced the 
facts that hemorrhages are known to occur where the blood is more thin, pale, and 
serous than common ; and still more remarkably where that fluid has undergone a 
demonstrable change in its chemical nature, or is even visibly altered in its sensible 
quahties ; as, for example, in certain cases of purpura and sea-scurvy. And hemor- 
rhages of this kind are often cured by measures calculated to repair the blood ; to 
restore it to its natural condition by improvement in diet ; or by food of a peculiar 
kind, as the juice of lemons. 

AVhatever may be the true explanation of the differences in question, there can 
be no doubt that they exist, and are often strongly pronounced in case of hemorrhage, 
which, inasmuch as they cannot be traced to any pre-existent local disease, we class 
together as idiopathic. And it will be worth while to run over the distinctive cha- 
racters of active and passive hemorrhage, as they are broadly and decidedly visible, 
in well-marked cases. 

Active hemorrhage (which is preceded, I repeat, by active congestion) occurs 
principally in persons who are young and robust, who hve fully, and lead indolent 
lives, and are subject to the influence of those causes which tend to generate plethora. 
Occasionally the hemorrhage can be traced to some exciting cause, such as exposure 
to heat, strong mental emotion, violent exercise, or bodily efforts. More frequently, 
perhaps, no exciting cause is apparent. It is sometimes ushered in by a set of 
symptoms expressive of what has been called the molimen hemorrhagicum. The 



IDIOPATHIC. 163 

patient experiences a general feeling of indisposition, with wandering and o"bscure 
pains that gradually settle in the part from which the blood is about to be discharged. 
A series of local symptoms, such as a sensation of weight, or of tension, or of heat 
and tingling, sometimes a slight degree of turgescence and redness, and a visible 
fullness of the larger veins, indicate the afflux o^" blood towards the labouring organ, 
and the parts in its vicinity : while chilhness, paleness, and shrinking of distant 
parts, and especially of the feet and hands, denote an opposite condition of the cir- 
cuiation in them. And to this state of things there often succeeds a general increase 
of heat, with a frequent pulse, — a pulse which is so characteristic sometimes, as to 
have acquired a name ; you may often hear or read of a hemorrhagic pulse. The 
blood, when at length it breaks forth, commonly escapes with rapidity ; is of a florid 
colour ; proceeds from a single organ ; and readily coagulates, though it seldom 
separates distinctly into serum and crassamentum. While it is flowing, the signs of 
local congestion diminish and disappear ; warmth returns to the extremities, and the 
pulse regains its natural strength and frequency. The patient becomes conscious of 
a sensible rehef ; and feels stronger and more lively than before. This kind of 
hemorrhage is, in some sort, its own remedy ; it ceases in virtue of the discharge of 
a certain quantity of blood, and it is followed by morbid consequences only when 
that quantity has been excessive ; or when it inflicts some mechanical injury upon 
the parts along which the blocd passes. 

I said that active hemorrhage is preceded by active congestion, and is consequently 
akin to inflammation. Perhaps it may be more true that in some of these cases we 
actually have th^ initial stage of inflammation, of which the hemorrhage proves the 
natural cure : stranghng it in its birth ; applying that remedy, in the very moment 
when it is most efTective, which I told you, in the last lecture, was the most potent 
of all the remedies of inflammation : namely, loss of blood. 

Passive hemorrhage on the other hand is characterized by circumstances of an 
exactly contrary nature. It occurs in those who are naturally feeble, or who have 
been debilitated by disease, fatigue, insufficient nourishment, great evacuations, or 
the depressing passions. It is not, in general, announced by any precursory symp- 
toms, nor attended by any re-action. The effused blood is of a dark colour, serous, 
and but little disposed to coagulate : and it often is poured forth from several parts 
of the body at the same time. If the quantity lost be at all considerable, the natural 
debihty of the patient is rapidly augmented : his face becomes pale, and his body 
loses its heat. The hemorrhage leaves him in a worse condition than that in which 
it found him. The flow of a certain quantity of blood is not, as in the cases of active 
hemorrhage, suspensive of its further effusion ; frequently, indeed, passive hemor- 
rhage resists the means opposed to it, the more, in proportion as it has continued 
longer, or been more profuse. 

Hemorrhages of the kind I have now been describing — that is to say, depending 
upon no palpable disease of any organ, and, therefore, idiopathic — are of no uncom- 
mon occurrence, whether we regard the active or the passive form in which they 
appear : but by far the greater number of hemorrhages by exhalation are sympto- 
matic ; that is, they result from some previous disease, either in the organ from 
which the blood proceeds, or in some other organ connected therewith by community 
or dependence of function. 

These secondary or symptomatic hemorrhages are preceded by congestion, but 
for the most part the congestion is not of the active, but of the mechanical kind ; and 
has more to do with the veins of the part than with the arteries. 

Thus we have hemorrhage from the bronchial membrane, in consequence of crude 
tubercular matter in the lungs, filhng up a portion of the pulmonary tissue, and 
obstructing the circulation of the blood through it. This is an example of symp- 
tomatic hemorrhage by exhalation, depending upon previous disease in the organ 
itself from which the blood proceeds. 

In some of these cases the presence of pyrexia renders it probable that the hemor- 
rhage is the consequence and the relief of active congestion, provoked by the 
irritation of tubercles ; rather than the result of a mechanical obstruction of the 
circulation. 



164 



HEMORRHAGE. 



Again, we have hemorrhage into and from the lungs, as a consequence of such 
disease of the heart as mechanically impedes the return of the blood from the lungs 
to that organ ; a narrowing of the mitral orifice, for instance. Here the blood is 
barred up, as it were, in the lungs, till at length the capillaries, incapable of further 
distention, either give way, or become so dilated as to allow of the exit of the blood 
through their exhalant openings, or through inorganic pores in their sides. In pre- 
cisely the same way blood is poured out by the mucous membrane of the stomach 
and bowels, in consequence of disease in the liver, obstructing the portal circulation. 
These are examples of symptomatic hemorrhage by exhalation, depending upon 
previous disease, not of the organ itself from which the blood proceeds, but of ano- 
ther organ intimately connected with the former. 

When I say that hemorrhage into and from the lungs may result from such dis- 
ease of the heart as implies an impediment to the circulation, you must not suppose 
that the lungs are the only channel through which the mechanical congestion can be 
relieved. Disease of the central moving organ of the circulation leads often, at 
length, to universal venous congestion : and the hemorrhage, which is apt to be the 
consequence of such congestion, may burst forth from any part where the veins are 
so overloaded. Hemorrhages from various portions of the mucous membranes are 
in truth very common effects of cardiac disease. 

The influence of mechanical congestion as a direct cause of hemorrhage is some- 
times very distinctly seen in the bodies of persons who have been hanged. You 
know that when suffocation has been produced by suddenly cutting off the access 
of air to the lungs, the right side of the heart, the great veins, and ^ndeed the venous 
system generally, become loaded and distended with dark blood. Dr. Yelloly exa- 
mined the stomachs of five men who had been executed by hanging: he found them 
all exceedingly vascular ; and in two of the five cases, blood was actually extra va- 
sated, and adhering to the surface of the membrane ; there had been, in short, une- 
quivocal hemorrhage. 

There are several things, worthy of notice, in respect to hemorrhage by exhala- 
tion, of whatever kind. 

In the first place, it occurs much more frequently and readily from some tissues 
of the body than from others: and most especially of all, from mucous surfaces. 
Thus we have hemorrhage from the mucous membrane lining the nasal cavities ; 
from the pulmonary mucous membrane ; from the stomach and bowels ; from the 
urinary organs ; and from the uterus ; constituting distinct forms of disease, which 
we are, by and by, to investigate more particularly. Epistaxis, hsemoptysis, hxrna" 
temesis, melsena, hssmorrhois, hmmaturia, menorrhagia, are names descriptive of 
hemorrhage, as it is apt to occur from different parts of one or other of the three 
tracts of mucous membrane met with in the body: and you will find that these 
comprise very nearly all the complaints enumerated by nosological writers under the 
head of hemorrhage. 

Now this is a very remarkable fact : and very interesting questions arise out df 
it. Has it any relation to the manner in which these membranes, and the tissues 
subjacent to them, are supphed with a capillary circulation 1 or may the fact be 
explained by the laxity of their attachment, which facilitates and favours the accu- 
mulation of blood in the vessels of the submucous tissue ? Or has the density or 
consistence of their natural exhalations any thing to do with this disposition to 
hemorrhage in the mucous membranes 1 May we suppose that the vessels or orifices 
appointed to exhale mucus, afford a more easy passage to the blood than those which 
give egress to thinner fluids; serum, for example, or the cutaneous perspiration? 
Whatever answers may be given to these questions, you will do well to recollect tho 
fact which has suggested them. 

Hemorrhages by exhalation are not, however, exclusively confined to mucous sur- 
faces. They are liable to occur, but much more rarely, from serous membranes. In 
the majority of cases, however, in which blood is found effused into any of the serous 
sacs, it has either been an event of inflammation, or the blood has been poured out 
from an accidental opening in some considerable vessel. Cutaneous hemorrhage is 
also very rare ; probably because the cuticle opposes a barrier to the exit of the 



0 



USUAL SYMPTOMS. 165 

blood : for the little red spots which characterize purpura are m fact hemorrhages, 
although the blood has not penetrated the epidermis. There are cases, however, as 
I mentioned before, in which blood has transpired, in a sort of dew, from the exter- 
nal surface of the body. 

Another important general fact in respect to hemorrhages by exhalation is, that 
they proceed more frequently from certain parts of the mucous membranes than 
others, according to differences, of age. Thus in children they are most common 
from the membrane that lines the nasal cavities : in youth from the mucous mem- 
brane of the lungs and bronchi ; in the middle years of life, and towards its decline, 
from the rectum, uterus, and urinary organs. I should add here, from the blood- 
vessels of the brain, in old age ; except that this, as I have already intimated, is not 
(speaking generally) hemorrhage by exhalation. 

Of course when I say that, in the instances specified, the blood is commonly poured 
out by exhalation, you will understand that the hemorrhage sometimes occurs from 
the laying open of a single vessel of some magnitude. Thus hemorrhage from the 
fauces may be the result of ulceration there, which has penetrated the coats 
of a vein or artery : hesmoptysis is occasionally produced by the laceration of a 
blood-vessel during the softening and expulsion of tubercles. Hsematemesis some- 
times is the consequence of a breach made in a considerable blood-vessel during the 
progress of cancer of the stomach, or by the extension of small corroding ulcers ; 
hemorrhage from the bowels is no uncommon effect of ulceration, such as happens 
in fever, of the mucous follicles of the small intestine ; calculous matter in the kid- 
neys will often lead to the rupture of some of the blood-vessels there, and to the 
discharge of blood by the urethra. Aneurisms also may burst into almost any part 
of the body. But events of this kind are unfrequent when compared with hemor- 
rhage from the same parts in the way of exhalation. 

In the head, however, the ratio is reversed. Blood does, sometimes, I believe, 
exude from the membranes of the brain^ but much more commonly cerebral hemor- 
rhage is caused by the giving way of a diseased artery in the brain. 

How, in all these cases, to distinguish whether the blood has oozed out by many 
orifices from a surface, or has escaped from a hole in the sides of a vein or artery, 
will form matter for future inquiry. Sometimes we can make the distinction, and 
sometimes, it must be confessed, we cannot. 

You will readily understand that hemorrhage must vary greatly in respect to its 
importance, and to the danger which it imphes, according to the part from which it 
proceeds, and the circumstances under which the blood is poured out. It sometimes 
happens that death ensues from the mere loss of blood : either at once, by one pro- 
fuse bleeding, or more slowly, by repeated bleedings which we are unable to restrain: 
but this is comparatively rare, and when it does happen, the blood is generally found 
to have proceeded from one considerable vessel, which has been ruptured or eroded. 
The case approximates to traumatic hemorrhage, except that we cannot cut down 
upon and tie the injured vessel. Much more commonly danger arises from the 
presence and pressure of the extravasated blood in and upon internal parts ; upon 
the brain, for example, in cerebral hemorrhage ; in the lungs, in pulmonary. 

The symptoms, also, are hable to much variation in different cases. Even the 
diagnosis of hemorrhage is not always equally easy or certain. When the part 
into which the blood is directly poured communicates with the exterior of the body, 
the expulsion of some of that fluid will, generally, sooner or later demonstrate the 
case to be one of hemorrhage. I say, g-mem//?/, because cases have been known 
to occur, in which patients, previously in a state of great weakness, have died out- 
right, by syncope, from the mere extravasation of the blood, and before any of it 
made its way out of the body. The stomach and bowels have been found full of 
blood, when none had passed either by vomiting or by stool. And when the blood 
does make its appearance outwardly, it is sometimes not easy to determine whether 
it has come from a certain organ, or from the parts that lie between the same organ 
and the natural outlet by which it ultimately escapes. For instance, it is sometimes 
a matter of uncertainty whether the blood, in hematuria, proceeds from the kidneys, 
or the bladder, or the urethra. 



166 



HEMORRHAGE. 



The blood, itself, when it reaches the exterior, will generally be more fluid, and 
brighter, in proportion as it is effused in greater quantity, and nearer the surface : 
more in clots, and darker in colour, in proportion to the length of time that it has 
remained within the body after its escape from its proper vessels ; and this length 
of time may depend upon the smallness of the quantity of blood effiised, and the 
consequent tolerance of the organs through which it may have passed ; or upon the 
actual space traversed. Respecting the colour, however, of the effused blood, I shall 
have some curious explanations to offer you when I come to speak of hematemesis 
as a disease. It would be superfluous to enter upon them now. 

If the site of the hemorrhage does not communicate with the external air, we are 
without that certainty which results from the actual spectacle of the blood. But 
in such cases we are much assisted by local disturbances of function, springing from 
the pressure upon, or the laceration or distension of, the suffering organ, or the parts 
contiguous to it. And we may derive good information from observing the indirect 
symptoms which declare themselves through the system at large ; many of which 
indirect symptoms are the same whether the blood reach the exterior or not. They 
principally vary according to the quantity of blood poured out, and to the rapidity 
of its effusion : and some difference will occur according to the age and strength of 
the patient. 

Some of these indirect symptoms have not always' been imputed to their true 
cause. Paleness of the face, feebleness of the pulse, coldness of the extremities, and. 
a tendency to syncope — symptoms which are apt to be connected with hemorrhage 
— have sometimes been ascribed to the alarm and sense of danger which the sight of 
the blood is calculated to produce in the mind of the patient. This may, to a certain 
extent, be sometimes true ; but the explanation cannot apply to those cases in which 
the hemorrhage is strictly confined to the interior of the body, yet in which the 
symptoms just alluded to are often strongly marked. They then depend — and 
probably in all cases they chiefly depend — upon the actual abstraction of the blood 
from the circulation. 

The management of individual cases of hemorrhage must be mainly regulated by 
the particular circumstances under which they occur. The few observations that I 
have at present to make respecting their treatment cannot be otherwise than very 
general. 

But a preliminary question, of some importance, presents itself. Is it in all cases 
of hemorrhage proper, or safe, to attempt to stop the bleeding ? 

Without going into detail, it may, I think, be laid down as a rule, that what I 
have called habitual hemorrhages ought not to be interfered with, so long as they 
have no perceptible injurious influence upon the health, and so long as they proceed 
(as they mostly do) from parts of which the structure is not hkely to be spoiled, nor 
the function impaired, by the repeated passages of the blood. The most common 
seat of these habitual hemorrhages I have stated to be the rectum ; to which the 
two conditions just mentioned are, fortunately, both of them applicable. Epistaxis 
supplies a less frequent example of the same kind. When they deviate from their 
usual channel, and are transferred (as it were) to some more important organ, it will 
generally be right, among other remedial measures, to endeavour to recall the 
original hemorrhage. It is very seldom that the metastasis takes place for the better. 
— i. e., from a part where the bleeding is attended with danger, to one where it is 
comparatively harmless. 

However, when these habitual hemorrhages happen, as they often do, in plethoric 
persons ; and when they are urged and kept up, as they frequently are, by intem- 
perate and luxurious habits ; we ought not to content ourselves with merely looking 
on. Hemorrhois often performs the office of a safety-valve in sudfi persons ; and 
there are many who have what are called bleeding piles, and who would rather 
continue to have them, than to submit to any change in their mode of hfe, or to the 
employment of other means of evacuation. Certainly these are cases in which 
nothing should be done to slop the bleeding ; yet such patients ought to be told that 
the hemorrhoidal discharge is but a precarious, and often an inadequate rehef of the 
plethora: that while the plethora is suffered to exist there is danger of a cessation 



TREATMENT. 



167 



of the piles, and of the supervention of serious or fatal affections of other pans, and 
especially of the head. Apoplexy, or cerebral hemorrhage, has frequently been 
known to follow hard upon the suspension of constitutional hemorrhois. The 
patient should be admonished also that the discharge of blood from the vessels of the 
rectum may become excessive ; that if it be aggravated by exercise, or in any other 
way, it may lead to inflammation about the anus, and to great inconvenience ; and 
that there are safe and tolerably sure methods of getting rid of the plethora ; (which 
is what chiefly constitutes the danger of such cases), if they will submit to the ob- 
servance of them. It is in the intervals between the hemorrhages that the danger 
of which they are in some sort the token, may best be met. 

Again, it will seldom be proper to employ direct expedients for staunchflg the 
flow of blood, in the small class of active idiopathic hemorrhages ; unless the 
quantity lost is so great as to endanger the safety of the patient. Such hemor- 
rhages have commonly a tendency to cure themselves, by relieving the general 
plethora, or the local congestion, on which they depend. For these hemorrhages, 
which bear so strong an analogy to inflammation, the treatment of inflammation 
may often be requisite, as an indirect mode in which their amount may be mode- 
rated, and their recurrence obviated. 

With these exceptions, both direct and indirect measures are to be used, for 
arresting the effusion of blood as speedily as may be. 

To this end the patient is to be surrounded as much as possible with cool fresh 
air, and kept in a state of absolute quiet. All motion of the body, and emotion of 
the mind, all kinds of stimulating food and drink, every thing, in short, which has 
a tendency to hurry the circulation, should be diligently avoided ; and that position 
of the body should be chosen which is. the least favourable to the afflux of blood 
towards the part affected. The horizontal posture will be proper in hemorrhage 
from the bowels, the uterus, or the urinary organs. In epistaxis, and in cerebral 
hemorrhage, the head should be raised. 

In two words, the antiphlogistic regimen should be strictly enjoined in all cases 
of hemorrhage sufficiently severe to require medical assistance. 

Of the actual remedies used for checking the further escape of the blood, one of 
the most important has already been alluded to — I mean venesection. Herein we 
are guilty of homosopathy ; to prevent bleeding, we draw blood. After what was 
stated respecting the use of blood-letting in inflammation, I need not dwell upon the 
objects aimed at by this measure : they are, briefly, to abate the vigour and force of 
the heart's contraction, to lessen general plethora when it exists, to remove local 
congestion, and to divert the current of the blood from, the suffering organ. The 
method, and the amount, and the repetition of the blood-letting, must of course be 
regulated by the circumstances of each particular case. And the same objects may 
sometimes be effected by other modes of general depletion, especially by the use of 
purgative medicines. 

Another important remedy for inward bleedings is mercury. Whatever may be 
the modus operandi of that mineral, the fact is certain, that hemorrhage, which had 
resisted other modes of treatment, has, in very numerous instances, ceased at once 
upon the occurrence of a moderate degree of salivation. 

Next to blood-letting and mercury, astringents constitute the great resource against 
actually existing hemorrhage : and among these, cold is one of the chief. It may be 
placed in direct contact with the bleeding surface : as when ice is swallowed to 
restrain hematemesis ; or cold water injected into the rectum in excessive and 
exhausting hemorrhois ; or into the vagina, in flooding from the uterus. Or it may 
be apphed to the surface of the body, as near as possible to the seat of the hemor- 
rhage ; as to the nose and forehead in epistaxis ; to the chest in hemoptysis ; to the 
epigastrium in hemorrhage from the stomach ; to the lower part of the abdomen or 
to the perineum in hemorrhage from the intestines, uterus, or urinary organs. But 
the influence of cold in eonstringing the smaller vessels is not confined to the part 
with which it is in contact ; it will stop hemorrhage by the sympathetic shrinking 
which it produces in distant parts. Epistaxis, for example, has often been arrested 
"by the sudden apposition of cold water to the neck, back, or genital organs. The 



1^ 



DROPSY. 



nursery remedy consists in slipping a cold key down the back between the clothes 
and the skin. 

Of the mischievous power even of cold in this way we have continual illustration 
in the suppression of the catamenia by cold and.^vet accidentally apphed to the feet. 

There is a long catalogue of medicinal substances which are esteemed to possess 
more or less of a specific virtue, when taken internally, in checking the flow of 
blood. Most of these are of an astringent nature, and some of them are eminently 
useful. The acetate of lead enjoys, in this country, a higher character, perhaps, 
than any other of these substances. 

Many vegetable matters, and some artificial compounds, frequently employed in 
interil^l hemorrhage, seem to owe their astringent and styptic properties to the galhc 
acid which enters into their composition. Such are the rhatany root, uva ursi, bistort, 
tormentil, the pomegranate, kino, catechu, the several preparations of gall nuts, and 
the nostrum called RuspinVs styptic. 

The power of arresting internal hemorrhage has also been confidently ascribed, 
by different persons, to nitre given in large doses, to the mineral acids, to the muriated 
tincture of iron, to alum, to the oil of turpentine, to the secale cornutum or spurred 
rye, and to various other substances, a more particular account of the rules and indi«- 
cations for administering which, I may return to, when 1 have to speak of individual 
hemorrhages. 



LECTURE XVI. 

Dropsy : its General Pathology. Passive Dropsy ; Cardiac and Renal. Active, 
Acute, or Febrile Dropsy. Prognosis ; and General Principles of Treatment 
in Dropsies. 

There remains now only one subject, of the pathology of which it will be con- 
venient and, I hope, instructive, to take a short general view, before we enter upon 
the consideration of special diseases. I proceed to speak of dropsies : by which I 
mean collections of serous hquid in one or more of the shut cavities of the body, or 
in the areolar tissue, or in both, independent of inflammation. 

We have already considered serous effusion as occurring as an effect or event of 
inflammation. We are commonly able to say of this, that it has originated in inflam- 
mation ; either from its being mixed with some of the less equivocal products of that 
disease, such as coagulable lymph ; or from its having taken place while symptoms 
of inflammation existed. But there are numerous examples of serous accumulation, 
which cannot with any show of reason be regarded as events of inflammation. It is 
to these that I would apply the simple term dropsy. 

It has been said — and said with much truth — that dropsy is rather a symptom of 
disease, than a disease in itself. And it has been affirmed that it would be more 
philosophical and scientific to treat of the original malady upon which the effusion 
or accumulation depends ; to erase dropsy from the list of substantive diseases, and 
to place it in the catalogue of mere symptoms. 

But this, in my mind, is a very mistaken view of the matter. For, first, it is 
oftentimes uncertain, while the patient is yet aJive, what or where the primary dis- 
ease may be ; and even after death we sometimes can discover no organic change 
that would satisfactorily account for the effusion. Practically speaking, in such 
cases the dropsy is the disease, and the sole object of our treatment. 

And, secondly, dropsy is, in fact, to a medical eye, in all cases, something more 
than an effect or symptom of disease. The imprisoned liquid is often a cause of 
various other symptoms ; embarrassing, by its pressure, important functions, and 
even extinguishing fife. The removal of the dropsy (although its original cause, of 
which it was a symptom, may remain behind, untouched, to be again productive of 
effusioa under circumstances favourable to its operation} — the removal of the dropsy 



DROPSY. 



169 



will often restore a person to comparative comfort; or even to what, so fas. as his 
sensations, and powers, and beHef are concerned, is, to him, for the time, a state of 
health. 

You see then, already, that in a dropsical person, whose dropsy depends upon 
organic disease, there are two sets of symptoms to be distinguished : viz., those 
which depend on the primary disease ; and those which depend on the collected 
fluid. The latter, often the most grievous, are often to be got rid of : the former, 
frequently permanent, are frequently also but httle complained of or felt by the 
patient, except when effusion is the result. 

Some persons, I fancy, have regarded dropsy as a less attractive subject of inves- 
tigation than it might be if it were less frequently, in its nature, incurable. But as 
far as the dropsy itself is concerned, the complaint often is curable ; and there are 
some forms of dropsy that are curable in a more absolute sense ; that is, both the 
effusion, and that condition which was the f>hysical cause of the effusion, are some- 
times remediable. 

Besides, it is our business to cure when we can ; but whether we can cure or 
not, to relieve and palliate human suffering ; and this, under Providence, we are able 
to do, in many or most cases of dropsy, to a very considerable extent. 

Wherever there is a shut sac, or wherever there is loose and permeable areolar 
tissue, there we may have dropsy. 

Thus there may be dropsy of the ventricles of the brain, or of the meshes of the 
pia mater, leading to death by coma ; of the pieurse, of the areolar texture of the 
lungs, or of the submucous areolar tissue of the glottis, any of which may cause death 
by apnoea; of the pericardium, producing death by syncope. I mention these 
instances in particular, to show that almost every mode of dying may result from 
dropsical effusion ; and to win your attention to a disorder so full of peril. 

When the cerebral ventricles are distended with water, we express the diseased 
condition by the term hydrocephalus. When serous liquid collects in the pleura, 
Or in the pericardium, we say that the patient has hydrothorax, or hydropericar- 
dium. If the cavity of the peritoneum be the seat of the effusion, we call the com- 
plaint ascites. When the areolar tissue of a part becomes infiltered with serous 
fluid, the part is said to be (Edematous ; and anasarca is the name given to the 
more or less general accumulation of serum into the areolar tissue throughout the 
body, and especially to .visible subcutaneous oedema of considerable extent. Finally, 
the term general dropsy signifies the combination of anasarca with dropsy of one 
or more of the large serous cavities. 

Other local dropsies indeed there are, but, as they belong entirely to surgery, I 
need not emunerate them. 

Now what reasonable account can be given of these remarkable conditions ? How 
is it that the hollows and interstices of the hving body, or of parts of the body, 
become thus water-logged ? 

To solve this question, we must carry in our minds some physiological recol- 
lections. 

The closed cavities, or the interstitial tissues, within which the fluid of dropsy is 
confined, are kept moist, during hfe and health, by a continual serous secretion from 
their surfaces : and they are kept merely moist, for the fluid thus constantly secreted 
is as constantly reabsorbed into the circulation. 

When these tissues or cavities, without having undergone inflammation, become 
filled and distended with the serous fluid which they habitually secrete, one of three 
things must have happened. Either the quantity of fluid exhaled has been aug- 
mented, the absorption remaining the same ; or the absorption has been diminished, 
the exhalation continuing the same ; or else the exhalation has been increased, 
while at the same time the absorption was either lessened or not proportionally 
increased. 

The last is a mixed case ; and we need only consider the two others. 
Now the balance between exhalation and absorption is often deranged, and dropsies 
do actually arise, in each and all of these ways. 

p 



170 DROPSY. j 

It will best suit my purpose to speak first of those dropsies which are occasioned, 
by defective absorption, and which are usually called chronic or passive dropsies. 

The direct agency of the blood-vessels in the production, as well as in the removal 
of dropsy, although indicated by many common and obvious facts, has not been 
generally recognized till a comparatively recent period. Perhaps I should rather, 
say that more importance used to be assigned, in these respects, to the agency of tho. 
lymphatic absorbents, than they are really entitled to. You will find that patho- 
logists, even in modern times, speak of a want of tone, of deficient energy, in the 
absorbents, as a cause of dropsical accumulations ; the superfluous fluid of the part | 
is not adequately taken up (they say) by the enfeebled absorbents, meaning the ab- , 
sorbents strictly and anatomically so called. And this view of the matter, connecting 
dropsy always with debility as its cause', has led to a corresponding plan of treat- 
ment : the object aimed at being the stimulation of the absorbents to more energetic 
action. 

But to the doctrine that dropsy is a consequence of the deficient action of the ab- 
sorbents, this obvious difliculty presents itself, — that absorption really goes on, and 
goes on very actively, in dropsical patients : their adipose matter disappears, they 
become wretchedly thin. There is no complaint in which wasting and emaciation 
go to a greater extent than in dropsy. You will find also that persons labouring 
under anasarca are readily enough affected by mercury ; which must of course be 
absorbed before it can produce any of its specific effects. i 

It must be confessed that our knowledge respecting the mechanism of absorption | 
is neither complete nor certain; but there is good reason for supposing that the , 
process is shared among the lacteals, the lymphatics, and the veins ; and it is pro- | 
bably distributed between these sets of vessels somewhat in this manner ;~that the | 
lacteals absorb the chyle from the surface of the alimentary canal, and convey into 
the blood the materials of its renovation ; that the office of the lymphatics is to take ; 
up and carry into the blood those old and effete portions of the solid constituents of 
the body, which require to be removed to make way for a fresh deposit ; while the 
veins imbibe the serous fluid exhaled from the surfaces of serous membranes, and 
into the meshes of the areolar tissue, as weU as poisons and other substances that are f 
soluble and dissolved in that fluid. 1 

If this be so, the difficulty just now mentioned vanishes. Of the two sets of ab- j 
sorbing vessels, the lymphatics and the veins, one set may continue to perform its 
functions, while the other fails to do so. This theory is quite consistent with the i 
actual phenomena of dropsical disease ; and whether it be altogether true or not, a i 
part of it is certainly true ; that, namely, which assigns to the veins a large share in \ 
the whole proces-s of absorption. The experiments of Magendie and of others are j 
quite conclusive upon that point. ] 

It has also been fully established, that fluids may and do pass into or out of the | 
veins, in the living body, not by any vital process, but by mere physical imbibition I 
and transudation, through the coats of those vessels ; that when the veins are dis- i 
tended to a certain degree with watery fluid, the entrance of more of the same fluid ' 
through their sides, is impeded or prevented ; that, when the distension is still greater, ■ 
the aqueous part of the blood may even pass in the other direction out of the vessel ; i 
and that, on the other hand, when the veins are comparatively empty, the surround- {' 
ing serous fluid passes readily into them, or, in common language, is absorbed, y. 
The venous absorption is explicable therefore upon the principles of endosmose and ' 
exosmose, as laid down by Dutrochet ; or I would rather say, according to the more ; 
general and more simple laws of heterogeneous attraction, as explained by Professor | 
Daniell. : I 

Imbibition, being a form of that attraction, belongs in various degrees to all the 
tissues of the body. Its rapidity — and even its direction in respect to the elastic j 
coats of a vessel surrounded by fluid, and also carrying fluid of a certain consistence ;| 
— will vary with the varying distension of the vessel. When the vessel is mode- • 
rately full, the exterior fluid passes uninterruptedly inwards, and is conveyed aAvay 
by the internal current. When, on the other hand, the vessel is kept much dis- 
tended by its contents, the contained fluid, or its thinner part, passes continually out- 



PASSIVE DROPSY. 



171 



wards ; and there is an intermediate degree of distension, at wnich the pressure is 
just sufficient to prevent the transit of fluid in either direction. Magendie found, 
accordingly, in a well-conducted and conclusive series of experiments, that by regu- 
lating the conditions of comparative emptiness or fullness of the circulating system, 
he could accelerate, or retard, or suspend altogether, the operation of a poison dis- 
solved in the humours of the body. In other words, he could thus accelerate, retard, 
or prevent, the process of absorption or imbibition through the blood-vessels. 

Bearing these physiological truths in remembrance, we shall have no difficulty in 
showing that the chronic forms of dropsy are attributable partly, and chiefly, and in 
many instances entirely, to undue plenitude of the veins ; and that this venous re- 
pletion is produced, almost always, by some impediment to the free return of the 
blood towards the heart. 

When the areolar tissue of a limited part of the body becomes filled and distended 
by serous liquid, we call the swelhng oedema; but this is exactly the same, in its 
nature, as anasarca. Now oedema is often the consequence of some mechanical ob- 
struction to the venous circulation. We can produce it whenever we will. Our 
countryman Dr. Lower, 170 years ago, tied the jugular vein of a hvingdog. When 
a few hours had elapsed, he observed that all the parts beyond the ligature, reckoning 
from the heart, were much swollen : and upon dissecting the animal after death he 
found that the areolar tissues of the head and face were filled, not with red blood, as 
he had expected it might be, but with clear and limpid serum. On another occasion 
he placed a ligature upon the vena cava, just above the diaphragm : death soon 
ensued, and a large quantity of water was discovered in the cavity of the peritoneum, 
" non aliter quam si ascite diu (canis) laborasset." 

These experiments were not instituted with any reference td the pathology of 
dropsy ; yet that Lower perceived their bearing upon that subject is plain from this 
sentence : " Quantum hsec ad ascitis et anasarcse causas investigandas conducant, 
alns judicandum relinquo." He even explains the extravasation of the thinner or 
serous part of the blood as taking place by infiltration, " velt in filtro," through the 
pores of the vessels. 

Precisely similar phenomena succeed the compression or obliteration of a large 
vein in various parts of the body. In operating for pophteal aneurism, Mr. Travers 
was obliged to tie the femoral vein ; the areolar tissue of the hmb was speedily infil- 
trated with serous fluid. Long-abiding (Edema of one foot and ankle has been cured 
at once by the reduction of a crural hernia, which had been pressing for the same 
length of time upon the femoral vessels. You have heard, most probably, of the 
disease called phlegmasia do lens ; a disease that is very common in women soon 
after childbirth, although it is not pecuhar to them, nor to the female sex. The foot, 
leg, and thigh, become enormously oedematous. The essence of this disorder is 
inflammation of the femoral vein ; blocking up that vessel near the groin, and retard- 
ing or precluding the return of the venous blood from the limb. One arm often 
swells in the same way, and from a similar cause, in women who are afflicted with 
cancer of the breast. In pregnancy, the gravid uterus sometimes presses upon the 
iliac veins, and obstructs the current of blood within them : the consequence is, ana- 
sarca of the lower extremities, which disappears as soon as the pressure is removed 
by the deHvery of the woman. The flow of blood through the vena portce is fre- 
quently hindered, by disease in the fiver, or by other causes ; and serous liquid 
accumulates in the peritoneum, constituting ascites. A French physician, M. Ton- 
nelle, narrates several cases in which serosity was found in the cavity of the arach- 
noid, in conjunction with obliteration of the venous sinuses of the dura mater. In 
all these instances we have retardation of the venous current, undue plenitude of the 
veins, and dropsy of the part from which they proceed. The natural exhalation 
goes on, and the exhaled fluid collects and stagnates because the channel through 
which it ought to be drained away is choked up. The larger the vein, and the 
nearer we approach the heart, the more extensive is the dropsical accumulation : and 
if we could plant an obstacle at the very termination of the venous stream, we should 
dam up the blood in the whole system of veins, and produce a general dropsy. 

Such an obstacle is frequently placed there by disease. The returning blood is 



172 



DROPSY. 



checked at its entrance into the heart ; at the confluence of all the veins of the body^ 
where they unite to empty themselves into the right chambers of that organ : and 
then anasarca of the universal areolar tissue comes on, and water collects in all or 
most of the great serous cavities. 

It is no part of my present purpose to inquire how such disease of the heart as is 
productive of dropsy, arises. Commonly we find the right auricle and ventricle 
enlarged in capacity, the opening between them unnaturally wide, and the tricuspid 
valve unequal to its office of closing that aperture. Such a morbid state of the right 
heart may be occasioned by any cause which impedes the flow of blood out of its 
cavities. The diseased condition of those cavities may be primary ; but it is oflener, 
perhaps, consecutive to other disease. It may be produced by disease of the lungs, 
preventing the right ventricle from freely delivering its contents into the pulmonary 
blood-vessels. Or the retarding cause may be still more distant, in the left side of 
the heart, keeping the pulmonary blood-vessels unduly full, and thereby hindering 
indirectly the escape of the blood from the right ventricle. The dropsy may ulti- 
mately depend, therefore, upon some bar to the circulation, placed even at the mouth 
of the aorta. Obstacles situated anywhere in the circuit formed by the right heart, 
the lungs, and the left heart, have the effect of producing secondary changes in the 
parts behind them. But disease, thus propagated in a direction retrograde to the 
course of the blood, is propagated gradually, and sometimes very slowly. These 
are points of much interest, which we shall investigate together by and by. I allude 
to them now, that you may not be perplexed by a knowledge of the fact, that dis- 
eases of the heart often exist for a long while without inducing dropsy. It is with 
disease of the right side of the heart, whether primary or secondary, that passive 
dropsy is especially associated. 

As if to furnish the experimentum crucis in respect to this doctrine, disease does 
sometimes, with a curious precision, dam up one only of the two great venous trunks, 
at the junction of which the right auricle is placed : and then the dropsy is as curi- 
ously limited to that half of the body in which the tributary veins of the obstructed 
trunk originate. The first example of this which I ever saw was a most remarkable 
one. The patient was dropsical in his upper half only. His arms were so hugely 
anasarcous that he could not bring his elbows near his sides ; his neck and face 
were hideously bloated and exaggerated, and his eyes prominent and staring ; while 
his lower limbs were of their natural size, and appeared preposterously small and 
out of proportion. The poor man looked as if the upper part of his body had been 
stuffed, for acting some ridiculous part upon the stage. The cause of this strange 
and distressful state was found to be the obhteration of the vena cava superior, close i 
to the auricle. Its sides had been pressed together by a large aneurism of the aorta; i 
and a portion of the vein was fairly sealed up. I have seen two similar cases since. | 

Objections have, hov/ever, been taken to the accuracy , of the conclusions drawn | 
from such cases as I have related ; and it is fit that you should be aware of them* j 
Thus it is stated that veins have been found obhterated, and yet there was no dropsy, ' 
Now to this objection it may be answered, in the first place, that it is not every vein,. 
the obliteration of which would cause manifest oedema. It must be the principal 
venous trunk of the part concerned. When some of the secondary and smaller veins [; 
alone become impervious, the blood may reach, and return by, the primary branches, 
with sufficient readiness to reheve the turgid capillaries, and prevent any serous 
accumulation. 

But (it may be said) the principal vein itself has been found converted into a solid 
cord, and still there w^as no dropsy. Granted : but it does not follow that there 
never had been dropsy. You know that when a large artery is tied, the circulation 
is carried on in the corresponding limb, by means of collateral arterial branches : 
imperfectly, indeed, at first ; but, at length, as the supplemental channels become 
more numerous and free, the supply of blood to the limb is as copious as ever. It 
is precisely the same, mutatis mutandis, with the veins ; only that the anastomosing 
venous tubes are not (perhaps) so readily developed as the arterial. Now I am not 
aware of any instance in which it has been shown that the principal vein was oblite- 
rated, and yet there neither was, nor had been, any oedema of the hmb. The 



PASSIVE DROPSY. 



173 



recorded cases have "been met with in dissecting-rooms, and the previous history of 
the subject has been unknown or unregistered. Mr. Kiernan has told me that he 
once examined the body of a woman who had excited much curiosity among the 
medical men by whom she had been seen during Kfe, on account of a remarkable 
and enormous dilatation of the superficial veins of the abdomen. She was not drop- 
sical, and the cause of the huge varix was sought for with great interest after her 
death. The inferior cava was obliterated. Here the compensating result was obvi- 
ous to the sight ; the new channels had answered their purpose, and performed the 
functions of the original channel. The history of this case was incomplete : it was 
not ascertained whether the woman had always been free from dropsy. 

I hold this objection therefore to be invahd, until some authentic instance shall be 
brought forward of the obhteration of a large venous trunk, without a corresponding 
accumulation of serous fluid, either at the time when the observation is made, or at 
some previous time in the life of that individual. It is, besides, possible enough, 
that the obstruction of a large vein may be effected gradually, by the slow encroach- 
ment, for instance, of a growing tumour ; and the collateral circulation may begin 
to be enlarged with the first impediment in the vein, and may keep pace with and 
counterbalance that increasing impediment, till the closure of the vessel is complete ; 
so that, from first to last, there may be no noticeable drOpsy. 

Again, it is affirmed, and truly affirmed, that anasarca often occurs, without any 
obliteration of veins, and independent of any discoverable organic disease in the 
heart or anywhere else. We see this every day, in weak chlorotic girls, with blood- 
less cheeks, and pale hps. Some of you saw a case of this kind which was lately 
under my care in the hospital ; besides the anasarca, the systolic sound of the heart 
was accompanied by a loud, unmistakeable bellows sound. This girl got quite well, 
and left the hospital without bellows sound, or any other ti€ce of disease. There 
could not then have been an organic change : in fact there was not. Yet was there, 
virtually, a retardation of the venous circulation ; not by any mechanical obstacle 
opposed to its course, but in consequence of the debihty of that hollow muscle, the 
ofHce of which is to propel onwards, with a certain degree of force, the blood that 
reaches it. Girls of this description have weak and flabby voluntary muscles ; and 
it is reasonable to presume that the involuntary muscle, the heart, partakes of the 
general debility of the muscular system, and becomes incapable of sending the blood 
forwards with the requisite energy. Nay, I beheve that a heart thus feeble may 
yield a little and dilate under the resisting pressure of the blood that enters its cham- 
bers ; and that so an occasional but temporary bellows sound may arise, from the 
altered relation between the cavities of the heart and their outlets. Certainly this 
view of the matter is strengthened by the juvantia and loedentia. If you are tempted, 
by the pain complained of by your patient, or by the violence with which her heart 
is throbbing, to take av/ay blood, you find that she is ultimately made worse by the 
depletion ; on the other hand, if you give her steel, feed her well, keep her bowels 
free, and place her every morning under a cold shower-bath, you find that she recpo- 
vers her lost strength, that colour returns to her hps and cheeks, that her palpitations 
cease, and her dropsy vanishes. In proportion as the muscular system in general 
receives fresh tone and vigour, does that particular muscle, the heart, also regain the 
degree of power necessary for the effectual discharge of its proper function, which is 
very much that of a forcing-pump. Such is the way in which I should explain both 
the cause of the dropsy, and the cause of its cessation. In such cases our patients 
do not simply recover ; they are cured. I should apply a similar explanation to 
some other forms of dropsy. Andral describes a certain cachectic disposition of the 
body as being a cause of dropsy ; persons may be bled into a dropsy, or starved or 
weakened into a dropsy. These are genuine instances of dropsy from debility, 
which is what the ancients conceived all dropsies to proceed from. It may be that 
the thin and watery quality of the blood induced by frequent bleedings, by insuffi- 
cient nourishment, by certain poisons, or by other causes, may facilitate its passage 
through the coats of the veins. But admitting this as a concurrent cause, I am dis- 
posed to the belief that all passive dropsies occurring under the circumstances just 
adverted to, and without any apparent organic disease or change, are mamly to be 



174 



DROPSY. 



ascribed to debilit}'- of the heart : and viewed in this way, they are all brought under 
the same general principle ; viz., the retardation of the blood in the veins. 

A large class then, of passive dropsies, depending upon mechanical congestion, 
and defective absorption by the veins, are traceable, in their origin, to the heart ; and 
we call them, according^, cardiac dropsies. But another class, perhaps numerous, 
are connected in a remarkable manner with certain diseased conditions of the kid- 
neys ; and these, for the sake of distinction, we style renal dropsies. I shall say a 
few words respecting them, after I have briefly considered the other source of drop- 
sical swellings, adverted to in the commencement of this lecture : namely, excessive 
exhalation of serous hquid. Dropsy so caused comes on suddenly and tumukuously, 
and is spoken of as being acute or active. It borders closely upon inflammation, 
and sometimes can scarcely be discriminated from inflammation with serous effusion. 
The condition of the capillary circulation is supposed to be intermediate between 
that in which the ordinary amount of secretion is maintained, and that in which 
inflammatory effuision takes place. The excessive increase of secretion is analogous 
to what we observe in other parts and predicaments of the body ; to the abundant 
perspirations, for example, that are occasioned by violent exercise ; to th^ plentiful 
flow of tears caused by any irritation of the eye, or by the passion of grief ; to the 
augmented watery discharges from the mucous membrane of the bowels produced 
by purgative medicines ; all of which may be independent of inflammation, but all 
of which are attended w'wki congestion that might readily be pushed into inflamma- 
tion. In point of fact, if the secretions to which I have now referred were poured 
into close cavities, instead of proceeding from the surfaces that are situated on the 
exterior of the body, or that communicate readily with the exterior, they would con- 
stitute dropsies. 

The phenomena of Active dropsy are of this kind : a labourer is engaged in some 
employment, which, while it requires considerable bodily exertion, and causes copious 
perspiration, necessarily exposes him also to the influence of external cold and mois- 
ture : he has been digging (perhaps) in a wet ditch, in winter time, and he pauses 
to take his meal ; or he has been unloading a waggon, and rides home, some miles 
in a heavy rain that wets him to the skin ; or he has been mowing, in the heat of 
summer, and hes down to sleep upon the darnp grass. All these suppositions are 
derived from actual occurrences. The perspiration is suddenly checked ; and in the 
course of a few hours he becomes universall}/- anasarcous. Again, a patient recover- 
ing from scarlet fever ventures out into a cold atmosphere, while the process of des- 
quamation is yet going on ; and he is attacked with dropsy of the areolar tissue ; 
and, it may be, of some of the larger cavities also. The urine at the same time is 
observed to be scanty, troubled, mixed with blood. 

To comprehend this rapid change from a state of health to a state of dangerous 
disease, we must again have recourse to the findings of physiology. 

Besides the constant exhalation that takes place from the inner faces of the shut 
serous cavities, a large amount of watery fluid is continually thrown out of the system, 
by all those surfaces that communicate with the air — by the skin, the lungs, the 
bowels, the kidnej^s. Now it is well ascertained that when the excretion of aqueous 
fluid from one such surface is checked, the exhalation from some other surface becomes 
more copious. It is probable that the aggregate quantity of water thus expelled 
from the system in a given time, cannot vary much, in either direction, without de- 
ranging the whole economy. But we are sure that the amount furnished by any 
excreting surface may vary and oscillate within certain hmits consistent with health, 
provided that the defect or excess be compensated by an increase or diminution of 
the ordinary expenditure of watery liquid through some other channel. Sound 
health admits and requires this shifting and counterpoise of work between the organs 
destined to remove aqueous fluid from the body. This supplemental or compensating 
relation is more conspicuous in regard to some parts than to others. The reciprocal 
but inverse accommodation of function that subsists between the skin and the kid- 
neys affords the strongest and the most familiar example. In the warm weather of 
summer, when the perspiration is abundant, the urine is proportionally concentrated 
and scanty. On the other hand, during winter, when the cutaneous transpiration is 



ACTIVE DROPSY. 



175 



checked by the agency of external cold, the flow of dilute water from the kidneys is 
strikingly augmented. All this is well known to be compatible with the maintenance 
of the most perfect health. But supposing the exhalation from one of these surfaces 
to be much diminished, or to cease, without a corresponding increase of function in 
the related organ, or in any excreting organ communicating with the exterior, then 
dropsy, in some form or degree, is very apt to arise. The aqueous hquid thus de- 
tained in the blood-vessels, seeks, and at length finds some unnatural and inward 
vent, and is poured forth into the areolar tissue, or into the cavities bounded by the 
serous membranes. 

Dropsy of one part sometimes supervenes suddenly upon the rapid disappearance 
of a watery collection from another part. It is no uncommon thing to see the swollen 
unwieldy legs and thighs of an anasarcous patient quickly unload themselves, and 
resume their natural bulk and symmetry. His friends congratulate him, and each 
other, that his disease is leaving him ; but as his legs are emptying, he becomes 
drowsy, forgetful, comatose, apoplectic ; and after his death we find the ventricles of 
the brain distended with serous fluid. 

Or the dropsical accumulation may be transferred from its place through a safer 
channel. The best instance of this that occurs to my recollection I heard related by 
Dr. Farre. A gouty individual had hydrocele ; dropsy of the tunica vaginahs. After 
the disease had lasted for some time he got very drunk one evening, with rack punch, 
which greatly disordered his alimentary canal, and brought on a kind of cholera. 
He had profuse vomiting and purging, which quite exhausted him : and at length he 
fell asleep. When he awoke in the morning he found that his hydrocele, which 
had been a large one, was gone : and it never returned. Such an accidental cure is 
most instructive. 

If water be injected, in some quantity, into the blood-vessels of a living animal, • 
the animal soon perishes ; dying generally by coma, or by suffocation : and when 
the carcass is examined, the lungs are found to be charged with serous liquid, or 
water is discovered in the areolar tissue of some other part, or in the shut serous 
membranes. If, however, the animal be first bled, and then a quantity of water l)e 
injected equal to the quantity of blood abstracted, the injection is followed by no seri- 
ous consequences. 

Facts hke these throw, as it seems to me, a strong light upon a confessedly obscure 
part of pathology. It appears that under various circumstances the blood-vessels 
may receive a considerable and unwonted accession of v/atery fluid ; and that they 
are very prone to get rid of the redundance. When they empty themselves through 
some free surface, their preternatural distension is relieved by a flux. If, on the 
other hand, the surface be that of a shut sac, in discharging their superfluity they 
cause a dropsy. Why sometimes this organ, and sometimes that, is selected as the 
chaijnel by which the superabundant water shall be thrown out of the vessels, we 
caiT seldom tell. We often find it diflicuk to determine which of the two facts in 
question is to be considered the antecedent, and which the consequent. For not only 
is it true that when the blood-vessels become overloaded with serous fluid, they rea- 
dily deposit a part of it : but also that when they are in the opposite condition of 
comparative emptiness, when they contain less blood than is natural, they are equally 
ready to replenish themselves by absorbing fluids from any source to which they can 
find access. In the case of the man who was cured of his hydrocele upon the oc- 
currence of profuse watery discharges from the stomach and bowels, it seems clear 
that the expenditure of serous liquid from one part led to its absorption into the blood 
from another. When anasarca suddenly leaves the extremities, and fatal coma fol- 
lows, it appears probable that the absorption is the first of the changes, and the 
effusion the second : and had this effusion been determined to the mucous membrane 
of the intestines, to the skin, or to the kidneys, it would have brought rehef and 
safety to the patient, instead of causing his death. 

We have obtained, then, a glimpse of one or two most important principles in 
respect to the pathology of dropsy. The blood-vessels, when preternaturally full of 
aqueous fluid, have a strong tendency to empty themselves : when preternaturally 
empty, they readily drink up watery fluid wherever they come in contact with it. 



176 



DROPSY. 



From the discharge of their superfluity of water arises a dropsy or a flux. The 
cause and the cure of many dropsies he in these propositions. 

The application of these principles to the supposed case of active dropsy must be 
obvious. No doubt, in some such cases, actual inflammation takes place ; but in 
many of them there is merely the dropsical effusion, without any other trace or evi- 
dence of inflammatory action. The two facts which it chiefly concerns us to remark 
are these — first, that the aqueous .portion of the blood which in health is habitually 
carried off' to a very coasiderable amount by the skin, is suddenly diverted from that 
tissue ; the perspiration, sensible and insensible, is suppressed : and secondly, that 
the areolar tissue, or the large serous bags, or both, become filled with serosity. 

It is not by any necessity, however, that the vicarious excretion is turned upon these 
serous surfaces. In truth, the intercepted perspiration more often escapes, or labours 
to escape, from some free surface ; and then we have, not a dropsy, but a flux. 
Diarrhcea, for example, is more common, under the supposed circumstances, than 
anasarca or ascites : apparently because there is a closer analogy of structure, and a 
more direct consent or agreement in function, and a stronger reciprocal influence, be- 
tween the skin and the mucous membrane of the ahmentary canal, than between 
the skin and the serous tissues. 

Brief aUusion has been made to a large class of chronic dropsies, connected with 
and dependent upon a peculiar renal disease. This important species of dropsy will 
require a detailed examination hereafter. It is more complex, and of more obscure 
pathology, perhaps, than cardiac dropsy. It certainly has a more direct relation also 
to what 1 have just been describing as active dropsy ; of which it may almost be 
regarded as the chronic form. Sometimes the kidney disease, of which the dropsy 
is an incidental and not an essential symptom, springs up silently and without obvi- 
ous cause. Sometimes it may distinctly be traced back to its origin in an attack of 
acute dropsy : in which complaint the kidney always and manifestly labours, its 
functions being violently deranged, and the urine being small in quantity, and mixed 
with blood. 

In this chronic and renal dropsy, the watery accumulation is accounted for by the 
deficient excretion through the customary channels. The blood-vessels deposit that 
excretion in a wrong place. The urine, in the outset of the dropsy at least, is 
scanty. The skin is almost always dry, harsh, and unperspiring. The anasarca 
■usually increases or decreases, as the quantity of urine diminishes or augments. 
Remarkable alterations take place also in the quahties and composition of the urine 
itself : it has a very low specific gravity, contains albumen, and is deficient in urea. 
The blood degenerates too ; and other organs of the body, and especially the heart, 
are apt to fall into disease. The suppression of perspiration, and the appearance 
in the urine of blood or serum, unchanged by the secerning power of the kidney, 
form striking hnks of connection between acute and renal dropsy. 

In the sketch that I have been endeavouring to give you of the pathology of 
dropsy, I have taken extreme cases to elucidate the two varieties of that disease 
which have been respectively denominated active and passive. Let me once more 
present to you, in a summary view, the points of resemblance, and the points of 
distinction between them. 

They resemble each other in the result ; namely, in the collection of serous liquid 
in the circumscribed cavities and vacuities of the body. They differ in the rate at 
which the collection augments. 

In the weU-marked acute dropsies the liquid is rapidly effused, in quantity much 
beyond the natural amount of exhalation^ In the well-marked passive dropsies the 
exhalation goes on as usual, but the fluid exhaled is not taken back again into the 
circulating vessels with sufficient facility. In the one case the circulation is dis- 
turbed and tumultuous ; in the other, it remains tranquil. It is probable that in the 
more acute forms, the serum transudes through the coats of the arteries, or of the 
capillary vessels next adjacent to the arteries. In the completely chronic and car- 
diac forms, there is a defect of absorption by the veins. Active dropsies are 



DROPSY. 



177 



sometimes spoken of as belonging to the left side of the heart ; passive dropsies to 
the right. 

But there are intermediate degrees, in which the full veins are not only unable to 
admit any addition of aqueous hquid, but also to retain that which they already hold ; 
and serosity gradually exudes through their parietes. 

What connects all these forms of dropsy is a preternatural fullness in some part, 
or the whole of the hydraulic machine. And this seems to be the grand key to the 
entire pathology, as well as to the remedial management of the disease. 

I scarcely need point out to you the fact, that the water of dropsy is liable to 
change its place, in obedience to the force of gravity. In general ansarca, when 
the serous accumulation slowly augments, it first becomes visible about the feet and 
ankles. There are two causes for this : the one occasional in its operation, the other 
general. The veins of the lower extremities are apt, when the patient is erect, to 
be more turgid than other veins ; for unless the action of their valves be quite per- 
fect, those vessels sustain the weight of a large superincumbent column of blood, 
which concurs with other causes to retard the upward current, and to keep the 
depending capillaries unduly full. Under such circumstances the effusion, or the 
arrest of absorption, may take place around the insteps earlier than in any other part. 
But in general it is not so. In most cases, the truer and simpler reason of the ear- 
lier manifestation of dropsical swelling about the ankles, is merely that the serous 
liquid which fails to be removed from the areolar tissue in all parts of the body, 
gravitates towards the lowest part ; and being thus collected into a comparatively 
small space, is rendered more perceptible. During the night, when the horizontal 
posture is maintained for several hours, the oedema of the ankles disappears, but the 
neck and face, perhaps, become bloated and pufTy. And it is obvious why, in these 
cases, the feet, towards evening, swell more than the hands. The hands receive the 
serous fluid from the areolar tissue of the arms alone ; the feet, that which sinks 
down, not only from the legs and thighs, but from the head and trunk also. The 
limbs may be looked upon as bags, which fill up in proportion to the quantity of 
liquid detained. And the lungs are similarly bags : and in these cases we com- 
monly may hear the crepitation of pulmonary cedema in their lowermost portions. 

I mentioned an instance in which one-half only of the body was anasarcous, and 
that the upper half. The descent of the dropsical fluid was prevented by the dress 
of the patient ; the waistband of his trowsers having compressed the areolar tissue 
through which alone the gravitating hquid could seek a passage. So sometimes, it 
is stopped at a lower point of its descent by tight garters, and the thighs swell ear- 
lier than the insteps. It is not at all uncommon to see persons who, in the daytime 
at least, and in the erect posture, are anasarcous in the lower half only of the body. 
We do not so often meet with anasarca of one moiety of the body, the division being 
made by an imaginary plane drawn through its axis. Yet this does occasionally 
happen. This curious phenomenon is usually the result of a mere accident, the 
anasarcous patient being unable to leave his bed, or to lie at all, except on one side ; 
and then the accumulating liquid gravitates to that side. I have, however, seen one 
case to which this explanation would not apply. I believe that some local obstruc- 
tion to a large vein in the neighbourhood of the shoulder caused oedema there, and 
the fluid sank down and filled the areolar tissue of that side alone. As the man 
recovered, I had no means of verifying the truth of this conjecture. 

CfSteris paribus those parts of the body become the most loaded with serous fluid, 
and show the anasarca the plainest, of which the areolar tissue is plentiful and loose ; 
as the eyelids, and the scrotum. But in extreme cases the liquid pervades the same 
tissue, where it is much more dense and compact : as where, for example, it is sub- 
jacent to mucous membranes. In the examination of a dropsical corpse, the mucous 
coat of the intestines may sometimes be seen to be elevated by the water collected 
beneath it. It then looks like jelly, and the valvulx conniventes, which are flat and 
thin in their ordinary state, become round and convex. Dropsy of the submucous 
tissue of the air-passages is frequently a cause of death. 

Many persons seem disposed to ascribe these anasarcous swellings, especially 
13 



178 



DROPSY. 



when they make their appearance suddenly, to inflammation ; and much is said 
about the frequency of inflammatory dropsy. But the facts we have just been 
considering sufficiently refute this theory. If the serous hquid be the product of 
inflammation, what is the part inflamed ? It cannot be, as some appear to think, the 
distended areolar tissue itself; for if so, the inflammation must shift its quarters under 
the influence of gravity. The term inflammatory dropsy may not, perhaps, be inde- 
fensible when appHed to that class of dropsical affections that have been spoken of 
under the head of active dropsy. I am far from denying the frequent agency of 
inflamniation in producing changes which, in their turn, lead to dropsy, but we shall 
do well not to confound those collections of serum mixed with blood or with coagu- 
lable lymph, which are distinctly events or products of inflammation, with other 
collections of serum which resemble the former in that respect only, but differ 
entirely from them in every other particular. To the class denominated active, 
which occur suddenly, from defect of some one or more of the usual channels of 
aqueous excretion, and which are usually attended with much disturbance of the 
whole system, the epithet febrile would not be inappropriate. There may be some 
few cases in which it is impossible to determine whether the effusion be inflammatory 
in its origin or not. If the serum be turbid, if we can discover in it the smallest ad- 
mixture of pus, or of flakes of lymph, or if the disease has been marked by the ordi- 
nary signs of internal inflammation, we need not hesitate in our opinion. One of the 
latest systematic writers on dropsy in this country holds that all dropsies are more 
or less inflammatory. We can see one reason for this mistake (for a mistake it 
surely is) in the rehef and amendment which often ensue upon the employment of 
blood-letting in dropsy. 

The geuexdl prognosis in this disease may be readily gathered from what I have 
said of its causes and conditions. The anasarca which occurs in chlorotic young 
women is the least perilous, and the most curable. Of the rest, febrile dropsies are 
more obedient to treatment, and oftener admit of complete recovery, than the passive 
or chronic. Local dropsies are to be regarded with hope, in proportion as the 
obstruction on which they depend is capable of bein^ removed, or compensated by 
the development of fresh channels for the delayed blood. As far as the mere water 
is concerned in the chronic forms of the disease, cardiac dropsies are more readily 
dispersed for a time, but more hkely also to return, than dropsies which are compli- 
cated with renal disease. It is obvious also that the immediate danger of dropsical 
accumulations will depend much upon the place the liquid majr occupy. The dif- 
ference in this respect is immense between the tunica vaginalis, and the pericar- 
dium; between the areolar tissue of a limb, and that which lies beneath the mucous 
membrane of the glottis. 

It remains that I should offer a very few final remarks concerning the principles 
upon which dropsies are to be treated. 

The first object is to get rid of the preternatural accumulation of watery fluid : 
the second is to prevent its collecting again ; in other words, to remedy the diseased 
conditions which gave rise to the dropsy. Indeed, if we can accomphsh this second 
object without delay, the dropsy will generally disappear of its own accord. Now 
venesection will often sensibly reduce the dropsical sw^elling. In what has been 
called active or febrile anasarca, general blood-letting is advantageous in several 
ways. It helps to relieve the congestion, akin to inflammation, upon which the 
effusion depends : it tends to abate the undue action of the heart : and by emptying 
the blood-vessels, it facilitates the re-absorption of the effused liquid, and its ultimate 
ejection from the system. 

But although blood-letting is the most direct and certain way of unburdening the 
loaded veins, and therefore, in many instances, the most effectual remedy for the 
dropsy, it is by no means adapted to all, nor even to many, forms of the malady. It 
will always, indeed, remove a portion of the aqueous ingredient of the blood, but it 
expends at the same time its fibrin and its red particles. It impoverishes the circu- 
lating fluid, and thus enfeebles the patient more than would the indirect measures, to 
be mentioned presently, for evacuating the collected liquid. Perhaps, by rendering 
^he bipod more watery, venesection may indirectly favour the transuding of its serum 



TREATMENT. 



179^ 



outwards whenever the venous current happens to be retarded. It certainly weakens 
the central organ of the circulation : and to muscular debility of the heart we have 
already seen that certain forms of general dropsy may owe their origin : and thus it 
is that ill-timed or excessive bleeding may be the cause of dropsy. In these forms 
of anasarca, instead of robbing the veins of their blood, we seek to repair the quality 
and richness of that fluid, and so to restore the deficient tone and vigour of all the 
muscles, and of the heart among the rest. 

In many cases, then, it is inexpedient to let blood ; and we endeavour to empty 
the vessels indirectly, and in such a manner as to withdraw from them the more 
watery parts only of their contents. In other words, it becomes our object to aug- 
ment the discharge of watery fluid from one or more of the secreting surfaces of the 
body : but it must not be the inner surface of a shut sac. 

I noticed before the close analogy that obtains between dropsies and fluxes. Dropsy 
is a flux into a closed cavity. Fluxes would be dropsies if the fluid poured forth did 
not escape. And you are to observe that we frequently try to cure a dropsy by pro- 
ducing a flux. 

By what surface or channel this artificial drain shall be attempted, is often a 
matter of great nicety and importance. In some cases we strive to promote the 
discharge of the superabundant water by the way of the kidneys ; in others, by the 
mucous hning of the ahmentary canal : in others, by the external skin. The cir- 
cumstances by which our choice must be determined will come under review here- 
after. 

Passive dropsies are much more difficult of cure than active, and will often baffle 
our best directed efforts. You are not, however, to regard those passive dropsies 
which depend upon the obliteration of a large vein as necessarily incurable ; for if a 
collateral venous circulation be accomplished, the dropsy w^ill permanently disap- 
pear. But we must give nature the credit of the cure in such cases. Time is the 
best remedy ; and all that we can sometimes do is to alleviate in the meanwhile the 
most distressing or threatening of the symptoms. 

I mentioned, in the outset of the lecture, that the presence of the dropsical fluid 
may constitute nearly all the suffering of the patient, as well as much of his danger. 
Now, when we cannot get rid of the water by bleeding, or by internal remedies 
which excite serous discharges, we may often afford great present comfort to our 
patient, and prolong his days, by letting the water out by a slight mechanical opera- 
tion. Paracentesis is the scientific, and tapping the vulgar name, for this proceed- 
ing. It has been performed successfully, by means of a small trocar, to evacuate 
the water from the brain in chronic hydrocephalus ; it is often resorted to for the 
purpose of emptying the peritoneal cavity, and the tunica vaginalis testis ; and it is 
not seldom practised to let out the fluid of anasarca ; for acupuncture of the legs and 
thighs and scrotum, is only another form of tapping. 

In the local variety of dropsy that is called hydrocele^ the re-accumulation of the 
liquid is sometimes prevented by exciting just so much inflammation of the mem- 
brane as may cause its opposite surfaces to cohere ; whereby the cavity itself being 
abolished, any return of the disease is rendered impossible. 

This is an expedient which we do not dare to employ in other species of dropsy ; 
in ascites, for example : first, because the inflammation itself would place the 
patient's existence in imminent peril ; and secondly, because if it could be safely 
conducted, the adhesion and obhteration would seriously embarrass and impede the 
functions of important organs. 

The circumstances which require and justify this mechanical remedy; the rules 
and precautions to be observed in its performance ; and the measures to be adopted 
for preventing the recurrence of the accumulation, by the removal of its efficient 
cause, wiU all be considered in detail when we come to treat of the special forms of 
dropsy. 



180 DISEASES OF THE EYE. 

LECTUEE XVII. 

Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults. 

Having brought my observations^ on general pathology to a close, I next proceed 
to the consideration of individual diseases ; and I shall take them up, one by one, in. 
that anatomical order to which I adverted in the introductory lecture of this course. 
That is to say, I shall go a capite ad calcem : interpolating those disorders which, 
although they have a name, have as yet no ascertained local habitation, wherever it 
may seem most convenient to introduce them. I mentioned before one advantage, as 
it seems to me, of bringing together, in juxtaposition, all the diseased conditions to 
which the same part, or the same neighbourhood, of the body is liable — namely, the 
facility thus afforded of comparing the phenomena by which they are characterized, 
and of discriminating one disorder from another. In taking the parts in succession 
from the head downwards, we adopt a sort of order, definite enough for the purpose 
of aiding the memory, and yet free from the trammels which belong to all attempts 
at arranging diseases according to their essential nature and affinities. 

I propose then to speak, in the first place, of certain diseases of the organ of 
vision. Diseases of the eye occupy a sort of neutral ground, upon which the sur- 
geon and the physician may both lawfully enter. For some of them there are no 
means of relief but in manual operations of the most delicate kind. On the other 
hand, many of the internal parts of the eye require, when diseased, exactly the same 
species of general treatment which the physician adopts in diseases of other internal 
parts. We seek to change the condition of a small portion of the body, by remedies 
which act upon and through the system at large. My real and only motive, however, 
for beginning with a few of the numerous morbid states to which this little part is 
liable, is this : — that we find, in the eye, more satisfactory and plain illustrations of 
the general facts and doctrines of pathology, as I have been endeavouring to set 
them before you, than in any other single organ of the body. "Here" (to use the 
v/ords of Dr. Latham, in his httle volume on Clinical Medicine — a book which I 
strongly recommend you to study) " here you see almost all diseases in miniature : 
and from the peculiar structure of the eye, you see them as through a glass ; and 
you learn many of the Httle wonderful details in the nature of morbid processes, 
which but for the observation of them in the eye would not have been known 
at all." 

"Within the small compass of the visual apparatus," says Mr. Lawrence, "we 
meet with a greater variety of structures than in any other part of the body. Indeed 
the eye, with its appendages, exhibits specimens of every one of the animal tissues. 
We find in it bone, cellular and adipose substance, and blood-vessels ; mucous, 
fibrous, and serous membranes ; the conjunctiva exemplifying the first ; the sclero- 
tica, the sheath of the optic nerve, and the lining of the orbit, the second ; the sur- 
faces containing the aqueous humour, the third: muscular, nervous and glandular 
parts ; common integument and hairs. Besides these, it contains several tissues of 
peculiar nature, to which there is nothing strictly analogous in other parts." 

The eye itself, taking it apart from its appendages, the spheroidal eyeball itself, is 
scarcely an inch in its longest diameter. Yet it seldom happens that disease, of any 
kind, occupies the whole, even of this small space, at once. Inflammation, for exam- 
ple, is often confined to one of the tunics of the eye, external or internal ; and when 
it affects more, it is usually in consequence of the extension of the inflammatory pro- 
cess, from some one texture in which it took its rise. You will not expect me to 
treat of the vast number of disorders to which the several parts of the eye are hable. 
I shall bring, I repeat, a few of them only under your notice ; and I shall select 
those concerning which the physician is most frequently consulted ; which every 
one, whatever branch of the profession he may follow, ought to be competent to 
treat ; and, more particularly, which are calculated to elucidate other diseases, and, 
above all, other internal diseases, that are usually assigned to the care of the phy- 



CATARRHAL OPHTHALMIA. 



181 



sician. With the anatomy and physiology of the organ, I may take for granted that 
you are already acquainted. 

I will first briefly inquire into the inflammatory affections of what may be consi- 
dered the mucous membrane of the eye. Like other mucous membranes, it forms 
a surface communicating with the external air. Some of these affections are very 
trifling : some are very severe. 

There is a mild form of inflammation of the conjunctiva, which constitutes the 
most common disease of the eye to which adults are subject. It results, in most 
cases, from vicissitudes of temperature ; or from certain conditions, or sudden varia- 
tions, of the atmosphere. It is very apt to be excited by exposure to a stream or 
draft of air, especially in the night, and during sleep. It has a strong analogy — 
indeed it is the same disease, except in situation — with that moderate degree of 
inflammation, produced by the action of the same causes, in the mucous membrane 
of the nasal cavities, the throat, and the bronchi, which in common parlance we 
style a cold in the head, or in the chest, as the case may be : and accordingly that 
inflammation of the conjunctiva of which I speak is often called by the unlearned, a 
cold in the eye: and the same analogy is expressed in its technical appellation : the 
cold in the head or chest is termed by nosologists a catarrh; and the cold in the eye 
of the vulgar, is, with them, catarrhal ophthalmia. The suddenness (sometimes) of 
its accession has procured for it also the denomination of a blight in the eye. 

The term ophthalmia is at present used to denote inflammation of the eye gene- 
rally; it conveniently expresses in one word what would otherwise require more. 
Formerly, when the diseases of the eye were not so well understood in this country 
as they are at present, almost all the inflammatory conditions to which that organ is 
subject, were lumped together under the common appellation of ophthalmia, or the 
ophthalmia. That word now requires some epithet to distinguish the seat or the 
kind of inflammation that is meant. 

It can scarcely be otherwise than interesting to mark the phenomena which occur 
in catarrhal ophthalmia, when we know that in its cause and nature, it is the same 
with inflammation of a similar surface, in parts which we cannot so well inspect as 
we can the conjunctiva. This membrane, as you know, hnes the eyehds, and covers ' 
about a third part of the globe of the eye anteriorly. The inflammation, in catarrhal 
ophthalmia, is confined to the conjunctiva and the meibomian folhcles. Its leading 
symptoms are redness of the surface of the eye ; some pain and uneasiness there ; 
an increased discharge from the affected membrane and the follicles : and a stick- 
ing together of the eyelashes and lids. 

The redness is worth notice, both in respect to its tint, and to the arrangement of 
the vessels in which it appears. It is superficial, and of a bright scarlet colour; 
and usually irregular, or diffused in patches, some fascicuU of vessels being more 
distended than others. When, however, the inflammation is more intense, the 
whole surface, except that of the cornea, becomes of a scarlet red. The vessels of 
the conjunctiva, thus rendered visible by inflammation, anastomose continually with 
each other, and form a network, which can be slipped and dragged about over the 
subjacent surface by moving the eyelids with the finger. Frequently some of the 
meshes of this network are filled up with little patches of extravasated blood ; the 
eye is what is called blood-shot, or, to speak learnedly, there is ecchymosis ; and 
sometimes all distinction of separate vessels is nearly lost. In the com.mencement 
of the complaint the redness is confined to that part of the conjunctiva which lines 
the lids ; and it afterwards advances gradually, from the angle where it is reflected 
over the eyeball, towards the cornea. 

Now all these particulars are of consequence, since they are diagnostic of the seat 
of the disease; and to show this I must mention, by anticipation, the appearance 
and the arrangement of vessels that are observed when inflammation affects some of 
the textures which lie deeper than the conjunctiva, and especially the sclerotica. 
The sclerotic redness is seen through the conjunctiva. It is of quite a different tint 
from that of the conjunctiva. Instead of showing a bright scarlet colour, it is pink, 
or sometimes of a slight violet hue. The vessels are much smaller and finer than / 
those belonging to the conjunctiva, hke hairs. They are straight also, and arranged 



182 DISEASES OF THE EYE. 

regularly, after the manner of radii in a circle. They lie in the sclerotic, round the 
cornea, Uke what is called by painters a glory, or Hke a halo, or zone surrounding 
the central cornea ; and they cannot be made to shift their place by any dragging 
of the lids. These are very important distinctions. They are such as are easily 
recognized when two eyes are examined in which the two membranes in question 
are separately inflamed and vascular ; and they are still more palpable, perhaps, 
when both membranes are simultaneously inflamed, as they often are, in the same 
eye. Then, unless the conjunctiva is so universally red as to prevent our seeing the 
sclerotica through it, the contrast between the larger, more tortuous, scarlet, and 
reticular vessels of the conjunctiva, and the fine, straight, rose-coloured, radiating 
vessels of the sclerotic, is exceedingly striking ; and those of the conjunctiva, which 
lie naked on the loose mucous membrane, admit of being shpped about over the 
fixed zone of vascularity which is presented by those of the fibrous tunic. 

The pain which attends catarrhal ophthalmia is sHght and trifling. At the outset 
there is generally some uneasiness when the eye is exposed to the light ; but there 
is no intolerance of light when the disease is fairly developed. The patient com- 
plains rather of a sensation of stiflhess and dryness, and feels as though there were 
some foreign substance in the eye, between the globe and the lids, especially when 
the eye is moved ; a grain of sand, or gravel, or a little fly. So exact is the resem- 
blance of this feehng, that you can with difficulty persuade the patient that there is 
nothing of that sort in his eye. No doubt this sensation is produced by the ine- 
quality and roughness of the surface, consequent upon the irregular distension of the 
vessels of the inflamed membrane ; irritating the organ mechanically, just as a piece 
of dust would irritate it. 

Now in this respect, again, there is a marked difTerence bet^veen conjunctivitis 
and sclerotitis. In the latter disease, the pain is much more severe, of a dull aching 
character, with a sense of tightness : the part inflamed is denser, and less yielding 
than the conjunctiva. The pain is attended also, frequently, by throbbing, and is 
felt in the surrounding parts more severely perhaps than in the eye itself ; in the 
brow, temples, and head. It is a very remarkable circumstance, too, that the pain 
is distinctl}^ aggravated towards night ; increasing in violence from the evening till 
after midnight, abating towards morning, and ceasing in a great measure daring the 
day, to be again renewed in the evening. I am speaking now particularly of inflam- 
mation of the sclerotica produced by the same causes as give rise to catarrhal oph- 
thalmia ; of w^hat is generally called rheumatic ophthalmia. 

The increased discharge that takes place from the eye in catarrhal ophthalmia is 
not a discharge of tears. In the beginning of the complaint there is sometimes a 
slight degree of lachrymation. But this soon ceases, and the mucous secretion from 
the surface of the membrane is augmented in quantity, and changed in quality. At 
first it is somewhat thin, but it soon becomes thicker, and it is often puriform ; i. e., 
opaque and yellow : sometimes it retains more exactly the characters of mucus, is 
transparent and viscid ; so that the eye looks moist to a bystander, while to the 
patient it feels gummy. The puriform secretion is not, in general, in any great 
abundance. You may see it lying in the angle betwean the eye and the lower lid, 
by pulling them apart ; or it makes itself visible at the corner of the e3^e, or between 
the eye-lashes along the edges of the lids, which it glues together at night. Some- 
times, how^ever, the discharge is more copious, so as to approximate to what is 
observed in the less severe forms of another disease I shall presently mention ; viz., 
purulent ophthalmia. 

There is seldom much swelling of the conjunctiva. If there be an}^ it results 
from an effiision of serous fluid into the meshes of the areolar tissue that connects 
the membrane with the subjacent sclerotica : by which effusion the conjunctiva is 
partially raised and separated. This kind of effusion often goes to a very great 
extent in purulent ophthalmia, or in violent inflammation of the external membranes, 
as I shall show you by and by. 

So much, then, for the symptoms and causes of catarrhal ophthalmia. It is neces- 
sary that you should be familiarly acquainted with them ; not so much because the 
complaint is very serious in its nature, but because it is common ; because you are 



CATARRHAL OPHTHALMIA. 



183 



sure to be again and again consulted about it, and because it is of great importance 
to distinguish it from other forms of ophthalmia, in order to adopt the proper treat- 
ment. A mistake of diagnosis might lead to mischievous activity on the one hand ; 
or to still more pernicious inertness on the other. 

When the inflammation does not extend beyond the mucous membrane, it will run 
a certain course, and then, under favourable circumstances, subside. But if it be 
improperly treated, or if the patient cannot guard himself against a repetition of its 
exciting causes, it may continue for weeks, and harass him a good deal, and even 
produce such a change in the inflamed lids as may prove a source of permanent 
irritation, and of chronic disease, of the cornea over which they sweep. 

Remedies of an active kind, such as influence the whole economy, are scarcely 
ever necessary. The patient should observe the main particulars of the antiphlo- 
gistic regimen, and avoid exposure to drafts or currents of air, and to cold and mois- 
ture generally. When the external weather is inclement, he should remain in rooms 
of a uniform temperature. It will be right to purge him in the outset with calomel 
and jalap, or with calomel followed by a black dose ["infusion of sennas]. 

If the system at large sympathize with the local disease, it may become necessary 
to take blood from the arm, or to apply leeches ; but neither of these measures is 
requisite, except the inflammation is unusually severe, or the disease has been ne- 
glected or mismanaged. 

After the bowels have been thoroughly cleared by an active purgative or two, 
remedies which encourage moderate perspiration will be hkely to forward the cure ; 
such as warm diluent drinks ; fi.ve grains of Dover's powder, and immersion of the 
feet in warm water, at bed-time ; and saline draughts containing two or three drachms 
of the liquor ammonise acetatis, taken at intervals during the day. 

But in this complaint local measures are of greater importance than those which 
are addressed to the general system : stimulating or astringent applications to the 
affected membrane itself. Almost all modern writers on diseases of the eye agree 
in this. Dr. Mackenzie, of Glasgow, states it as the result of his observations on 
Beer's practice in Vienna, and of his own subsequent experience, upon an extensive 
scale, at the Glasgow Eye Infirmary, that " general remedies in this disease are in- 
ferior to local ones ; that violent general remedies are worse than useless ; and that 
a local stimulant treatment may almost entirely be relied on." Mr. Mehn, in a 
report of ocular diseases at the General Hospital, Fort Pitt, states that he had treated 
nearly 300 cases, some of them severe, upon the same principle, without either local 
or general bleeding : and that he had satisfied himself of the efficacy of this plan 
of management. And Mr. Lawrence, who for ten years was one of the surgeons 
to the Ophthalmic Infirmary, in Moorfields, and who during that period had ample 
opportunities of studying this disease of the eye as well as others, says that it is one 
to which the use of powerful astringents is more particularly applicable. In dis- 
orders which manifest a strong natural tendency to terminate in recovery, it is only 
by taking advantage of the conclusions derived from extensive observation that we 
can be quite sure of our ground ; and when the same result is reached by different 
and independent observers, we may safely place confidence in their concurrent 
testimony. 

Dr. Mackenzie and Mr. Melin both employ and recommend the same application, 
viz., a solution of the nitrate of silver in distilled water, in the proportion of four 
grains to the ounce. A large drop of this solution is to be applied to the membrane 
once or twice, or three times, in the course of the day. If the patient recline his 
head backwards, and the drop be placed in the hollow formed at the internal angle 
of the eye, it will be diffused over the globe upon the separation and subsequent 
winking of the lids. After a minute or two this causes a pricking or smarting sen- 
sation, which subsides in from ten to twenty minutes, and the eye then feels much 
easier than it did before the drop was apphed. Dr. Mackenzie says that the feeling 
as if of sand in the eye, is uniformly relieved, and the inflammation abated, by the 
use of this solution, which he speaks of as a remedy of sovereign utility in the puro- 
mucous inflammations of the conjunctiva. The eye continues easy, after its appli- 
cation, for five or six hours perhaps ; and when the symptoms return, they are again 



184 



DISEASES OF THE EYE. 



to be met by the introduction of another drop. As the disease subsides the remedy 
gives less and Jess pain, till at last it is scarcely felt. He tells us that " he has some- 
times alarmed other practitioners by proposing to drop upon the surface of an eye 
highly vascular, affected with a feehng as if broken pieces of glass were rolling under 
the eyelids, and evidently secreting puriform matter, a solution of lunar caustic ; and 
that he has been not a little pleased and amused at their surprise when, next day, 
they have found all the symptoms much abated by the use of this application." He 
declares, also, that the acetate of lead, and the sulphate of zinc, siibstances which 
are much used in what are called collyria or eye-washes, are greatly inferior, as local 
applications, to the nitrate of silver, in this disease. 

There is another expedient that requires to be attended to in these cases. When 
the eyelids are gummed together by the viscid discharge, much hurtful irritation is 
often produced by the hasty attempts which the patient makes to separate them. 
Now all this may be obviated by smearing their tarsal edges at bed-time with any 
mild ointment ; the spermaceti ointment, or a bit of lard. There is no necessity, 
as I believe, in this form of disease, to use medicated or stimulating salves : the 
object is to prevent the mutual adhesion of the hds ; and this is accompanied by 
simple grease. 

Purulent ophthalmia is another disease of the conjunctiva ; differing from catarrhal 
ophthalmia in degree, in the severity of its symptoms, in the danger which it imphes 
to the sense of vision, and in its exciting causes. It takes its name from the profuse 
discharge of pus, or of altered mucus which cannot be distinguished from pus, that 
pours from the inflamed surface. There are three remarkable varieties of purulent 
ophthalmia, called respectively — 1, purulent ophthalmia of adults, or Egyptian 
ophthalmia, or contagious ophthalmia; 2, gonorrhceal ophthalmia; and 3, purulent 
ophthalmia of newly-born children. 

The symptoms of the two first-mentioned varieties, especially in their severer 
forms, are so much the same that it would involve us in mere repetition if I did not 
take them together. In truth it appears to me much the simpler and better mode to 
look upon purulent ophthalmia as one disease ; and then to specify, as we go on, the 
differences by which its several forms are characterized : and not to split it into three 
different diseases, and to give a separate description of each. 

Although purulent ophthalmia is inflammation of the very same part that is in- 
flamed in catarrhal ophthalmia, from which it differs chiefly in degree, it is a hideous 
complaint, either to suffer or to treat : on account of the rapid progress it frequently 
makes, and its destructive tendency. The inflammation is greatly more intense ; 
the surface becomes, in the worst cases, highly vascular throughout. A copious 
discharge of thick, yellow, puriform matter is speedily estabhshed ; this flows out 
from between the swollen lids, and runs over the cheek which it often excoriates. 
At the same time considerable effusion takes place into the areolar tissue that connects 
the sclerotica and the conjunctiva. You are aware that the conjunctiva extends 
over the whole anterior face of the globe ; adhering, however, so much more closely 
to the cornea than to the sclerotica, that we might doubt at first whether it did not 
stop at its margin. This close and firm adhesion over the cornea, and the looser 
attachment to the sclerotica, give rise to a very singular phenomenon. The conjunc- 
tiva is raised to some distance from the subjacent sclerotica by the effusion that takes 
place between them ; and it projects around the cornea in the shape of a large thick 
ring, leaving the cornea buried, as it were, in a pit ; nay, sometimes, the swollen and 
prominent membrane will lap over, so as nearly to exclude the cornea from our 
sight. The same kind of effusion takes place, also, sometimes very rapidly, into 
the areolar tissue connecting the conjunctiva with the palpebrte, producing great ex- 
ternal tumefaction, and a livid red appearance of the eyehds, which project forwards 
in large convex masses, and often prevent our seeing the globe of the eye at all ; 
the upper hd especially becoming hard and stiff, and complete^ overhanging the 
lower. This sweUing from effusion, into the subconjunctival tissue is of a pale red, 
fleshy colour, sometimes marked here and there with patches of extravasated blood. 
The appearance is called chemosis : not ecchymosis, as the similarity of the sound 



PURULENT OPHTHALMIA. 



185 



has led some erroneously to suppose, but chemosis. Exxvfuogt^, from £x%sco, signifies 
an effusion, and by common consent among medical writers, an effusion of blood. 
X-z^.tits^t-s, the root of which is zvf^"^^ hiatus, means a gap or hollow. 

Now this puriform or puruletit inflammation, so long as it is confined to that part 
of the membrane which lines the eyelid, is not of any serious importance ; but it is 
prone to extend itself to the cornea, and the whole anterior surface of the eye, and 
to produce ulceration or sloughing of the cornea, either in consequence of the actual 
inflammation of that part, or in consequence of the pressure made upon and around 
it by the swelling of chemosis. Frequently, when the cornea remains visible, a 
furrow or trench of ulceration may be seen at its margin ; sometimes forming a 
complete circle, sometimes portions of a circle, sometimes going quite through ; and 
when this happens, or when the cornea bursts, from the effects of deeper-seated 
inflammation, the aqueous humour is evacuated, and the iris protrudes through the 
aperture. Even when these horrible consequences do not take place, the eye is often 
as effectually spoiled for the purposes of vision by an interstitial deposit between the 
laminas of the cornea, rendering it opaque, and permanently precluding the passage 
of light towards the retina. 

And when neither of these lamentable effects of the inflammation is produced, it 
is apt to leave behind it a chronic and very troublesome condition of the membrane. 
The conjunctiva that lines the lids remains thickened, granular, hard, and rough, 
instead of regaining its natural smoothness, softness, and poHsh. One consequence 
of this is a perpetual irritation of the surface of the cornea, by the mechanical fric- 
tion of tlTe rough and hard lid in opening and closing the eye, and in the various 
motions of the eyeball. The continuance of this irritation leads at length to hazi- 
ness or opacity of the cornea, which becomes traversed also by visible red vessels. 
Chronic inflammation of its investing membrane is produced, and kept up. 

The most severe forms of this disease are attended, at length, with a good deal of 
pain ; doubtless because the inflammation penetrates to the deeper-seated textures of 
the organ. The pain then presents those characters which I mentioned before as 
belonging to certain inflammations of the sclerotica : i. e., it is pulsative ; and some- 
times sharp and lancinating, sometimes dull and aching ; and it is intermittent ; or 
if constant, it is aggravated by paroxysms : the paroxysms coming on at night, and 
abating towards morning: and it is not confined to the eye itself, but extends to the 
parts around it. This circumorbital pain is characteristic of inflammation of the 
sclerotica and cornea, and of the internal tunics, the choroid and iris. When the 
eye is not visible, from the swelKng, we may conclude that the inflammation is as 
yet confined to the conjunctiva, if the pain be only scalding or "sandy ;" and that 
it has extended to the sclerotica and cornea if the pain.be severe, throbbing, and 
paroxysmal. In the cases in which the latter kind of pain is felt, the cornea gene- 
rally gives way. Sometimes this event brings rehef to the pain, and sometimes the 
pain continues to return after the bursting of the cornea. It is curious that with all 
this, there is seldom much intolerance of hght. 

In the earlier stages of this malady, it is entirely local : the system at large is 
scarcely disturbed at all. But the constitution begins to sympathize and suffer when 
the local symptoms increase in severity : the pulse becomes frequent, and the tongue 
white, but there is seldom much thirst or fever; and when blood is drawn from a 
vein, it does not, in general, exhibit the buffy coat. A good deal of variety in these 
respects has been noticed, however, in different cases. Children manifest more 
constitutional disturbance when labouring under purulent ophthalmia than adults. If 
there be not much fever, there is always much uneasiness and irritation, and the 
sleep is broken by the nocturnal accessions of pain. 

Such being the general features and course of the disease, at least as it occurs in 
adults, or in patients beyond the period of infancy, we may next inquire into the 
circumstances under which it has been observed to arise. 

Purulent ophthalmia has been ascertained to be a common disease in hot chmates : 
in India, Persia, and Egypt. It was brought into England, from the latter country, 
by our troops in the beginning of the present century, after the well-known contest 
which there took place between the French army and our own under Sir Ralph 

q2 



186 



DISEASES OF THE EYE. 



Abercromby. In tbis way it got tbe name of the Egyptian ophthalmia. It naturally 
excited very great attention at that time, and it does not appear to have been accu- 
rately described before. 

To give you some notion of its prevalence in certain places and at certain periods, 
and of its serious nature, I may state that, according to returns made from the military 
hospitals at Chelsea and Kilmainham, there were, on the 1st of December, 1810, no 
fewer than 2317 soldiers a burden upon the public from blindness in consequence of 
ophthalmia ; and in this number those soldiers who had lost the sight of one eye 
only were not included. 

Again, in the year 1804, within nine months, i. e., from April to December, 
nearly 400 cases of purulent ophthalmia occurred at the Royal Military Asylum ; 
and within six years from that time, without including relapses, upwards of 900 
cases had taken place in the same estabhshment. 

You will find these statements in a paper in the third volume of the Transactions 
of a Society for the improvement of Medical and Chirurgical Knowledge, by the 
late Sir Patrick Macgregor. Many of our best regiments were for a time crippled 
and rendered unfit for service by this disease ; which they carried from Egypt to 
other foreign stations as well as to this country, especially to Sicily, Malta, and 
Gibraltar. Nor were the French troops less extensively affected by it. Assahni, 
who wrote an account of the ophthalmia of Egypt, states that two-thirds of the 
French army were labouring under it at one time. It occurs also, but fortunately 
not to such an extent, in civil life. It broke out, some years ago, in a large boys' 
school in Yorkshire ; and blindness of one or both eyes, or serious injury, to sight, 
from opacity of the cornea, and other consequences, took place in nearly twenty 
cases. 

You perceive, therefore, that this formidable complaint has been ascertained, within 
the last forty years, to have prevailed as an epidemic ;. attacking great numbers of 
persons living under the same circumstances, and having constant communication 
with each other. And one of the first questions that naturally arises in one's mind 
is, whether it is capable of being propagated from one person to another by conta- 
gion. Much difference of opinion has existed on this subject. .<F or my own part I 
cannot imagine how any one can doubt its contagious properties. 

I will give you a case or two, as related by Sir Patrick Macgregor, proving two 
very impjilant facts : first, that the disease is capable of being excited in the eye of 
a person, previously healthy, by the direct application of the puriform discharge 
from an eye affected with this ophthalmia ; and secondly, the very rapid operation 
of the poison so apphed. 

One of the nurses employed at the Military Asylum, while syringing the eye of 
a boy who had much purulent discharge, found that a considerable quantity of the 
matter had spurted into her own right eye. This was at four o'clock in the after- 
noon. She felt little or no smarting at the time ; but towards nine o'clock the same 
evening her right eye became red and somewhat painful, and when she awoke the 
next morning, the eyelids were swelled, there was purulent discharge, and she com- 
plained of pain in the eyeball. The usual remedies were begun in the morning, 
and she recovered in the space of three weeks or a month. The left eye, into which 
none of the matter had gone, remained free from disease. 

On another occasion a precisely similar mischance befell another of the nurses, 
* xcept that the matter spurted into her left eye, about nine in the morning. Sir. P. 
Macgregor happened to be in the hospital at the time when the accident occurred. 
He desired the nurse to bathe her eye immediately with lukewarm water, and she 
did so for several minutes ; but notwithstanding this early precaution, about seven 
o'clock in the evening the left eye began to itch to such a degree that she could not 
refrain from rubbing it. When she awoke next morning the eye was considerably 
inflamed, the lids were swelled, and upon moving the eyeball she had a sensation as 
if some sand were lodged beneath it. In the course of the same day, purulent 
fluid issued from the eye, and other symptoms followed, which were similar to those 
of the children under her care. The disease subsided under the usual treatment, in 
fourteen days. In this case also the other eye remained sound. 



PURULENT OPHTHALMIA. 18t 

A third nurse in the same institution did not come ofT so well. She was spong- 
ing, with warm water, the eyes of a boy suffering severely from purulent ophthal- 
mia: and she inadvertently applied the sponge she was using to her right eye. 
This happened at eight o'clock in the morning. She mentioned the circumstance to 
the other nurses, but she took no means to prevent infection. Between three and 
four o'clock of the afternoon of the same day, itching of the right eye came on ; and 
before she went to bed it was considerably inflamed. Next morning her eyelids 
were swollen, she complained of pain in moving them, the whole anterior surface of 
the eyeball was in a state of high inflammation, and a purulent discharge began to 
trickle down the cheek from the inner canthus. The symptoms increased in severity 
in spite of all the means employed to check them, and on the fourth day the eyeball 
burst. The sight of the eye was irrecoverably lost, and the inflammation continued 
for upwards of three months. The left eye did not suffer. 

These were cases in which the poisonous matter was accidentally applied. But 
' a similar apphcation has been made intentionally and by the way of experiment, and 
with the same results. Dr. Guilhe, of Paris, introduced the puriform secretion fur- 
nished by some children affected with purulent ophthalmia, under the eyehds of' 
four other children belonging to a separate institution for the bhnd. These four 
children were amaurotic, but the external surface of their eyes was healthy and 
entire. In each instance a regular attack of purulent ophthalmia followed the intro- 
duction of the matter. 

Facts of this kind prove, I say, beyond the possibihty of question, that the disease 
may be propagated from a diseased to a healthy eye by actual contact of the puri- 
form matter. Here we have not one case (which might be considered as an acci- 
dental coincidence), but several: the morbid secretion is apphed to one eye only; 
the symptoms of inflammation commence, and the regular form of the disease is 
fully developed within a few hours after the first application of the pus; and that 
eye only is affected. It is impossible to get over evidence of this kind. 

The only questions, therefore, that can be raised respecting the sources of the 
disease are these : — whether the malady can be communicated through the medium 
of an atmosphere impregnated with the effluvia that proceed from the diseased 
part, without any actual contact of the pus in substance ? — whether the disorder 
is ever produced in any other way than by contagion ? — and if so, how it is then 
excited ? 

I ought to observe, that independently of such isolated examples of the direct 
communication of the complaint, by contact with the diseased matter, as I have just 
laid before you, the history and progress of ophthalmia, since it has been noticed ia 
Europe, are very strongly indicative of its contagious nature. I have already stated 
that it was not known in Europe till the commencement of the present century — till 
after the Egyptian campaign in fact. It is not alluded to by any of the authors on 
disorders of the eye who wrote previously to that period ; although some of the 
Itahan physicians and surgeons, and many of the Germans, had paid great attention 
to ophthalmic diseases. It spread from Egypt both to France and to this country, 
and to other places in which detachments of the Egyptian force were subsequently 
stationed : in Sicily to wit, and in Gibraltar and Malta. Whenever it has prevailed 
among our troops at home, this circumstance has been uniformly observed : that it 
first broke out in soldiers who had come from Egypt, or had communicated with regi- 
ments which had been in Egypt. In all cases its origin could be traced to the intro- 
duction of fresh troops into the regiment or the barracks. 

Again, the manner in which it spreads is exceedingly instructive on this point. It 
diff'uses itself rapidly, when once introduced, in places where a considerable number 
of persons are collected together; especially under circumstances favourable to the 
propagation of contagious maladies ; as among soldiers assembled in barracks, where 
many of the men live in the same apartments, and use the same towels: while the 
officers, who live in larger and better ventilated rooms, and apart from each other, 
generally escape. And the good effect, in checking the further extension of the 
disease, of separating the healthy from the sick, and of restricting every one to his 
own washing utensils, and clothes, and towels and sponges, leads to the same con- 



188 



DISEASES OF THE EYE. 



elusion. Rust, a German author, mentions this striking fact in corroboration of what 
I have just been saying. The disease broke out in the town of JMayence. This 
place was garrisoned by Prussian and Austrian troops. The ophthalmia began and 
spread extensively among the Prussian soldiery ; while the Austrians, who were 
stationed in separate barracks from the Prussians, in another quarter of the town, 
remained quite free from it. 

Those persons who deny, or who doubt, the contagious nature of purulent oph- 
thalmia, rest their opinions upon some such considerations as these. They hold, in 
the first place, that the pecuharities of the atmosphere, in Egypt, where the disease 
has been found so common, are sufficient in themselves to account for it. That the 
inhabitants of that countr}^ never dream of its being caused by contagion. AssaUni, 
who saw the complaint raging in the Frenciii army, professes his belief that it did 
not arise or spread by contagion. He remarks that the atmospheric conditions which 
are known to occasion catarrhal affections, are very frequent and powerful in Egypt: 
the days are very hot, the nights chilly, and attended with heavy dews ; and men's 
eyes are perpetually exposed in the day time, to a dazzlmg glare of light from the 
white and arid surface, while the air is fuU of floating particles of hot sand, which 
are raised from the ground by the shghtest breeze. His opinion, therefore, and the 
opinion of others who saw the disease as it prevailed in that country, was, that it 
consisted simply of acute catarrhal inflammation of the conjunctiva ; and that it 
affected those persons most who were most exposed to the exciting causes of 
such inflammation : the common soldiers, therefore, more frequently than the 
officers. 

Other circumstances adduced b}^ the disbelievers or sceptics, in respect to contagion, 
are that many who have intercourse with the sick escape the disease ; and that when 
bodies of men, among whom purulent ophthalmia has been prevailing to a great 
extent, are broken up and dispersed, the complaint is not thereby disseminated, as 
thej^ say it ought to be, supposing it to be communicable from one person to another; 
that, in fact, this dispersion, the disbanding of troops, for instance, and sending them 
to their friends and famihes all over the country, is the surest way of stopping the 
disorder. 

Again, many ineffectual attempts have been made to inoculate the eyes of ani- 
mals with the matter of purulent ophthalmia. Miiller, a German, with that pains- 
taking industry, for which the Germans are so remarkable, collected on a camel's 
hair pencil matter from the eyes of patients labouring under purulent ophthalmia, 
earlj' in the morning, before they had washed them, and inserted it under both the 
lids of each eye, in a great number of animals, leaving the pencil there for a few 
seconds, and then pressing it so as to squeeze the matter out. He also smeared 
the pus copiously and repeatedly along the edges of the lids. He served in this 
way five cats, ten dogs, two rabbits, two squirrels, two blackbirds, a starling, a 
yellow-hammer, and a cock. And in none of them did the inoculation produce the 
slightest effect. 

It is a sufficient answer to these negative experiments, however, that other persons 
were more successful in producing the disease in this manner. Yasani and Grafe 
have both excited it repeatedl}^ in dogs and cats, by the application to their eyes of 
matter taken from human patients. And I have already informed you of many in- 
stances in which the disease was generated in men by accidental, and even by- 
intentional inoculation. No amount of negative evidence can do away with positive 
testimony so often repeated. 

And \vith respect to the other objections, and especially the main objection, that 
persons may associate and hold close intercourse with individuals labouring under 
purulent ophthalmia without contracting the disease, I would have you* remark that 
this is no more than what continually happens in regard to diseases which are 
acknowledged on all hands to be contagious, and to have no other source at present, 
however they might have originated at first, but contagion ; the small-pox, for 
example. I think there is some reason for believing, from the facts which I have 
been relating, that purulent ophthalmia, like the smaFl-pox, is capable of being com- 
municated from one person to another, not only by positive contact, but by trans- 



PURULENT OPHTHALMIA. 



189 



mission of the specific poison somehow for a short distance through the air. But 
many persons exposed to the contagion of small-pox escape it altogether : and more 
persons still, perhaps, fail to be affected, though fully exposed, at one time, and yet 
readily accept the disease at another time, even when the exposure may seem much 
more slight than on previous occasions. Now what is true of the small-pox may 
be presumed to be hkely, although, perhaps, in a different degree, of purulent 
ophthalmia. 

As to the circumstance that the disbanding of a regiment infected with the disease 
prevents instead of favouring its dissemination, that circumstance is really no ar- 
gument at all against our belief in its contagious nature. We shall see hereafter, 
that when fever patients are collected in numbers in distinct wards, or in fever 
hospitals, that disease is very apt to be communicated to the nurses and medical 
attendants of the sick ; whereas, when such patients are distributed here and there 
among others, in a general hospital, the disease is scarcely ever known to spread. 
In the one case the poison is concentrated and effective, in the other it is diluted 
and harmless. 

Dr. Mackenzie, indeed, has come to the conclusion, from what he has himself 
observed, that the discharge in catarrhal ophthalmia, especially when it is distinctly 
puriform, if conveyed from the eyes of the patient to those of others by the fingers, 
or by towels, and so forth, is capable of exciting inflammation of the conjunctiva, 
still more severe, more distinctly puriform, and more dangerous, than was the original 
ophthalmia. And with respect to the disease which 1 have been speaking of as 
purulent ophthalmia, or Egyptian ophthalmia, the author calls it contagious oph- 
thalmia; he holds that the mflammation of the conjunctiva, whether in the mild or 
the more severe form, may and often does originate from common atmospheric in- 
fluences ; but that, when so caused, it may be communicated from person to person, 
especially when it is attended with a puriform discharge. 

And this is an opinion which, I think, is fully warranted by the facts which we 
are in possession of upon this subject. There is a strange reluctance, which I have 
never been able to account for, in some medical men, to admit of the operation of 
contagion, as a cause of disease. Undoubtedly there are some difficulties belonging 
to the doctrine of contagion, and I hope in the progress of the course, and especially 
when I come to speak of fever, to give that subject the careful attention which its 
great importance demands ; and to enable you to make up your minds respecting it. 
At present I will only remark, that there is nothing absurd, nor unlikely in the sup- 
position, that diseases may first arise from some other source, and then become 
capable of spreading by contagion ; and that in all cases, even when the contagious 
principle is most manifest, there seems to be something else required besides the 
presence of contagious matter ; there must be a readiness to receive it, a suscep- 
tibility of its inflxuence, on the part of the person exposed to it : a predisposition which 
is less common in regard to some diseases than to others ; but without which there 
is scarcely any complaint that can be so propagated. 

At any rate I would desire to impress upon you the expedience and propriety of 
acting whatever your doubts or your belief may be, upon the safe side. We are 
bound to proceed, in all questionable cases of this kind, upon the most unfavourable 
supposition. Very great discredit and loss of reputation have fallen upon practi- 
tioners who, having themselves no belief that a given complaint was contagious, 
have neglected those precautions which, under a contrary impression, they would 
have thought necessary. Perhaps they may have sometimes suffered unjustly ; but 
you had better not commit yourselves, especially while you are young in years and 
in experience, by strong assertions of the non-contagiousness of any disease, the 
mode of propagation of which is at all questionable. And as for the disease that we 
are now concerned with, you will do well to act as though it were certainly conta- 
gious ; whether you meet with it as a sporadic or as an epidemic complaint : whether 
it be severe in its symptoms, or mild. You should forbid the use of your patient's 
towels and washing vessels by other members of the family ; you should avoid em- 
ploying the same instruments or sponges to any sound eye, which you have beea 
using for one that is affected with this complaint ; and you should take care to wash 



190 



DISEASES OF THE EYE. 



your own hands, after touching a diseased eye, before you apply your fingers to 
another that is yet, in this respect, healthy. 



LECTURE XVIII. 

Purulent Ophthalmia, continued. Gonorrhceal Ophthalmia. Purulent Oph- 
thalmia of Infants. Strumous Ophthalmia. 

When we last met, I spoke of catarrhal ophthalmia, i. e., a mild and common 
form of inflammation of the conjunctiva, resulting from atmospheric influences. I 
described its characteristic symptoms, and explained the treatment that has been 
found most successful for its cure ; consisting chiefly in local stimulating or astrin- 
gent applications. 

I began also to speak of the severer forms of inflammation aflecting the same part, 
and included under the head of purulent ophthalmia. The symptoms and course 
and consequences of the two varieties of ■ this complaint, as it occurs in adults, are 
so essentially the same, that one description of its phenomena is enough. There are 
certain differences, however, that require to be- noticed, in respect to its exciting 
causes. I laid before you the reasons which satisfy me, that what is called the 
Egyptian ophthalmia is a contagious disease ; and which make it probable that the 
complaint is capable of being propagated from person to person, through the medium 
of the air, without the necessity for any substantial application of the morbid secre- 
tion from a diseased to a sound eye. These reasons, briefly stated, are as follows : 
that the disease was unknown in Europe till after the war in Egypt ; that, arising 
among our own and the French troops in that country, it was conveyed by them 
to various places, and extended itself to soldiers who had intercourse with those 
troops ; that when once introduced it spreads rapidly wherever men are crowded 
together within a small compass, pay insufficient attention to cleanliness, and use 
the same towels and utensils ; that it has been propagated again and again by the 
direct application of the morbid secretion ; and that its progress is checked by 
measures that provide against such accidental application, and by separating the 
diseased from the healthy. 

On the other hand, it has been contended that the disease is nothing more than 
an extreme degree of catarrhal ophthalmia; that the peculiar conditions of the 
atmosphere in Egypt and other hot countries, where it is prevalent, are enough to 
account for it; and that when troops are disbanded, they do not give the disease to 
their friends and famihes all over the country, but, on the contrary, the dispersion of 
the sick in this way is the most effectual mode of stopping the disease. 

To these arguments the proper answer is, that the. same difficulties meet us in 
respect to some other diseases which are confessed by all persons to be strictly con- 
tagious. 

My own creed upon the matter is this — that the disease may, and often does arise, 
independently of contagion, from the agency of ordinary causes of inflammation ; 
and that having so originated, it acquires contagious properties, which develop them- 
selves only under circumstances that favour the propagation of most of the contagious 
complaints. 

I shall next advert to purulent ophthalmia as it is observed to occur, in the adult, 
in connection with gonorrhoea. If we look to the mere phenomena presented by 
the inflamed eye, we find nothing to distinguish the gonorrhosal from the Egyptian 
ophthalmia. Taking the average of a large number of cases, the gonorrhoeal is the 
severer form of the two, and runs the more rapid course. It is said, also, that the 
inflammation usually commences on the lids in the Eg3"ptian variety, while it attacks 
the whole conjunctiva at once in the gonorrhceal. But comparing individual in- 
stances, these mere differences, and slight differences, too, in degree and situation, 
will not he Ip our diagnosis. 



GONORRHCEAL OPHTHALMIA. 



191 



But other circumstances may guide us. If a patient presents himself with 
severe purulent ophthalmia, who has not been exposed to any of the known atmo- 
spheric causes of that disease, and at a time when purulent ophthalmia is not pre- 
vailing^ as an epidemic, and if this patient have a clap, we may conclude that we 
have to deal with a case of gonorrhoeal ophthalmia ; and this conclusion will be fur- 
ther strengthened if the disease affects one eye only. For what, through the lack 
of any better nomenclature, I am constrained to call Egyptian ophthalmia, seldom 
restricts itself to a single eye. Dr. Vetch says, "there is but one case in a thousand 
in which one eye only becomes affected." Walther observes that contagious oph- 
thalmia almost always appears in both eyes together, but not in the same degree ; 
and Eble (another German author) states that the contagious ophthalmia has not 
confined itself to one eye in any instance. These round assertions require, how- 
ever, some qualification ; the nurses, whose cases I quoted in the last lecture from Sir 
Patrick Macgregor's paper, suffered each in one eye only. On the other hand, 
gonorrhceal ophthalmia mostly, but by no means always, is hmited to one eye. In 
Mr. Lawrence's instructive book On the Venereal Diseases of the Eye, he mentions 
fourteen cases of gonorrhoeal ophthalmia. In nine of these, one eye only was 
inflamed. 

It is always a matter of some interest to make out whether the disease has or has 
not any connection with gonorrhoBa ; even though we may gain nothing, in respect 
to the treatment, by the distinction. ' 

Purulent ophthalmia has been said to be connected with gonorrhoea in three seve- 
ral ways ; 1st, by direct contact of the gonorrhoeal discharge from the urethra with 
the conjunctiva; 2d, by metastasis of the inflammation from the urethra to the eye, 
without any such contact of matter ; and 3d, independently of either of these ways ; 
i. e., purulent ophthalmia has been supposed to occur in connection with clap, just 
as ulceration of the throat is apt to occur in venereal diseases. 

Now the last two of these three modes of origin are more or less questionable ; 
the first is certain. 

Very odd speculative opinions are apt to possess themselves of the minds of medi- 
cal as well as of other philosophers. Some who believe that the disease is commu- 
nicable by direct contact of gonorrhoeal matter to the eye, yet hold that it must come 
from the urethra of another person ; that the Hudibrastic aphorism is true, " No 
man of himself doth catch." Dr. Vetch seems to have fallen into this opinion 
through the very common mistake of drawing positive conclusions from negative 
experiments. He had known a hospital assistant who, " with more faith than pru- 
dence," conveyed the matter of gonorrhoea from his urethra to his eyes, with impu- 
nity. He states also the converse experiment : a soldier in a very advanced stage 
of Egyptian ophthalmia, attempted to divert the disease from his eyes by applying 
some of the matter they were discharging to the orifice of his urethra : no effect 
followed this trial. But in another case the matter taken from the eye of one man, 
labouring under purulent ophthalmia, was applied to the urethra of another man ; 
and inflammation commenced there in thirty-six hours, and he had a very severe 
attack of gonorrhoea. Some persons, judging from such cases as this, and from the 
similarity of the discharge in the two diseases, " have gone the length of concluding 
(according to Dr. Mackenzie) that gonorrhoea has been originally an inoculation of 
the urethra by the matter derived from the eye in the Egj^ptian ophthalmia ; whilst 
others are of opinion that this last disease is nothing else than the effect of an inocu- 
lation of the conjunctiva with matter from the urethra in gonorrhoea." 

To satisfy you that a person may " catch" the complaint from himself, or from 
others, it is right that I should bring before you one or two well-marked cases. 

It is a common persuasion, among the lower classes, that to bathe the eyes in 
human urine is good for the sight. This piece of practice has cost several persons 
their vision. A gentleman belonging to the. class mentioned to me the other day two 
cases of purulent ophthalmia so produced, which he had seen among Mr. Guthrie's 
patients at the Ophthalmic Hospital. In the one, a young woman, not so healthy as 
she ought to have been, used her own water: in the other, an older woman, For 
what reason it did not appear, preferred her husband's to her own. Mr. Lawrence 



192 



DISEASES OF THE EYE. 



alludes to several similar cases. He details an instance also, in which partial slough-' 
ing of one cornea occurred ; the disease having been caused by the patient's wiping 
his eyes with a towel soiled with the gonorrhoeal discharge from his own urethra. 
But one of the neatest and most conclusive examples of the production of the dis- 
ease in this way has been furnished by Dr. Mackenzie. A patient was brought to 
him from the country with his left eye violently inflamed and chemosed, and dis- 
charging a large quantity of purulent fluid ; the lower lid everted, and the cornea 
totally opaque. Thirteen days before, this man, who had then a profuse gonorrhoea, 
hut whose eyes were perfectly well, while stooping down and shaking away the dis- 
charge from his penis, flung a drop of it fairly into his left eye. Violent inflamma- 
mation immediately set in, was confined to the eye that was thus inoculated, and 
produced the results I have mentioned : the gonorrhoea going on just as before. 

Numerous authentic cases have been recorded of gonorrhoeal ophthalmia produced 
by the application to the eye of gonorrhoeal matter from another individual. Mr. 
Wardrop met with the following example. An old lady went into the dressing-room 
of her son, who had gonorrhoea, and washed her face with a towel which he had 
recently been making use of. Purulent ophthalmia quickly supervened, and de- 
stroyed the eye in a few days. Delpech mentions the instance of a young and 
healthy woman, who bathed her eyes with goulard water, by means of a sponge 
which had been used by a young man who had a clap : violent inflammation soon 
arose, and the sight of one eye was lost. Several cases of purulent ophthalmia 
have been observed in laundresses, who had been employed in washing linen foul 
with the discharge of gonorrhoea. 

Mr. Lawrence seems to be of opinion that purulent ophthalmia is not a very fre- 
quent consequence of the application of the urethral discharge to the eye of the 
same person. " When we consider," he says, " how this matter is diffused over 
the linen of patients, both male and female, how often the fingers must be smeared 
with it, and how inattentive to cleanliness the lower classes are, we cannot help 
concluding that the gonorrhoeal discharge must be often apphed to the eyes of the 
same individual ; yet gonorrhoeal ophthalmia is comparatively rare." Dr. Macken- 
zie, on the other hand, thinks that the application of the matter to the eye is seldom 
made. " The instinctive closure of the eyehds," he observes, " when the finger 
approaches the eye, making it actually diflScuk for a person to touch his own con- 
junctiva, unless with one finger he draws down the lower Hd, and intentionally 
applies another finger to the eye, will serve in some measure to explain the rarity of 
this kind of inoculation." 

It has been noticed that women are much less frequently the subjects of gonor- 
rhoeal ophthalmia than men. 

Does gonorrhoeal ophthalmia ever occur by metastasis ? This question does not 
admit of a positive answer. Practical men are divided in opinion on the subject. 
In the majority of cases of gonorrhoeal ophthalmia, we are unable to trace any appli- 
cation of the urethral discharge to the eye, either from the same or from another 
individual. Yet it does not follow that no such application took place. The Ger- 
man and Itahan writers believe in metastasis. "In all the instances," says Beer, 
" which I have seen, this ophthalmia has occurred in young, plethoric, robust, and 
truly athletic men ; and it has always taken place in a very short time, generally in 
a few hours, after the suppression of gonorrhoeal discharge from the urethra." Mr. 
Lawrence never knew the urethral discharge stop upon the coming on of the oph- 
thalmia ; it has generally diminished, but in some instances has continued as copi- 
ous as before. He seems to regard the occurrence of the ophthalmia as analogous 
to those successive attacks of distant parts that are common in gout and rheumatism. 
Dr. Mackenzie evidently doubts the occurrence of metastasis at all in this disease, 
and is inclined to refer all the cases in which it has been alleged, to inoculation, or 
to an accidental occurrence of purulent ophthalmia and gonorrhoea in the same 
person. 

The supervention of purulent ophthalmia as a part of the gonorrhoeal malady, 
independently of inoculation and of metastasis, seems to me extremely problematical. 
The eye is well known to suffer, as well as other organs, in the secondary forms of 



GONORRHCEAL OPHTHALMIA. 



syphilitic disease, but the conjunctiva is not the part that is attacked. I have never 
seen nor heard of any satisfactory example of purulent ophthalmia alternating with 
gonorrhoea, where the possibihty of inoculation was excluded. And, upon the 
whole, my own opinion — (you will take it for whatever it may seem worth) — is 
against the existence of this alleged form of purulent ophthalmia. Whether it exists 
or not is of very little consequence in regard to the main question ; namely, what is 
the proper mode of treating the purulent ophthalmia of adults? 

Now the two chief points to consider, so far as respects the treatment, are — first, 
blood-letting; and secondly, the application of strong astringents to the inflamed 
membrane. 

Blood-letting has been carried to a very great extent in this disease, or in these 
diseases, if you choose to consider the Egyptian purulent ophthalmia and the gonor- 
rhosal purulent ophthalmia as two different inflammations. Its effects have not been 
very decisive or satisfactory ; indeed, we could hardly expect that they would. In 
the first place the inflammation is so rapidly destructive, that, in many of the worst 
cases, irreparable mischief is done before the patient applies for medical assistance. 
In forty-eight hours, or a little more, Mr. Lawrence tells us, the affection may have 
proceeded to such an extent as to be beyond our control. Of course this reason for 
the want of success is equally applicable to every reiyiedy that has been, or could 
be, proposed. But independently of this, even when the disease is seen and sub- 
mitted to treatment in its very beginning, we should have the less confidence in the 
power of general blood-letting to control it, for these two reasons : that the part 
affected is a mucous membrane ; and that there is so little constitutional sympathy 
with the local inflammation. Free venesection tells most upon inflammation, when 
it is attended with fever and a hard pulse, i. e., with increased action of the heart ; 
which the abstraction of blood tends to abate. It is also a matter of experience, that 
general bleeding has more influence over the inflammation of serous and fibrous 
membranes than over that of the mucous tissues. Accordingly, though bleeding 
has been even lavishly employed in purulent ophthalmia, it has too often disap- 
ointed the practitioner. There is one lesson, however, to be learned from copious 
lood-letting in this disease, even when it fails of its object. It clearly demonstrates 
what may be hoped for, by having recourse to that measure in internal inflamma- 
tions. " You see a person," says Mr. Lawrence, who has both had, and used 
freely, very numerous opportunities of putting this remedy to the test, " you see a 
person with his eye bright red, and very painful ; he cannot face the fight, and tears 
gush out, with great suffering, if he attempts to do so. You bleed to fainting, and 
immediately the capillaries are emptied, so that the organ resumes its natural pale- 
ness ; the pain is gone, the eye is opened without difficulty, and the full influx of 
light can be borne without an uneasy sensation. For the time the part has passed 
from violent inflammation to a nearly natural state. With the restoration of the 
circulation the inflammation wiH recur after this temporary suspension ; but its vio- 
lence is diminished, and it often gradually abates." Mr. Lawrence is here speaking 
of acute inflammation affecting the textures of the eye generally, and not of purulent 
ophthalmia in particular; but I am desirous that, in passing, you should take notice 
of this direct effect of bleeding to syncope, upon the capillaries of the eye, because 
it teaches us what the same expedient may do for the capillaries of any other inter- 
nal part, which we cannot see-, when that part is attacked with inflammation. In 
purulent ophthalmia, however, if you trusted to bleeding alone, you would often 
reduce your patient to a very dangerous state of weakness, and after all fail of your 
mark. Dr. Vetch bears strong testimony to the usefulness of blood-letting when 
freely employed in the early stages of Egyptian ophthalmia ; and certainly it ought 
never to be neglected. In the very onset of the disease, it will aid the local expe- 
dients which I shall presently mention ; and if the patient be not seen till the globe 
of the eye is invisible for the swelling, the propriety of general bleeding will be still 
further indicated by the occurrence of throbbing and circumorbital pain, returning 
in nocturnal paroxysms ; for this symptom denotes that the inflammation has de- 
scended deeper than the conjunctiva. The bleeding should be performed in the way 
I formerly spoke of as being required in serous inflammation : the patient should be 
13 R 



194 



DISEASES OF THE EYE. 



bled from the arm in an upright position, till fainting is about to ensue, or the pulse 
begins to falter. You will do more towards obtaining safety for your patient's vision 
in this way, and at less expense of his strength, than by bleeding him many times 
to a smaUer amount. The bleeding ad deliqinum may require to be once or twice 
repeated ; and when the patient begins to rally from his faintness, from twelve to 
twenty-four leeches may often be applied with advantage ; round the eye and not 
upon the tumid lids, where their bites are apt to add to the existing irritation, and to 
fester. You had better bleed your patient from the arm, and not from the jugular 
vein, or the temporal artery, for reasons which, as I have fully stated them abready, 
I need not now repeat. 

But of late years, more reliance has been placed by many practitioners upon local 
stimulants, for checking this horrible malady, than upon general or topical bleeding. 
Dr. A'etch strongly recommended the insertion of undiluted liquor plunihi acetatis ; 
and Mr. Briggs, in his translation of a w^ork of Scarpa on the eye, advised the intro- 
duction of a very minute quantity of the oil of turpentine between the eyelids. But 
Mr. Guthrie has the merit of having applied, in its full extent, this principle of 
curing conjunctival inflammation, even in its severest forms, by stimulant and astrin- 
gent substances. 1 told you, when speaking of catarrhal ophthalmia, that Mr. Mehii 
and Dr. Mackenzie treat that complaint w^ith a wash, made by dissolving four grains 
of lunar caustic in an ounce of distilled water. I might have added other authorities 
in favour of the same kind of practice. Now Mr. Guthrie treats purulent ophthal- 
mia on the same principle, but with a much larger dose of the nitrate of silver. The 
greater intensity of the disorder is met by increasing the strength of the remedy. He 
considers it to be a local disease of a pecuhar character ; and, acting upon the aphor- 
ism of John Hunter (an aphorism, however, W'hich requires som.e quahfication) that 
two diseases or actions cannot go on in a part at the same time, he proposes to set 
up in the inflamed conjunctiva a new action, which shall supersede the original dis- 
ease, and create another that is more manageable. In this point of view Mr. Guth- 
rie's ratio medendi agrees with that of Hahnemann, about which there has been so 
absurd a noise made of late. I have never had the advantage of seeing Mr. Guth- 
rie's plan tried, but, from all that I have heard of it, I beheve it to be a valuable dis- 
covery. A priori, we should expect that the caustic application would add to the 
existing mischief, and destroy all chance of saving the inflamed eye. But it is not 
so. Even Mr. Lawrence, who was, I have reason to think, formerly ver}^ sceptical 
on this point, appears to be so no longer. In his treatise On the Venereal Diseases 
of the Eye, he uses this cautious language : — " Destructive or injurious consequences 
have so frequently resulted under the usual management of this disease" — he is 
speaking of gonorrhosal ophthalmia, — "that I should certainly employ the local 
astringent, if I met with a case favourable for the trial ; i. e., where the affection had 
not extended beyond the conjunctiva. Blood-letiing might be resorted to at the same 
time ; in most cases, however, our aid is not sought until the cornea has become 
affected, and it is therefore too late for the astringent plan." But he subsequently 
added a note, to the effect that after the statement I have just quoted was written, he 
had employed the caustic solution in two cases of conjunctival inflammation with the 
best result. 

Mr. Guthrie's plan, therefore, you ought to be acquainted with. After many 
trials, he has arrived at the conclusion that the best appliance, in this formidable 
complaint is an ointment, made by mixing ten grains of the nitrate of silver, reduced 
to an impalpable powder, with a drachm of hog's lard. This is what he calls his 
ten-^rain ointment. 

Before applying it to the diseased eye, the discharge must be well cleansed away 
by a solution of alum ; then the ointment having been inserted beneath the lids, they 
are to be moved freely up and down, so that the whole conjunctiva may get its due 
share of the remedy ; and that it has done so is shoAvn by its turning white. If the 
surface does not turn white, the ointment has not been sufficiently applied, and will 
not answer the purpose. If we wish to be quite sure, he says, Ave turn out the 
eyehds, and rub the ointment on them. This application gives pain, which lasts 
for half an hour or an hour, or more. " Warm narcotic fomentations may be em- 



PURULENT OPHTHALMIA. 



195 



ployed to relieve uneasiness, and opium given to allay pain, and to obtain sleep ; 
while a solution of alum, in the proportion of a drachm to a pint should be injected 
from time to time into the eye, to clear it ; but should the patient sleep, he must not 
be disturbed, A mild ointment may be applied to the edges of the hds at night, to 
prevent their sticking together. The next morning the discharge is again to be re- 
moved and the ointment to be reappHed ; for on no account should the action we are 
desirous of exciting be allowed to cease." Of course Mr. Guthrie means it is not 
to be suffered to cease prematurely. This, with free but not excessive venesection, 
is the substance of his peculiar mode of treating purulent ophthalmia ; and it appears 
to have been eminently prosperous in his hands. I have been informed, by one of 
yourselves, that purulent ophthalmia has been successfully treated, on a large scale, 
in jVlanchester, by applying the nitrate of silver, in substance, to the surface of the 
conjunctiva; that this gives less pain than the ten-grain ointment, though perhaps it 
may require to be oftener repeated. 

I say I have never seen this method of Mr. Guthrie's carried into effect ; but after 
what I have myself witnessed of the intractable and destructive nature of the dis- 
ease, under the treatment ordinarily adopted before his ointment was devised, I will 
say also that were I so unfortunate as to be attacked with severe purulent ophthalmia, 
I should desire to have the caustic applied as soon as possible, and to be freely bled 
at the same time. 

There are some minor points in the treatment that require a cursory notice 

Some persons, and Mr. Guthrie among the rest, recommend the exhibition of 
mercury, so as to affect the gums. Now I beheye that mercury is quite useless in 
this complaint ; and if useless, mischievous. The disease is too rapid to be over- 
taken by the mercury, and if you could obtain the specific influence of that mineral 
in tim.e, i. e., before any of the destructive effects of the inflammation were accom- / 
plished, you would do no good thereby. This is not the kind of inflammation over 
which mercury exercises any useful control. Mr. Lawrence tells us that he has 
seen both the ordinary purulent, and gonorrhoeal ophthalmia, proceeding apparently 
unchecked, under the full mercurial action. 

Practical men are not agreed about the propriety of scarifying the conjunctiva 
when it is swelled and elevated by chemosis. Mr. Lawrence objects to it, as hkely 
to increase the local iritation ; a disadvantage not compensated by the quantity of 
blood discharged from the divided vessels. Dr. Mackenzie recommends it, stating 
that the incisions will bleed copiously, and greatly allay the symptoms. Who shall 
decide in this puzzling discrepancy of opinion ? Mr. Guthrie's caustic ointment 
would, I presume, supersede any other meddling with the inflamed surface. But 
when the question happens to lie between scarification and no scarification, I should, 
give my vote for scarifying: not because I think any useful depletion of the blood- 
vessels could be brought about by that measure, but because, if properly performed, 
it would evacuate the serous effusion from the areolar tissue between the conjunc- 
tiva and the sclerotic, which effusion constitutes the chemosis, and hastens, if it does 
not cause, the sloughing of the cornea, by the mechanical pressure that it exerts 
around it. 

Are blisters of any use ? Hear Dr. Mackenzie. " Counter-irritants are hip^hly 
serviceable in this disease, and ought always to be employed. There is generally a 
rnarked change in the quantity and appearance of the discharge from the eye, as 
soon as a counter-discharge is established by blisters on the temples, nape of the 
neck, or behind the ears." But listen to Mr. Lawrence. "Experience does not 
warrant us in ascribing much efficacy to blisfers.^^ Now the truth is, I believe, that 
during the active stage of the disease, blisters are not of any use ; but that in the 
more advanced and chronic periods, they are. Indeed, JMr. LaAvrence admits that 
they may be regarded as auxiliary measures, and resorted to after antiphlogistic 
means. 

I agree with the same gentleman in thinking that no reliance is to be placed, in 
gonorrhoeal ophthalmia, upon any attempts to reproduce the urethral discharge ; 
indeed, in most cases it is not suspended. 



196 



DISEASES OF THE EYE. 



Although I have not mentioned purgatives, you will conclude that they form a 
very proper and necessary part of the treatment during the activity of the com- 
plaint. 

After what has already been said of purulent ophthalmia in the adult, and 
of gonorrhoeal ophthalmia, it will not be necessary for me to take up very much 
of your time in speaking of purulent ophthalmia as it occurs in newly-born 
children. 

This is a very common disease : it is very serious when neglected : it is very 
easily managed when it is seen and treated in time. These are all reasons why 
you should make yourselves familiar with the complaint, and with the mode of curing 
it. You may perhaps never have occasion to treat a case of purulent ophthalmia in 
the adult : you are sure to be consulted about the purulent eye of infants, the oph- 
thalmia neonatorum. 

The importance of the disorder is apt to be overlooked by mothers and nurses ; 
they say the baby has a cold in the eye, which will go off; and they wash it perhaps 
with a little of the mother's milk, or some such insignificant fluid. Meanwhile the 
eyelids swell, the mischief that is going on beneath them is concealed from sight, 
and when at last a medical man is consulted, he too often finds that one of the eyes 
has perished, or both : the cornea has sloughed or become opaque, or protrudes, and 
constitutes what is called staphyloma ; prolapse of the iris has taken place ; or the 
coats of the organ have shrunk up. 

The inflammation usually comes on about three days after the child is born, 
although it may commence later. It is confined, at first, to that part of the mem- 
brane which fines the lids. Their edges are observed to stick together when the 
infant wakes ; there is more intolerance of light, apparently, than is suffered in the 
analogous disease of adults. The little patients cannot indeed tell us their sensa 
tions by words, but they express them significantly enough by keeping their eyes 
shut, by knitting their small brows, and by turning their heads away from the 
light. At length the inflammation extends to the conjunctiva that covers the eyeball, 
the eyelids swell, sometimes enormously : and an astonishingly copious discharge of 
pus takes place. By the adhesion of the edges of the fids the puriform matter is 
sometimes pent up, causing them to protrude ; and when they are separated it 
escapes in a profuse hot gush. The eyelids are sometimes everted during the cries 
and strugghng of the httle sufferer, and their mucous surface is then seen to be 
villous and shaggy, and of as bright a scarlet as you ever saw the injected mucous 
membrane of a foetal stomach. At last those destructive consequences to the eye 
take place which I have already mentioned. The disease, however, may continue 
for eight or ten days without any affection of the transparent parts ; and so long 
as these remain uninjured, the eye is safe, provided that proper treatment be 
adopted. 

This disease is probably much the most fertile source of blindness with which we 
are acquainted. It is beheved to originate most commonly, if not always, in con- 
tagion. We might, perhaps, expect this from the analogy of the severe inflamma- 
tion of the same parts in adults. And it is a matter of fact, that in a very large 
number of cases the mother has been affected, at the time of her confinement, with 
some kind of vaginal discharge — leucorrhoea, or gonorrhoea; and the eyes of the 
children are exposed to these morbid secretions, as they are brought into the world. 
The circumstance of the disease commencing so regularly on the third day, is 
greatly in favour of the supposition that it results from inoculation of the eyes by 
the unhealthy fluids of the mother. The discharge from the infant's eyes has been 
ascertained to be highly contagious. Dr. Mackenzie mentions a lamentable illustra- 
tion of this fact, which fell under his observation at the Eye Infirmary, in Glasgow. 
An infant and its grandfather became his patients there at the same time ; the latter 
having been inoculated from the former. Both were so severely affected that the 
infant had one eye left in a state of total, and the other of partial staphyloma : while 
in each eye of the old man, the greater part of the cornea remained opaque, and 
adherent to the iris. 

However, the disease certainly occurs in the infants of mothers who seem to be 



PURULENT OPHTHALMIA. 



197 



healthy, and who deny that they have any unnatural discharge. It may probably 
be brought on, sometimes, by bad management on the part of the nurse : by expo- 
sure soon after birth to draughts of cold air, or to the injurious influence of a hot and 
bright fire ; or by the introduction of soap into the eye in the primary ablutions, or 
of gin, whereof the lower classes, in some absurd persuasion of its strengthening 
virtues, are wont to bathe the unlucky infant's head. The disorder is observed to 
be most common in damp and cold weather; in low crowded places; and among 
the children of the poor. 

[The remarks of Dr. Watson on the causes of purulent ophthalmia in children, present a 
brief summary of all that is positively known in relation to the subject — for further details, 
bearing more especially upon the question of the production of the disease in the infant by 
a morbid vaginal discharge existing in the mother at the period of its birth, and the circum- 
stances generally, under which the affection most frequently presents itself, the reader is 
referred to the Editor's Treatise on the Diseases of Children. We have not met with a single 
fact, during a long and somewhat extensive practice, in proof of the communication of the 
purulent ophthalmia of infants by contagion. — C] 

One striking difference between the disease as it exists in adults and in newly- 
born children I have already adverted to ; viz., its rapid and often uncontrollable 
progress in the former; and the facihty with which it yields to suitable and timely 
treatment in the latter. If a child is brought to you with purulent ophthalmia, and 
you are able to separate the lids sufficiently to obtain a glimpse of the cornea, and 
perceive that it is still brilliant and uninjured, you may confidently tell the anxious 
mother that, with due care on her part, her child's eye is safe. If the cornea has 
lost its transparency, it is still within the reach of recovery, but the chances are 
against it : if 3^ou cannot get a sight of the cornea at ail, you will do wisely to give 
a doubtful prognosis, or even an unfavourable prognosis ; for such is the ignorance 
of the vulgar (and I include both rich and poor under this phrase) that if they are 
not forewarned of the danger, they are very apt to attribute the bUndness that ensues 
to your stuff, as they call it. 

In the severer forms and stages of the complaint, if the lids be very much swelled 
and red externally, and especially if you are unable to obtain any satisfactory view 
of the cornea without using a degree of violence that might be hurtful, it will be 
right to apply a leech. In this case it may be placed upon the centre of the tumid 
upper lid ; and you should, whenever that is possible, stay by the httle patient until 
the animal drops off, and the bleeding ceases ; for sometimes the bleeding is difficult 
to stop, and must not be trusted to the care of the nurse ; and the loss of blood occa- 
sioned by the bite of a single leech will often blanch the infant's skin, and make you 
fear that the depletion, slight as it is in actual amount, has yet been too much. The 
child's bowels should be emptied by a little castor oil ; and a lotion, made by dis- 
solving two grains of the acetate of lead in an ounce of water, may be applied to 
the inflamed organ. 

In less severe cases, and I believe in all cases in which you can see the uninjured 
cornea gleaming through the pus that bathes it, it will be quite sufficient to keep 
the infant's bowels open with magnesia ; to apply a httle lard along the edges of tha 
hds, that they may not stick together; and to inject carefully into the eye, beneath 
and between the lids, a solution of alum ; in the ratio of four grains to one ounce of 
water. Such, Mr. Lawrence tells us, was the treatment in forty-nine cases out of 
fifty at the London Ophthalmic Infirmary when he was surgeon to it : no other 
means being used than magnesia internalkf, and the solution of alum locally : and 
out of many hundred instances he scarcely recollected one that suff^-red in any 
respect, if the cornea were clear when the infant was first seen. I had, for a con- 
siderable period, the advantage of watching Mr. Lawrence's patients under that 
treatment ; and the result of it was so entirely and uniformly satisfactory, that I 
•should never think of employing any other. If the eye became at length insensible 
to the stimulus of the alum, a solution of the nitrate of silver, (from one to four 
grains in the ounce of water,) was substituted with advantage. Mr. Guthrie uses, 
I fancy, his caustic ointment ; but I am sure that the simple and less severe plan I 
have been describing is quite sufficient. 



198 



DISEASES OF THE EYE. 



[A very excellent application, in cases of the purulent ophthalmia of new-born infants, is 
a strong infusion of common tea — when this cannot be introduced between the lids in any 
other manner, it may be carefully injected by means of a syringe. — C] 

There is just one more disease belonging to the conjunctiva, that I wish to bring 
before you ; and then I have done with the morbid affections of this external mem- 
brane of the eye. It has received several names ; sometimes it is called pustular 
ophthalmia, from the appearance of little pustules upon the surface of the organ. 
Dr. Mackenzie, who looks upon it as an eruptive disease, affecting the conjunctiva 
not so much as a mucous membrane, but rather as a continuation of the skin, names 
it phlyctenular ophthalmia. It has also acquired the title of scrofulous or strumous 
ophthahma, from its continual occurrence in children of a scrofulous habit, and its 
very frequent association with scrofulous disease in other parts. It is a disorder of 
childhood, and it is so common a form of disorder, that, of ten cases of inflammation 
of the eyes in young persons, nine will be of this kind. I shall call it strumous 
ophthalmia. It is a form of ophthalmia that differs in many striking points from 
those which we have been considering. 

In the first place, it is intimately connected with the scrofulous constitution ; the 
peculiarities of which I formerly explained. Although a disease of children, it is 
not a disease of infants at the breast. It is most prevalent from the time of wean- 
ing to about the age of eight. I mentioned to you, in a previous lecture, the remark- 
able fact — showing the strong influence of unsuitable or insufficient nourishment in 
developing scrofulous disease — that when asked to prescribe for children having bad 
eyes, you will find, in nineteen cases out of twenty, that you have to deal with pu- 
rulent ophthalmia if the child be still at the breast, and with strumous ophthalmia 
if it have been weaned. 

The leading symptoms of this disease are, slight redness ; great intolerance of 
light; the formation of little prominences or pustules on the surface of the conjunc- 
tiva ; and specks which are the resuk of these. The complaint sometimes occurs 
in one eye alone, oftener in both ; but then one eye is generally worse than the 
other. Mere catarrhal ophthalmia is apt to degenerate into this affection in scrofulous 
children. After seeing two or three cases of strumous ophthalmia, you cannot fail 
to recognize it whenever you meet with it again. 

The redness has this peculiarity, that it is slight and partial. Sometimes it is alto- 
gether confined to that part of the membrane which lines the eyehds : generally a 
few vessels, collected into little bundles, are seen proceeding from some point of the 
circumference — more commonly from the angles of the eye than from any othei 
point — towards the cornea : the vessels are evidently superficial, often prominent. 
These scattered bundles of vessels (sometimes there is but one) stop when they reach 
the cornea, or occasionally encroach a little upon it ; and where they stop, the small 
elevations of the membrane may be observed, which are called pustules. This is 
the most common situation of these elevated points, just at the line of junction be- 
tween the sclerotica and the cornea, or near that fine. Sometimes, however, you 
may see one or two near the centre of the cornea. They are smaller in size when 
they appear on the cornea, than when they are situated near its edge. 

These pimples may be absorbed, and leave behind them a temporary v/hite spot; 
more frequently they break and form little ulcers. When these ulcers are beyond 
the cornea they are of less consequence : when they are situated upon it, they be- 
come sources of danger in two ways ; they may penetrate the cornea, and let out the- 
aqueous humour, and cause prolapsus iridis and various other mischief ; or they may 
leave, after healing, a permanent white opaque speck, (called leucoma,) which, 
according to its size and its exact place, will interfere more or less with the patient's 
vision. 

The intolerance of fight is a very prominent symptom of this disease, and some- 
times it really is the only symptom that manifests itself. It is curious that this 
inability to endure a bright light bears no regular or definite proportion to the mten 
sity of the other symptoms. It is not that the eye is painful when protected from 
the light ; but that the access of the ordinary light of day occasions extreme suffer 



STRUMOUS OPHTHALMIA. 



199 



ing ; the eyelids being spasmodically closed and the orbicular muscle in such strong, 
and apparently involuntary action, as effectually to resist all attempts at opening 
them. Children that are affected with this disease, carry it legibly written in their 
physiognomy. Although you cannot tell what is the actual condition of the eye 
without examining it, you can tell, as soon as you look at the patient, what is the 
nature of the inflammation under which he is suffering. The child's brow is knit 
and contracted, while his alas nasi and his upper lip are drawn upwards; those 
muscles of the face (they happen to be also muscles of expression) are instinctively 
put in action, which tend to exclude the light without shutting out the perception of 
external objects ; producing a peculiar and distinctive grin. In the severer cases 
the child will skulk all day in dark corners ; or if in bed, will lie upon his face, or 
under the clothes ; and while the Kght is thus kept off, he does not appear to suffer. 
If brought towards a window, he holds his head down, and presses his hands or arms 
over his eyes. When you attempt to open his eye to examine it, a profuse discharge 
of scalding tears takes place : these pass partly into the nose, and excite fits of 
sneezing, and partly over the skin, which they sometimes inflame and excoriate ; and 
then, frequently, pustules arise, and produce a discharge that crusts over the cheek 
and extends to the forehead and temples. This is called crusta lacte.a, and is very 
characteristic of the scrofulous habit; it occasionally spreads over the whole body. 

You might suppose, from this extreme intolerance of light, that the retina was 
inflamed, or in danger. But it is not so. The affection of the retina is purely sym- 
pathetic, and need not of itself excite any fears about the vision. Towards dusk, 
indeed, in the twihght, the child can generally open his eyes, and then is quite as 
able to see as if he were well. Dr. Mackenzie endeavours to explain the connection 
of intolerance of hght, spasmodic contraction of the lids, and lachrymation, even 
when there is but httle visible redness, by the distribution of the lachrymal nerve ; 
which, after supplying the lachrymal gland, goes to the conjunctiva, and to the orbi- 
cularis palpebrarum. We have the same set of symptoms when a bit of dirt gets 
into the eye, and fixes itself beneath the upper hd. When little or no redness exists, 
this extreme intolerance of light has been called photophobia scrofidosa. 

With this strumous affection of the eye there are usually present other evidences 
also of scrofulous disease. Swelling and redness of the alas nasi and upper Hp ; 
enlargement of the absorbent glands about the neck ; eruptions upon the head ; sore 
ears ; a large and hard belly ; disordered bowels ; offensive breath ; grinding of the 
teeth ; and general debility. And the ophthalmia will alternate sometimes in seve- 
rity with some of these other local scrofulous complaints ; getting better as they get 
worse, and vice versa. 



LECTURE XIX. ^ 

Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Oph' 
thalmia. General Remarks on Conjunctival Injlammations. Iritis : its Symp- 
toms and Treatment. Causes of Iritis. 

When we separated yesterday, I was about to describe the treatment which has 
been found by experience to be the best for reheving strumous or phlyctenular oph- 
thalmia. Before I take up the subject where it was then dropped, let me briefly 
remind you of the character and principal symptoms of the disorder. It is a form 
of inflammation of the conjunctiva, to which scrofulous children, from the time they 
are weaned, to about the age of eight, are extremely liable. It may occur consider- 
ably later. Sometimes it is the first and only token of the existence of the scrofulous 
diathesis ; generally it is observed in children who bear other marks of the strumous 
habit, and are afflicted with other forms of strumous disease. 

Its symptoms are — first, slight vascularity ; the redness being partial, and proceed- 
ing from one or more fasciculi of superficial vessels, which advance from the circum- 
ference of the visible part of the eye towards the cornea, where they usually stop * 



200 



DISEASES OF THE EYE. 



sometimes, however, they pass a little beyond its edge. At the extremities of these 
fascicuH, upon or near the hne of separation between the cornea and the sclerotica, 
small prominences appear, which are sometimes absorbed, sometime^ break and form 
ulcers. Less frequently the phlyctense are situate towards the central part of the 
cornea. Secondly, with this partial vascularity and these pimples, and sometimes 
even without them, there is extreme intolerance of light. The pain produced by 
exposing the eye to the influence of Hght imparts a characteristic expression to the 
countenance of the suffering child. Tears flow over the cheek, and inflame it often, 
and give rise to the eruptive appearance termed crusta lactea : or, from its sometimes 
covering the cheek hke a mask, porrigo larvalis. 

I may add to this summary of what was stated in the last lecture, that sometimes 
the vessels which pass along the conjunctiva and over the cornea, instead of leading 
to pustules, extend laterally : so that several bundles of vessels unite by their mutual 
ramifications ; and that part of the conjunctiva which covers the cornea becomes 
thick, as if it were darned ; and more or less opaque. Indeed, the greater portion 
of the whole of the corneal covering may thus be rendered patchy and vascular. 
The appearance presented by the eye under these circumstances is called pannus. 

You will readily believe, from what has been said of this complaint, that it is an 
obstinate and troublesome one. Even w^hen it has been cured it is very apt to 
recur. The scrofulous habit on which it depends we cannot get rid of ; and when- 
ever the exciting causes of scrofulous diseases come into action, this form of scrofula 
is very prone to declare itself, at the period of life which I have already mentioned. 

More good is to be done by general treatment, apphed to the system at large, in 
this form of ophthalmia, than in those we were occupied with before ; and this is one 
strong point of difference between them. 

In the first place we must endeavour to correct that unnatural condition of the 
whole system, and especially of the digestive organs, which is commonly so striking 
a concomitant of the local disease. It will be proper to clear out the bowels in the 
outset, and occasionally, by a mercurial purge ; and to regulate them at other times 
by laxatives, such as rhubarb, or the confectio senns3, or castor oil. The recovery 
will be greatly promoted, also, by those measures which are found to benefit the 
general health in such constitutions ; warm clothing, frequent ablution of the body, 
nourishing though plain food, the respiration of a pure atmosphere, change of air, 
and regular exercise. 

In addition to these measures, tonic medicines should be administered ; the pre- 
parations of iron, for example, or the dilute mineral acids : but the best remedy of 
this kind is, undoubtedly, the sulphate of quina. This may be given to a child in 
grain doses, three times a day, dissolved in water, with a drop of the dilute sulphuric 
acid, and some syrup of orange-peel. Dr. Mackenzie, in particular, has put \his 
medicine fairly to the test, having employed it in a very large number of cases with 
the happiest results. In most of his patients he declares that it acted like a charm^ 
" abating, commonly, in a few days, the excessive intolerance of light and profuse 
epiphora ; promoting the absorption of phlyctenules, and hastening the cicatrization 
of ulcers of the cornea." And Mr. Lawrence adds his testimony to the same effect ; 
and his experience in this disease, like Dr. Mackenzie's, has been large enough to 
make it highly valuable. 

A few words will suffice to explain the kind of local treatment that has been 
found useful. You may feel tempted to apply leeches round the eye. This is sel- 
dom requisite, except when there are more redness and pain than common, and the 
tongue becomes white, and the skin hot. Certainly you must not take the intole- 
rance of light as a fit indication for the use of leeches. Abstraction of blood rather 
aggravates that symptom ; apparently by increasing the irritability of the retina. 
Warm fomentations are generally very comfortable to the patient's feelings. 

When the general disorder of the system has been somewhat rectified, local stimu- 
lants and astringents are of great service. The vinum opii and the solution of lunar 
caustic are the best. These are often tedious cases, and therefore it is necessary 
that you should be aware of one great objection to the long-continued employment 
of the nitrate of silver wash, which objection has been pointed out by Dr. Mac- 



STRUMOUS OPHTHALMIA. 201 

«• 

kenzie. It is apt (but only when frequently repeated for a long time together) to 
stain the conjunctiva of an indelible olive colour. For this reason the vinum opii is 
to be preferred in slow cases, and in cases where frequent relapses happen. The 
good effects of either of those preparations are very striking ; they diminish the 
irritability of the eye, and promote the heaHng of the ulcers. The red precipitate 
ointment, and the citrine ointment of the Pharmacopceia, diluted, are also found 
beneficial. 

[According to Dr. Glover (JPathol. and Treat, of Scrofula), there appears to be little doubt 
of the success of an infusion or decoction of M^alnut leaves in scrofulous ophthalmia. — C] 

Counter-irritation is another local measure, which is of undoubted utility in this 
complaint. A great change for the better in the state of the organ often occurs, 
almost suddenly, upon the rising of a blister placed behind the ear, or at the back 
of the neck. And issues in the arms are not only serviceable in promoting the 
cure, but have a marked effect in many children, in preventing relapses. Mr. Wel- 
bank, in his notes to Frick's Treatise on Diseases of the Eye, states that he has 
seen chronic strumous ophthalmia, of seven years' duration, quickly and effectually 
relieved by an issue in the arm. " Having once (says he), in the case of a boy in 
Christ's Hospital, directed the healing of an issue whicn had been made above 
twelve months, I found the immediate consequence to be a relapse of strumous 
inflammation and ulceration of the cornea, resisting every measure but the renewal 
of the issue. 

He suggests, also, (what parents are sometimes more willing to assent to,) the 
advantage of making counter-irritation by piercing the lobe of the ear, and inserting 
a ring or silk ; and " a very convenient form of vesication will be found in the 
application of a strong thread, smeared with the ernplastrum cantharidis, and firmly 
tied behind the ear at the angle of its reflection." 

When ulceration is going on in the cornea, and threatening to penetrate it, the 
progress of the ulcer may be checked by touching its surface once in two or three 
days with a pencil of lunar caustic which has been scraped to a fine point. 

When the more urgent symptoms have abated, and the discharge of hot and 
irritating tears has ceased, the crusta lactea may very easily be got rid of. The 
crusts are to be removed by a fight poultice, or by warm water ; and then the part 
must be bathed from time to time with a lotion made by mixing the oxide of zinc 
with water ; a drachm to four ounces is the proportion I am in the habit of prescrib- 
ing. If rose-water be used instead of common pump-water, the prescription will be 
thought the more elegant. This lotion will speedily dry up the discharge, and in a 
short time no vestige of the ugly-looking crust will remain. Parents are highly 
delighted and very thankful when you thus accomplish the removal of a large dis- 
figuring and disgusting scab, which they naturally enough felt apprehensive might 
leave behind it a corresponding scar. But it is quite superficial. 

I have now done with the exterior membrane of the fore part of the eye— with its 
mucous membrane. In examining some of its diseases, we have had the oppor- 
tunity of noticing several things which illustrate the pathology of the mucous tissues 
generally, and which exemplify the influence of other circumstances also, as well as 
of peculiarities of tissue, upon the morbid processes to which these membranes are 
obnoxious. 

We have seen that the mucous surface of the eye readily enough takes on inflam- 
mation, under vicissitudes of external temperature, and from the agency of other 
atmospheric conditions ; that the inflammation is apt to spread, often rapidly, over 
the whole surface of the membrane ; and that, in some cases, it may be stricdy 
limited for a long time together, or entirely, to the mucous tissue in which it began; 
but that when intense, or under special circumstances, it may dip through and 
extend to the subjacent textures : that, on the other hand, the inflammation some- 
times occupies separate specks only of the membrane, and then is more likely to 
penetrate to the deeper seated tunics: that although the membrane is folded upon 
itself, so that different portions of it are mutually in apposition and contact, these 
opposing surfaces do not become adherent to each other under inflammation ; on the 



got DISEASES OF THE EYE. 

«• 

contrary, that they readily pour forth pus. This tendency to the formation of pus I 
formerly showed you to be commonly observable, whenever the air finds free access 
to the inflamed part. The pus thus poured out possesses the remarkable property 
of exciting the same kind of inflammation when placed in contact with any healthy 
mucous membrane of the same or of another individual : whether it be the conjunc- 
tiva of the eye, or the internal hning of the urethra. The pus, in short, acts locally, 
upon certain parts at least, as a poison. And we perceive, in this fact, how a disor- 
der that originates in common and accidental causes may become capable of propa- 
gating itself indefinitely — may become, in one word, contagious. We have seen 
also that the most intense inflammation may occur in this membrane, without exciting 
much or any constitutional disturbance; an illustration of the fact that the inflamma- 
tion of mucous membranes is not so prone to light up fever, is not in general attended 
with so much pyrexia, as inflammation of some other tissues, and especially of the 
serous and fibrous tissues: and in proportion as this constitutional sympathy with the 
local disease is small or absent, so the influence of general bleeding upon the inflamed 
part is slight or ineflectual. The effect of a new and strong local irritation, in alter- 
ing or superseding the original inflammation in some cases, has been illustrated in 
the treatment of purulent ophthalmia as it occurs in the adult subject. The influence 
of age in modifying the phenomena, and in qualifying the plan of treatment, has 
been m.ade perceptible in the differences noticed in these respects between purulent 
ophthalmia in infants and in grown-up persons. We have witnessed, too, the 
remarkable characters impressed upon inflammation of the very same part, by the 
presence of the scrofulous diathesis. We shall hereafter meet with numerous 
examples of chronic inflammation, and the deposition of tubercular matter, and the 
formation of ulcers in consequence of the elimination of that matter, in other mucous 
membranes. Whether the phlyctense, or pustules, which appear upon the surface 
of the eye in strumous ophthalmia, resuk from a similar separation of tubercular 
matter from the blood-vessels, near the extremities of which these prominences are 
placed, has not been clearly ascertained. One other lesson we have learned from 
this review of conjunctival inflammation, viz., that general bleeding, carried so far as 
to produce syncope, will sometimes completely empty the capillaries of an inflamed 
part of the red blood wherewith they were, just before, so turgid. 

I shall next request your attention to a part of the organ which is strictly internal 
— to the iris : that thin curtain, with a circular aperture nearly in its centre, which 
hangs between the cornea and the crystalline lens, and is bathed on both sides by 
the aqueous humour. This httle part, the office of which is to regulate the quantity 
of light admitted to the retina, is of exceeding interest in respect to its morbid as 
well as its healthy conditions. It is frequently the seat of inflammation : and, small 
as it is, the inflammation seems to be entirely confined to it, or to the surfaces im- 
mediately before and behind it. No doubt, with inflammation of the iris, there is in 
many cases inflammation of the choroid and retina also, and of the sclerotica. But 
the inflammation seems to make the iris its point of departure, and there it w^orks its 
most striking changes. We cannot see so well w^hat is the actual condition of the 
choroid and retina; but we have this proof, either that they do not always partici- 
pate in the disease, or that they often suffer less than the iris ; viz., that when the 
natural pupil has been closed up by lymph, and a new or artificial one is formed, ^ 
vision is frequently restored. 

The httle cavity across which the iris is vertically stretched, is fined by a smooth 
membrane, the source of the watery fluid always contained in the cavity. This 
membrane is analogous in its smoothness, in its forming a shut sac, and in the nature 
of its secretion, to the serous membranes met with in other parts of the body ; it is 
analogous also to the serous membranes, in its behaviour under inflammation. It Z5, 
in fact, the serous membrane of the eye. Now we have the means of inspecting a 
portion at least of several of the mucous surfaces of the body ; but this serous cavity, 
constituting the anterior chambers of the eye, is the only serous cavity into which 
we have the privilege of looking, and of noting what is going on, when the mem- 
brane that forms its boundary is inflamed ; and this it is that makes iritis, to me, one 



IRITIS. 



203 



of the most interesting of all diseases. There is no single part of the body from 
which you can derive so much instruction concerning some of the minuter processes 
of inflammation, and concerning the power of certain medicines over those pro- 
cesses, as you may by watching a few examples of inflammation of the iris. 

All the changes which occur in iritis depend upon the circumstance that the 
inflammation, like that of the serous membranes generally, is of the adhesive kind ; 
i. e., is attended with the effusion of coagulable lymph. By means of this lymph 
the form and the colour of the part are changed ; the size and figure of the pupil 
undergo alterations, or that aperture is completely closed up ; the motions of the 
iris are hmited, or entirely put an end to. 

The symptoms which characterize inflammation of the iris are very obvious. To 
be perceived and understood, they require only to be looked at. Yet they long 
escaped notice, and even now are not always so carefully studied as they deserve to 
be. Not a great while ago I had to convince a surgeon of some pretensions, that he 
did not know this disease when he saw it. And Enghsh surgeons and physicians 
were all of them ignorant even of its existence as a distinct disease, until a most 
excellent account of it was pubhshed by a German, Schmidt, in the first year of the 
present century. 

What are these plain and obvious symptoms that were so long overlooked, or that 
were not understood when seen ? They are the following. I will first enumerate 
them, and then speak of each rather more particularly. Redness of the sclerotica ; 
a change in the colour of the iris itself, and in its general appearance ; irregularity 
of the pupil, produced by adhesion of the iris to the neighbouring parts ; immobility 
sometimes of the pupil from such adhesion ; a visible deposition of coagulable lymph. 
All these changes are apparent and conspicuous. Scientific writers term them ob- 
jective symptoms. Then there are also the subjective symptoms, of which the 
patient alone is conscious — impaired sight ; pain in the eye, and round it. 

The redness is such as I formerly described as resulting from the vascularity of 
the sclerotic. The cornea is surrounded by a zone of fine straight converging pink 
lines, very different in appearance from the tortuous, anastomosing, scarlet blood- 
vessels of the inflamed conjunctiva. These hair-like converging lines stop abruptly 
at the edge, or just before they reach the edge of the cornea; they dip through the 
sclerotic, in fact, to go to the iris. The vascular zone, therefore, is well defined in 
front, while it becomes fainter from before backwards, and is gradually shaded off; 
the posterior portion of the sclerotic being generally pale. As the disease advances, 
and in violent cases, the more superficial conjunctival vessels also sometimes enlarge, 
and mingle their tint of redness with that of the sclerotic, and more or less confuse 
or conceal it. Now this red zone or halo continues as long as the inflammation of 
the iris continues, and disappears when that ceases. It is an important symptom 
therefore. 

The change in the colour of the iris itself is also a remarkable circumstance. 
You know that what is called the colour of the eye is simply the colour of the iris. 
When the lymph begins to be effused into the texture of this coloured part, it deep- 
ens, and at the same time alters, its tint. A gray or blue eye is thus rendered yel- 
lowish or greenish. A dark eye presents a reddish tinge. The change is such as 
would be produced by a mixture of the colour of the lymph with that which is natu- 
ral to the iris. But besides a variation of colour, the peculiar brilliancy of the sur- 
face is spoiled. It becomes dull and tarnished, as it were, and the fibrous arrange- 
ment, which is usually so evident, is confused or gone. The change commences 
at the inner or pupillary margin of the iris, and extends gradually towards the outer 
or ciliary edge. This is a symptom which you can scarcely overlook. It is ren- 
dered certain and unequivocal by comparing the sound eye with that which is 
inflamed. 

The change of colour which I have been desi^ribing is occasioned by the effusion 
of lymph. But the same event of inflammation leads to various other changes not 
less striking and more important, in so far as the functions of the organ are con- 
cerned. The lymph becomes visible upon the surface of the iris. Its precise ap- 
pearance varies considerably in different cases. Sometimes it presents Mttle spots 



204 



DISEASES OF THE EYE. 



like freckles, or specks of rust : or a thin stratum of the same colour is deposited. 
Sometimes it exhibits the appearance of drops, or (as they have improperly been 
called) tubercles, embossing the surface, and projecting from its pupillary edge. 
These are commonly of a yellowish or reddish-brown colour, and they vary in mag- 
nitude from the size of a small pin's head to that of a large shot. There are seldom 
more than two or three of these masses. The lymph thus effused upon, or thrusting 
forward the surface, is confioed almost always to that part of the iris which is near- 
est to the pupil, to the annulus minor; while its ciliary portion, or annulus major, 
is dull and clouded. Sometimes, when the inflammation is very violent, or the dis- 
ease has been neglected, actual suppuration takes place. A reddish-yellow promi- 
nence arises from the surface of the iris, and at length breaks, and discharges matter 
which sinks down to the bottom of the anterior chamber, and presents the appear- 
ance that has been called hypopyon. All these changes, I say, become perceptible 
near the margin of the iris ; its free edge which, in the natural state, is clear and 
sharp, becomes rounded and blunt : and at the same time the pupil often begins to 
lose its jet-black colour. 

Another very common consequence of the effusion of lymph from and upon the 
surface of the iris (from its hinder surface, that is, which is called the uvea, or from 
its pupillary edge), is its adhesion to the capsule of the crystalline lens, which lies, 
you know, behind the iris and very near it. And the pupil itself is apt to become 
blocked up by lymph. 

The motions of the iris are seriously impeded by the mere effusion of lymph into 
its texture. At first it moves sluggishly under variations of the light ; gradually the 
pupil contracts, and becomes fixed and motionless. The adhesion of the iris to the 
capsule of the lens still more decidedly restrains the action of the part. When it 
adheres at one or more points of the margin, and remains free elsewhere, the pupil 
is deformed; loses its circular shape; becomes angular ; and this deformity is the 
most marked when the eye is examined either under a weak light, which allows the 
pupil to dilate, except at the points where the iris is tied down to the lens ; or under 
a very strong light, which forces the free portions of the margin, and those only, to 
approach the centre. Still more palpable does the akeration of figure become when 
the pupil is artificially dilated. 

Vision is always impaired in this complaint : partly because the posterior tunics 
of the eye are liable to be imphcated in the inflammatory process ; partly by the 
detriment done to the proper function of the iris, which should duly measure the 
quantity of light admitted to the retina; partly by the presence o? more or less 
lymph, fiUing up the pupil ; and partly by a change, not yet mentioned, which is 
apt to take place, especially in severe cases, in the cornea, and perhaps in the aqueous 
humour. The cornea becomes hazy and dull, and loses its bright polish. It looks 
like a piece of glass that has just been breathed upon. It has been thought (on the 
ground of analogy chiefly) that the aqueous humour grows turbid under the inflam- 
mation of the membrane that secretes it ; just as serous effusion into the pleura is 
often found to be troubled and thick. But there is no sure evidence that this is the 
case. While the cornea remains transparent, the aqueous humour is seen to be 
clear ; when the cornea is dim and semi-opaque, we cannot distinguish the state of 
the aqueous humour. 

Acute iritis is attended with pain and intolerance of Hgbt. To the latter circum- 
stance is probably owing the contraction of the pupil during the progress of the 
inflammation : and then the lymph fixes the pupil in that state of smallness and 
contraction. There is pain in the eyeball itself, and in the parts about the eye, the 
brow and temple, most severe at night. There is much variety, however, in regard 
to the pain. Sometimes it is constant and severe, but still more aggravated in noc- 
turnal paroxysms. Sometimes, even when the quantity of mischief that is visible 
is very great, scarcely any pain at ail has been experienced. 

The same remark apphes to the constitutional symptoms. In some instances these 
are but slightly pronounced ; but in most cases, particularly in acute cases (for iritis, 
as I have hinted before, is sometimes a chronic disease) there is a good deal of fever 
and headache, the pulse is full and hard, and the tongue white, and the sleep is broken. 



IRITIS. 



205 



If the progress of the inflammation be not checked, it extends itself beyond its 
original seat. It creeps from the pupillary margin to the ciliary; and thence it 
passes on to the ciHary body, to the choroid coat, and to the retina ; and as this takes 
place, the pain and the pyrexia increase, and bhndness is usually the result. The 
delicate texture of the retina is spoiled for ever. 

I have thus described the phenomena of iritis generally : and I will next consider, 
in the same manner, the treatment which it requires. It will afterwards be neces- 
sary for me to mention certain modifications of the disease, in respect to its rate of 
progress, its causes, and the circumstances under which it occurs. I say it will be 
necessary to mention these modifications, because they require a corresponding 
adjustment of the plan of treatment. 

When we have to deal with iritis alone — that is, when the inflammation and the 
changes to which it may have led, are confined to the iris — the disease is always, I 
beheve, manageable ; and affords a beautiful instance of the power of well-directed 
remedial measures. We cannot always tell whether the inflammation has been 
restricted to the iris or not. 

We have three powerful weapons wherewith to combat iritis ; blood-letting ; 
mercury ; and a remedy that hitherto has not been mentioned in these lectures, 
belladonna. 

If I were restricted to the use of one of these means, I should choose mercury ; 
if to two, mercury and belladonna ; but the combined employment of the three has 
the most powerful effect in curing the disease ; and cases that have seemed almost 
desperate, have been retrieved and rescued by these remedies. 

With respect to blood-letting, I shall not run the risk of fatiguing you by dwelling 
at any length upon the mode in which it should be employed, or the indications for 
its adoption. I shall content myself with saying that the intensity of the local symp- 
toms, especially of the pain, — and the degree in which the general symptoms, the 
fever, and the hardness of pulse, are present, — offer the best measure, both of the 
necessity for bleeding, and the amount to which it ought to be carried. Both will 
depend somewhat also upon the strength and constitution of the patient. Bleeding 
from the arm till some decided impression is made upon the circulation; cupping 
fi'om the temples ; or both these modes of taking blood, together or in succession, 
will often be required. At the same time active purgatives should be exhibited; 
and the whole of the antiphlogistic regimen strictly enforced. 

But bleeding, assisted by purgatives and the antiphlogistic regimen, will not cure 
the disease ; or it Avill not cure one case in a hundred. It will stop the inflamma- 
tion probably, but not till the organ has been spoiled. Such a termination cannot 
with any propriety be called a cure. We want not only to put an end to the inflam- 
matory process, but to repair the mischief which may already have been done. 

Yet bleeding is not to be despised or neglected because it is unequal to the cure 
of iritis. It is productive of direct benefit by abating the force of the circulation, and 
by checking the progress of the local inflammation : and it is productive of great 
indirect benefit by preparing the system to submit itself more readily and rapidly 
than it otherwise would, to the specific influence of mercury. Mercury is our sheet- 
anchor in this disease. 

After free blood-letting, then, or after such abstraction of blood from the system, 
or from the part, as the circumstances of the case may dictate, you must administer 
mercury in the manner that I formerly recommended. The object is, in acute cases, 
to affect the gums as speedily as possible ; the soreness of the gums, and the peculiar 
foBtor of the breath, being the tokens that the whole capillary system feels the specific 
influence of the remedy. Calomel with opium is, in most cases, the best form in 
which mercury can be introduced into the system ; the purpose of the opium being 
to prevent the calomel from running off by the bowels. Two, three, or four grains 
of calomel, with one-fourth, one-third, or one-half of a grain of opium, should be 
given every four, or six, or eight hours. Equal doses at equal intervals. 

Some persons prefer giving the calomel stiU more frequently ; one grain, for 
instance, with one-tenth, or one-eighth of a grain of opium, every hour. If the 
gums do not rise in the course of thirty-six or forty-eight hours, and a speedy effect 

s 



206 DISEASES OF THE EYE. 

is desirable, inunction of the mercurial ointment should be added. And in some 
cases mercurial frictions alone may be sufficient, and the most expedient. Or the 
hydrargyrum cum creta, in five or ten grain doses. 

You may have bled your patient freely, and purged him well, and yet, on looking 
into his eye, you perceive the mischief to be still going on, and the deposition of 
lymph increasing. But the instant that his gums and breath acknowledge the spe- 
cific agency of mercury upon his system, a welcome change becomes visible ; the 
red zone surrounding the cornea begins to fade ; the drops of lymph to lessen ; the . | 
iris to resume its proper tint ; and the puckered and irregular pupil once more to ' 
approach to the perfect circle ; till, at length, the eye is restored to its original in- 
tegrity, and beauty, and usefulness. 

I speak now of favourable cases. The changes for the better that I have been j 
describing are sometimes rapidly accomphshed, sometimes slowly. If the disorder i 
has been long neglected, irreparable damage may have been done ; the effused 
lymph may have become organized ; or firm adhesions may have been already 
contracted between the iris and the lens. But even in cases of some standing, : 
when the inflammatory action has in a measure subsided, the use of mercury 
will sometimes greatly improve, sometimes altogether restore, the impaired vision. 

With the mercury, both before and while its specific influence is manifested, we I 
combine the use of belladonna. 

Doubtless you are all aware of the singular effect of this vegetable poison upon ' 
the iris. It dilates the pupil. Now it is of great importance in iritis to prevent that j 
tendency to contraction which the pupil manifests. If we can artificially dilate the 1 
pupil, we may prevent the iris from forming adhesions with the capsule of the crys- 
talline lens ; and if it has recently contracted such adhesions, we may, while the 
lymph is yet soft, stretch or break them. And this power of artificially dilating the i 
pupil we possess in the agency of belladonna, and of certain other narcotic vegetables. i 
This remarkable effect of the belladonna was first discovered, accidentally, by our r 
countryman, the celebrated Ray. He tells us that a noble lady of his acquaintance 
applied a leaf of the plant to a small ulcer, suspected to be cancerous, just below 
one of her eyes. The pupil of that eye became greatly dilated, and the membrane 
remained motionless under the strongest hght. This effect gradually subsided when 
the leaf was removed. But it took place on- three several occasions, and was wit- 
nessed by Ray himself. Other vegetables have the same property : henbane, for 
example, stramonium, and the cherry laurel. And there are others which have it 
not, akhough we might have expected that they would possess it, from the analogy 
they bear to the former in other respects. It has been ascertained that neither hem- 
lock, nor aconite, nor foxglove, nor opium, has any such power. 

Preparations of belladonna are chiefly, if not exclusively, employed in ophthal- 
mic disorders in this country. It is used in two ways. The extract is rendered 
soft and semifluid by admixture with distilled water, and then is smeared freely 
around the eye, upon the Hds, and brow, and forehead. It is w^ashed off after 
remaining an hour: generally it produces a marked effect upon the pupil. 

A more efficacious and speedy mode of dilating the pupil, is to drop a solution 
of the extract into the eye itself. The solution is to be made by rubbing down a 
scruple of the extract in an ounce of distilled water, and filtering the fluid through 
linen. Two or three drops of this solution are to be introduced between the 
eyehds. 

Some very interesting experiments have been made in Germany by Dr. Rei- 
singer upon this property of befladonna and hyoscyaraus, of contracting the iris — 
in other words, of dilating the pupil. The result of these experiments is given in 
the 24th volume of the Edinburgh Medical and Surgical Journal. Dr. Reisinger 
procured atropine and liyoscy amine, the active principles of the two plants, and 
made comparative experiments with these principles, and with the coarser extracts ; 
and he concludes that the former are much to be preferred to the latter. Thus, he 
dissolved a grain of hyoscyamine in ten minims of Avater, and introduced a small 
drop of the solution into the eyes of several dogs and cats. No irritation whatever 
of the eye was produced in any instance, but the pupil was so much widened by 



IRITIS. 



207 



the application, that in an hour's time only a small ring of the iris could be seen 
beyond the edge of the cornea; and after three hours, the pupil seemed as large as 
the cornea itself. The dilatation did not begin to diminish till after three days ; and 
! the pupil did not recover its natural dimensions until the sixth day. Then he ap- 
plied a solution of the extract of hyoscyamus, made by mixing five grains vv'ith ten 
minims of water. This evidently caused irritation of the organ, which lasted from 
five to eight minutes, and was evinced by a discharge of tears, by the animal's shut- 
ling its eyes, and rubbing its eyebrows with its paws. Much less dilatation of the 
pupil followed, and continued not more than six or eight hours in dogs, and about 
twenty-four hours in cats. As soon as Dr. Reisinger had satisfied himself that the 
hyoscyamine had no injurious influence either upon the conjunctiva, or upon the 
deeper-seated textures of the organ, he applied it to the human eye. He dissolved 
a grain of hyoscyamine in a drachm of distilled water, and inserted a drop of the 
solution into the eye of an old lady of seventy-one, who had cataract. So great was 
the consequent dilatation of the pupil, that only a narrow ring of the iris remained 
visible. No irritation whatever of any part of the eye was produced ; and the dila- 
tation continued for seven days. 

As chemistry is now furnishing us every day, in greater abundance, and with 
more ease, the active principles of various of our medicinal vegetable substances, 
we shall soon, in all probability, adopt hyoscyamine or atropine, for artificially 
dilating the pupil, instead of the preparations now in use. Till that time arrives, 
you had better smear the surrounding skin with the moistened extract of bella- 
donna whenever the eye is painful or much inflamed. But under other circum- 
stances, the solution dropped into the eye is to be preferred for its readier action, 
and its greater power. The use of this curious virtue possessed by certain plants is 
not confined to the cure of iritis : it enables the surgeon to introduce instruments 
through the pupil with greater facihty and safety ; it affords us also the means of 
examining the deeper-seated textures of the eye ; and it is of great service to many 
persons who are partially Wind ; to such, for example, as have central specks on 
the cornea, or central opacities of the crystalline lens ; it enables such persons to 
enlarge the window of the eye ; to admit more hght ; and to have painted upon 
the retina, and represented to the mind, the images of objects which, but for the 
mysterious agency of these poisonous vegetables, they could never hope to see 
at all. It is a very fortunate circumstance that the power of belladonna over the 
iris does not diminish by repetition. Mr. Lawrence mentions two patients of his, 
one of whom had used it habitually for four or five years, and the other for four- 
teen or fifteen ; and it dilated the pupil just as well at the end of these periods as 
at the beginning. By carefully examining an eye in which lymph has recently 
been effused, you may distinctly see the good effects of the artificial dilatation of 
the pupil ; little strings of adhesion are often visible, connecting the edge of the 
iris with the surface of the lens ; and these are stretched, and not unfrequently 
broken under the influence of the belladonna : and minute black spots may some- 
times be seen upon the capsule, marking the points where the uvea had stuck, and 
where it left behind it, when it was detached by the belladonna, a portion of its 
pecuhar pigment. These black points are indelible. There is one case recorded 
in which the pupil, after being dilated by belladonna, became fixed in that con- 
dition ; probably by lymph subsequently efTused into its texture, and binding 
together its fibres. Even this is better than that the pupil should be contracted and 
fixed. 

These three remedies, then — bleeding, mercury, and belladonna — are the means 
by which w^e are to subdue inflammation of the iris, and repair the ravages it has 
occasioned. With respect to the most important of the three, mercury, there are 
some points that require to be further noticed. 

You may ask to what extent the mercury should be pushed, and how long it 
should be continued ? 

Why we have, in iritis, an illustration of what I have more than once mentioned 
before, viz., that the rapidity of a disease will require a corresponding haste in the 
use of its remedy. In acute and violent cases, the mouth should be made decidedly 



208 



DISEASES OF THE EYE. 



sore, as quickly as possible *, and when that has been done, the further administration 
of the mercury may be suspended. " Full salivation," says Mr. Lawrence, " quickly 
produced, cuts short recent disease, as if by a charm." In cases of longer standing, 
or of slower progress, we must be slower in the introduction of the remedy : it will 
be enough to obtain any, the smallest certain evidence of its action, in the gums and 
breath ; and we must keep up that moderate influence for some time. For what 
precise time it is impossible to say ; but t-iil the redness has gone, and the natural 
colour of the iris returns, and all the visible lymph has disappeared, and the sight is 
perfectly restored ; and this may require a month or two. 

When you look from day to day into the aqueous chamber of an eye in which 
iritis has recently produced its peculiar changes, and after the due effect of mercury 
upon the gums has been achieved, you will be surprised as well as delighted to see 
large masses of lymph rapidly disappear, mek away, as it were, from the surface of 
the iris, while that which had been deposited in its intimate texture, rendering it 
confused and discoloured, as quickly clears off. And you will be inclined to believe, 
as many have done, that mercury has a vast influence in promoting and accelerating 
absorption. It may have such a power : I am not disposed to deny it : but that it 
really has so we cannot safely infer from such circumstances. It clearly has the 
power of arresting the deposition of lymph ; of putting an end to the adhesive in- 
flammation. Whether it does any thing more towards completing the cure, we have 
these reasons for doubting. When blood happens to be effused into the anterior 
chamber ; or pus ; or when, as frequently happens, pieces of a cataract that has 
been broken up pass through the pupil, and show themselves between the iris and 
cornea ; they (the blood, the pus, the fragments of the lens) disappear, i. e., are 
absorbed, just as rapidly as the lymph in iritis, not a particle of mercury is taken. 
Mr. Lawrence even gives a case of syphilitic iritis, which got well without any 
affection of the gums by mercury, and which had been marked by the deposition of 
a large mass of lymph on the iris ; and he says that the lymph was immediately 
absorbed, as soon as the inflammation ceased ; and that he never saw it disappear 
more quickly under any circumstances. 

There is one local use of mercury which I must not omit to mention, because 
though it probably has no share in curing the complaint, it is productive of great 
comfort and relief to the sufferings of the patient. It is adapted to those cases in 
which severe pain is felt round and over the orbit of the eye at night. Ten grains 
of the strong mercurial ointment, intimately mixed with two grains of finely powdered 
opium, and well rubbed into the temple a httle while before the nocturnal pain is 
accustomed to recur, will in many cases completely prevent it. We owe this piece 
of practice to the Germans. 

Iritis is apt to occur from different causes, and in connection with different diseased 
states of the system. It is no uncommon accident from surgical operations performed 
upon the eye, the iris suffering mechanical injury. The inflammation thus excited 
is usually violent and acute, and requires that the whole plan of treatment that I have 
been sketching out should be actively prosecuted. 

But inflammation of the iris sometimes arises slowly and insidiously, without vas- 
cularity enough to cafl attention to the eye, and without pain. This generally 
happens when the eye has been strained by over-use ; in women who occupy them- 
selves with fine needle-work ; in engravers, and such as are accustomed to look at 
minute objects, or at bright objects. A more common effect of continued exertion 
of the eyes in this way, is a diseased state of the retina ; but (however the fact may 
be explained) the iris is sometimes the part that suffers. In this form of the disease 
mercury will often be found a successful remedy ; but its influence must be gra- ' I 
dually brought about ; and it is not so certainly productive of benefit as when it is J 
employed in acute iritis : — probably because the chronic inflammation has involved ^ 
the posterior tunics also. 

But most frequently iritis is met with in combination with syphilitic, or with rheu- 
matic disease, which manifests itself at the same time in other parts of the body. 
Syphihtic iritis is more common than any other. It is one of the secondary symptoms 
of syphilis ; and accordingly it is commonly associated with other secondary symp- 



IRITIS. 



•toms ; with syphilitic eruptions, nodes, pains in the limbs, and ulceration of the 
throat. It is also one of the earlier of these secondary affections, and therefore is 
sometimes the only one to be seen; and occasionally it declares itself before the 
primary disease is well. The pain that attends this species of iritis is chiefly felt 
at night, but at that time it is apt to be very severe and distressing, so as entirely to 
prevent sleep until it takes its departure in the morning. We cannot, I beheve, dis- 
tinguish syphihtic iritis with any certainty from other acute varieties of the same 
complaint, by mere inspection of the eye. However, there are some points worth 
remembering in respect of the local phenomena which it most commonly presents. 

Syphihtic iritis is never attended (according to Mr. Lawrence) with abscess of 
the iris, and h3^popyon; the lymph is usually deposited in distinct masses; and the 
pupil becomes angular, and is not unfrequently displaced towards the root of the 
nose, by the adhesions which the iris has contracted with the parts behind it. In 
another variety of inflammation of the iris (which I shall mention to-morrow, arthri- 
tic iritis) lymph is equally effused from the margin of the iris, but it is not usually 
deposited in a distinct drop-hke form. We ascertain the variety of iritis with which 
we have to do by these peculiarities ; by the co-existence of other tokens of syphilis ; 
by the periodical character of the nightly pain ; by taking into our account the age, 
the constitutional habit, and the probable state of morals of our patient. Syphilis, 
you know, is not uncommon in children ; it is sometimes even congenital : but it 
very seldom affects the iris at that early period of hfe. Among a large number of 
syphihtic children brought to Mr. Lawrence, he never witnessed iritis but once. 

It was in syphilitic iritis that the curative power of mercury over adhesive inflam- 
mation was first distinctly recognized. But you must not fall into the error of sup- 
posing that the success of the remedy depended upon the specific character of the 
disorder ; upon its connection, I mean, with the venereal virus. Mercury is fully as 
serviceable and as sure in common acute inflammation of the iris. Upon this point 
all men of experience are agreed. " Its influence (says Mr. Lawrence) is not con- 
fined to the syphilitic form of the disease, but extends equally to the idiopathic." 
And Dr. Farre bears testimony to the same efiect. 



LECTUEE XX. 

Iritis concluded. Rheumatic Ophthalmia. Amaurosis. 

The principal theme of tlie last lecture was that most interesting disease, inflam- 
mation of the iris. 

The symptoms of iritis are these : a radiating zone of vascular redness situated in 
the sclerotica, and surrounding the cornea ; a change in the colour of the iris, from 
gray or blue to a yellow or greenish tint, from brown or hazel to a dusky reddish 
hue ; a visible deposit of lymph upon the anterior and innermost portion of the iris ; 
a thickening of its free edge ; contraction, irregularity, and immobility of the pupil ; 
closure of the pupil by lymph ; adhesion of the uvea to the membrane of the chrys- 
talline lens. All these we can see and ascertain for ourselves. We can ascertain 
also the presence of fever, which attends the acute forms of the disease. And we 
learn from the testimony of our patient that his sight is impaired ; that the influx of 
light into the eye hurts him ; and that he experiences pain in and around the organ, 
especially at night. 

The grand remedies in iritis are three. 

1. Blood-letting : of which the objects are to abate the force of the heart's action; 
to moderate the febrile disturbance ; and to facihtate the operation of the second 
remedy : which is — 

2. Mercury. This is to be given so as to produce soreness of the gums, and the 
peculiar fcetor of the breath : and these effects are to be sought for rapidly or gradu- 
ally, according as the inflammation of the iris is recent and acute, or moderate and 

14 s2 



210 



DISEASES OF THE EYE. 



chronic. The object of this remedy is to arrest the effusion of coagulable lymph :' 
to put a stop to the adhesive inflammation. 

8. The application of the extract of belladonna to the conjunctiva, or lo the skin 
around the eye, so as to dilate the pupil. The objects of this measure are to pre- 
vent the adhesion of the iris to the parts in its neighbourhood ; to detach it from the 
lens when it has already been glued thereto by soft lymph ; and to stretch and 
elongate the bands of adhesion Avhen they cannot be broken : and thus to obviate 
any impairment of the free movements of the iris, and any deformity of the pupil, 
after the inflammation shall have ceased. 

I began to speak of the causes of iritis. 

I say it may be occasioned by mechanical injury ; as during the operation for the 
extraction of a cataract. A clean cut, how^ever, is frequently followed by no bad 
consequences ; a portion of the iris has been shaved off by the knife in making the 
section of the cornea, without any injurious result. When iritis is excited by mecha- 
nical violence, it is acute. 

2dly. A chronic form of iritis is sometimes brought on by excessive employment 
of the eye, in looking at minute or bright objects. 

3dly. The most common species of iritis is that which arises in connection with 
syphiltic disease. It is one of the early secondary symptoms of syphilis. It is 
marked by the co-existence of other secondary consequences of the introduction into 
the system of the syphilitic poison, and by the periodical character of the nightly 
pain : it is never attended with abscess of the iris and hypopyon ; the lymph that 
is effused is deposited in separate masses ; and the pupil is often displaced towards 
the root of the nose, as Avell as rendered irregular, by the adhesion of the iris to the 
capsule behind it. 

4thly. It is curious enough that iritis has actually been ascribed to mercury, as a 
cause. This notion can only have arisen from that loose kind of logic, and hasty 
generalization, for which, I am sorry to say, medical reasoners are too often distin- 
guished. Mercury is perpetually exhibited for the cure of syphihs ; and people 
who have been treated for syphilis are very hable to iritis. This seems to be the 
only foundation for the opinion in question. When we come to appeal to facts, Ave 
find no ground for believing that this mineral is thus both bane and antidote. If it 
were so, Benvoho's advice to the slighted Romeo might be very pertinently offered 
to the patient in such a case : 

" Take thou some new infection to thine eye, 
And the rank poison of tlie old will die," 

Mr. Lawrence has seen no instance of iritis, of whatever kind, in wdiich there 
has appeared to him an}^ reason for attributing the occurrence of the com.plaint to 
this cause. I have never heard it alleged that persons who have taken large quan- 
tities of mercury for other diseases, as for affections of the liver in India, are parti- 
cularly subject to inflamm_ation of the iris. On the other hand, iritis has come on, 
in hundreds of cases, in connection with syphilis, though not a particle of mercury 
had been sw^allowed by the patients. 

Lastly, there is a pecuhar form or variety of iritis, called the arthritic or rheu- 
matic. 

This affection is characterized hj the :^ollow"ing general features. It occurs in 
persons who are subject to gout or rheumatism, and often forms a part of the attack 
of the one or the other of those diseases. Like them it is liable to return again and 
again ; and this circumstance it is which makes arthritic iritis a serious disorder. It 
is seldom that much or permanent damage to vision is effected by a single attack ; 
but adhesions readily form under it, and lymph is effused : and in each successive •; 
attack fresh effusion takes place : the pupil becomes more and more contracted ; and 
it may be filled up, at last, by an opaque plug of l3^mph. Some patients, however, * 
will suffer ten or a dozen recurrences of the disease, and recover almost completely, 
and enjoy perfect vision in the intervals, before the vision becomes much impaired. 

Some of the local appearances are more or less characteristic of this variety of 
Iritis, It is seldomer attended than the syphihtic variety by a deposition of lymph 



RHEUMATIC OPHTHALMIA. 



211 



in distinct masses ; the contracted pupiJ keeps its central position, and is not dis- 
placed towards the root of the nose, as it is apt to be in syphihtic iritis. The adhe- 
sions that bind the iris to the neighbouring parts are said to be whiter in this variety 
of iritis than in others. It is also a very remarkable circumstance that the zone of 
red vessels encircling the conjunctiva does not approach so close to the cornea as in 
other species of iritis ; but a white ring is left between the cornea and the anterior 
margin of the zone. Sometimes the circular white stripe is partial, being most 
marked towards the angles of the eye ; sometimes, on the other hand, it is as perfect 
as if it had been described with a pair of compasses. I believe, with Mr. Welbank, 
that the appearance of this bluish ring depends upon the less intense degree of the 
sclerotic inflammation. He says that he has noticed its coming on, when syphilitic 
inflammation of the iris was beginning to yield to the action of mercury; although 
there had been no such interval during the height of the inflammation. Again, the 
colour of the zone is not so bright as in other forms of iritis ; it is of a somewhat 
Hvid, or slightly purplish tint: and the larger vessels at the back part of the eye, 
belonging to the conjunctiva, are apt to become tortuous and varicose. 

Rheumatic iritis is often met with in combination with what is called rheumatic 
ophthalmia: a disease which I have not before mentioned. But eaCh may exist 
alone. And as rheumatic iritis, though frequently an independent disease, does also 
in many instances grow (as it were) out of rheumatic ophthalmia, 1 will take this 
opportunity of shortly describing the latter complaint. 

What is called rheumatic ophthalmia, then, is inflammation affecting the fibrous 
coat of the eye, the sclerotica. We know that the fibrous tissues throughout the 
body are frequently the seat of rheumatic inflammation. Some persons are more 
liable to rheumatism than others — are more readily affected by its external exciting 
causes, which are vicissitudes of temperature, and exposure to cold and wet. In 
such persons there seems a tendency to take on inflammatory action in all the struc- 
tures of the same kind ; and most particularly in the fibrous membranes, and ten- 
dons, that help to form the various joints ; and as the sclerotica partakes of this 
fibrous texture, so it is apt to suffer, in its turn, from rheumatic inflammation. The 
connection of the movable eyeball with the head may be considered as a sort of 
joint. The local symptoms are not in general of a violent kind ; and, as in other 
parts, the rhematism seldom leads to any permanent alteration of structure ; seldom, 
at least, when the ophthalmia is confined, as it often is, to the sclerotica alone. Per- 
haps the best way to put you in possession of the features that belong to rheumatic 
ophthalmia will be to describe an actual instance of it. I will take a well-marked 
example, related by Mr. Lawrence. He was sent for to see a gentleman who was 
suffering from what is commonly called rheumatic gout: swelling, some redness, 
and severe pain of one foot and knee, and one hand ; aching of the back ; and 
great constitutional excitement. He got well under the treatment adopted. After 
a short interval, upon Mr. Lawrence's caUing to inquire how he was, he said there 
was something the matter with his eyes ; and asked to have them examined. "I 
looked at them hastily," says Mr. Lawrence : " the room was dark, and the day 
dull ; and I saw no appearance of disease. When I called again, after a few days, 
as the complaint was repeated, I examined more attentively. On bringing him 
towards the window, he obviously felt the light troublesome ; he drew down the 
eyebrows, and half closed the lids, to avoid it. The conjunctiva was natural ; but 
the whole of the sclerotica had a livid red, and mottled appearance, which might 
have been called dull, or almost dirty, in comparison with the red colour of common 
active inflammation. The sclerotic vessels were partially distended ; the redness 
terminated short of the cornea, so that there was a distinct white rim round the latter. 
Vision was perfect ; there was no pain so long as the eye remained at rest ; but 
exertion of the organ, particularly under strong hght, brought on uneasiness. The 
nature of this gentleman's occupation, and of his tastes, which were literary, pre- 
vented him from giving his eye the necessary repose ; and the condition of the scle- 
rotica just described lasted for three or four months ;" so that Mr. Lawrence was 
apprehensive that some serious mischief would ensue to the organ. The affection 
remained confined, however, to its original seat, evincing only that obstinate charac- 



&12 



DISEASES OF THE EYE. 



ter which belongs to disordefs of such ' structures ; and at last it disappeared coih- 
pletely, leaving the eyes with their organization and powers unimpaired. 

The treatment that appears to answer best in simple rheumatic ophthalmia of this 
kind, consists in moderate topical bleedings, and counter-irritation : with such other < 
measures as conduce to improve the general health ; and among these, change of | 
air and scene have sometimes a decided effect. Those remedies also are to be given j 
which have been found by experience to be beneficial in rheumatic inflammation, I 
although we cannot always depend upon finding them useful : colchicum, I mean ; | 
bark ; sarsaparilla ; the iodide of potassium. In these abiding or frequently recur- j 
ring forms of disease, you will often be obliged to try the so-called specific remedies ; 
' one after the other. 

Now when the rheumatic inflammation is not confined to the sclerotic, but creeps 
inward, as by their vascular connections it easily may, to the iris also, we name the 
disease according to the most important part that it occupies — arthritic iritis. On 
the other hand, when, with that affection of the sclerotic which I have been de- 
scribing, there is combined a moderate degree of inflammation of the conjunctiva, 
this complex disorder receives a compound denomination ; it is called catarrho- 
rheiimatic ophthalmia. 

Dr. Mackenzie states it as the result of his experience, that arthritic iritis seldom 
occurs in connection with the earlier appearance of gout, while the patients still 
retain strong powers of digestion, and have the means of indulging their appetites; 
Tjut rather with the asthenic and irregular forms of gout and rheumatism ; when 
repeated attacks have been followed by mental depression, indigestion, flatulence 
and languor. He has generally met with the disease in subjects beyond the age 
of fifty, very frequently in tobacco-smokers, and whiskey-drinkers, who have often . , 
suffered rheumatic affections, who are teased by headaches, acidity of stomach, bad 
gums and teeth, and lowness of spirits: in persons, that is, whose health has been ii 
impaired and broken by intemperate habits. 1 believe you will find this to be a very 
correct statement ; although arthritic iritis may also take place in those who are 
more robust. 

After what has now been stated you will be prepared to beheve that arthritic iritis | 
neither requires nor bears those free emissions of blood, and that liberal use of mer- | 
cury, which are necessary for the cure of other varieties of the complaint. Mercury, 
pushed to salivation, is sometimes found to do more harm to the system than good 
to the eye ; and in a disease which is so apt to recur, we must not be continually 
salivating our patient. I can only say that the treatment must be conducted on the 
principles already laid down, and adapted to circumstances. If there be any fever, 
and a hard pulse, and a white tongue, you should bleed and purge your patient, and 
afterwards give him from twenty minims to half a drachm of the wine of colchicum 
two or three times a day. When the symptoms are less active, you must be less 
active too : strive to set the disordered digestive organs right, and to correct the bad 
habits of the patient : give small doses of mercury (such as five grains of Plummer's 
pill) three or four times a week ; excite counter-irritation by blisters, or by the tartar- J 
emetic ointment. After the use of bleeding or leeches, and the regulation of the \ 

^ bowels, preparations of iron, the sulphate of quina — tonics, in short, — have been r 

' found, in not a few cases, extremely beneficial. 

I should have mentioned another remedy, which of late years has been recom- \ 
mended in iritis, and especially in syphifitic iritis, by Mr. Carmichael, of Dublin : ' 
not as being a better remedy in itself than mercury, or so good, but as having con- ; 
siderable power over the disease, and as affording, therefore, a valuable resource i 
when from any cause the exhibition of mercury is forbidden. This remedy is the \ 
oil of turpentine. He gives it in drachm doses, three times a day. He relates 
cases of syphilitic iritis in which the pain, redness and other symptoms, were quickly i 
removed, and effused lymph was absorbed, and vision restored, under the use of this ! 
medicine. It is necessary to its beneficial action that the bowels should not be con- 
fined. In other instances of the same disease, Mr. Carmichael was not so success- j' 
ful. Mr. Guthrie, who has also tried this remedy, reports of it that " in some cases 
it succeeded admirably, in others it has been of httle service, and in some unequal \ 



\ 



AMAUROSIS. 



213; 



to the cure of the complaint." I do not know that it has been fairly put to the test 
in arthritic iritis. 

I proceed next to quite a different kind of ophthalmic disease from any that we 
have yet considered. I have spoken of inflammation of the exterior membrane of 
the eye occurring separately ; and of inflammation of certain internal parts, and par- 
ticularly of the iris, occurring separately. Between these exterior and interior tunics, 
the sclerotica forms a sort of natural barrier or shield, the chief point of connection, 
between them being near the edge of the cornea, where the sclerotic vessels dive 
through to reach the iris. Inflammation of the sclerotica itself has also been de- 
scribed. When vision is impaired or destroyed in consequence of any of the com- 
plaints which have hitherto engaged our attention, that effect results from the partial 
or total exclusion of light from the retina. The cornea is left opaque, or it bursts ; 
the pupil, or aperture in the iris, is shut up by a web of lymph ; or the capsule of 
the lens to which the iris adheres has undergone a change, and lost its transparency. 
In each case the retina suffers an eclipse. 

But hght may be freely admitted, and yet no vision ensue. The transparent parts 
of the eye, the several media, so skilfully and exquisitely adjusted for the due refrac- 
tion and collection of the rays of hght into an image of the object from which they 
flow, may all be perfect and in order ; but the beautiful apparatus is useless ; the 
patient cannot see with it. The fault is in the nervous matter that should receive 
and transmit the impression, and render it an object of perception to the mind. 

Now persons in this condition are said to have amaurosis. The term is derived 
from the Greek word a^uavpoj, which signifies obscure or dark. It expresses various 
degrees of imperfect vision, from defective nervous function. The words gutta 
Serena are applied to that form of amaurosis in which vision is totally lost. It was 
formerly supposed that this sort of blindness was caused by the effusion of some 
humour or fluid behind the pupil : and this was held to be a clear fluid, because the 
natural blackness of the pupil is sometimes not troubled in amaurosis. Milton has 
literally translated this term when, speaking of his own eyes, he says : 

" So thick a drop serene hath quenched their orbs." 

Amaurosis is a very obscure disease. It is capable of being caused by various , 
changes, the exact seat and nature of which we often have no means of determining, 
during hfe; and which frequently leave no traces behind them in the dead body. 
It would take a much larger space than I can possibly devote to it in these lectures, 
thoroughly to discuss this difficuh but interesting subject. I shall endeavour to give 
you such a sketch of it as you may fill up and complete by future observation and 
reading for yourselves. It wiU be something to learn the direction and objects of . 
our inquiries into what is yet unknown in the pathology of this affection. 

There is one division of the disorder which immediately suggests itself. The, 
cause of defect may exist in the brain, at or beyond the origin of the optic nerve ; 
or it may be situated in any part of the course of that nerve, from its commencement 
at the base of the brain to its termination in the retina ; or it may be confined to the 
retina itself. 

There is reason to believe that the functions of the retina may be impaired or sus- 
pended, by deviations from the natural quantity of blood sent to it ; by disturbances 
of its circulation. Various degrees of amaurosis are common among persons who 
employ the sense of vision overmuch, and strain the eye. This over-use is Hkely. 
to produce congestion, or chronic inflammation, in the vessels of the retina ; and very, 
sHght changes of that kind may seriously affect the function of a part so delicate and., 
tender. I say we frequently meet with amaurosis among those whose occupations, 
obhge them to look attentively at small or bright objects during many hours of the, 
day; or- what is still more pernicious, during many hours of lamp or candle light : 
so as habitually to fatigue the eye. Engravers, printers, watchmakers, tailors and 
milliners, mathematical instrument makers, persons who gain their bread by writing, 
miniature painters, cooks who are exposed to the heat and glare of large fires, men 
who have the charge of forges or furnaces, and so on. Here a continual stimulus 



214 



DISEASES OF THE EYE. 



leads to a chronic disorder, which, increasing in intensity, may terminate in total 
blindness. We call these cases of amaurosis, but they may be justly considered to 
be instances of chronic injlammation of the retina ; we cannot see the suffering part 
indeed during life ; and the complaint is not a fatal one, and, therefore, we have few 
opportunities, or none, of examining after death the condition of the retina while the 
amaurosis is yet recent. But judging from the nature of the causes that precede 
the defect of vision, and from the nature of the remedies that are often found to re- 
move it, we are warranted in regarding the essence of the disease to be retinitis. 
The same condition, apparently, may be suddenly produced by the transient opera- 
tion of some more powerful cause of congestion : such as intense hght. 1 will 
illustrate this form of amaurosis — amaurosis, that is, dependent upon congestion, 
which, perhaps, amounts to inflammation, sometimes slowly established, and some- 
times very suddenly — by the narration of a few cases. I may as well premise, 
however, that the treatment which promises most, or I should rather say, which has 
performed most, in this form and kind of amaurosis, is very nearly the same (except- 
ing the use of belladonna) that I have already recommended for chronic and acute 
iritis. Blood-letting, general or topical, according as there are more or less pain and 
fever, and fullness of the system, and according as the amaurosis is more or less 
recent ; and above all mercury, so administered as to affect the gums, and rapidly 
introduced into the system in the acuter cases : more slowly in proportion as the 
disease has crept on more gradually and lasted longer. This treatment is very often 
quite successful : the mercury is the most important part of it ; and we have in 
this fact a strong corroboration of the inference drawn from the nature of the exciting 
causes, viz., that the complaint is essentially inflammatory. And again, supposing 
it inflammatory, we need not be surprised that a remedy, the curative effect of which 
we can see in inflammation of the iris, should be equally serviceable when the same 
diseased process is set up in the retina, which we cannot see. Purgatives, counter- 
irritation, and perfect repose of the eye, are necessary parts of the treatment in both 
forms of disease. 

Mr. Allan gives the following account of the master of a printing-office, who be- 
came bhnd. He had corrected the press, and was otherwise engaged in reading, for 
eighteen hours daily out of the twenty-four. He continued this practice for twelve 
months, notwithstanding an evident failure of his sight. At the end of that time the 
amaurosis was so complete that he could not distinguish one object from another, 
but was merely capable of just perceiving the light, so as to grope his way along 
the streets. He continued in this state for several years, but ultimately recovered 
his vision. 

The next instance that I shall cite is recorded, in these words, by Mr. Lawrence. 
„"A young woman, of florid complexion and full habit, came to the London Ophthal- 
mic Infirmary, complaining that she had lost the sight of one eye. She was a cook 
in a family, and occupied for several hours daily before large fires, supporting her 
strength by free living. The pupil was shghtly dilated ; the iris motionless. A 
faint and scarcely perceptible pink tint was observed in the sclerotica near the cornea. 
Vision was dim, and had been so for three days. There were headache, flushed 
countenance, heat of skin, whitish tongue, and thirst. I considered the case to be 
pure retinitis ; and to afford a favourable opportunity for showing whether the affec- 
tion could be arrested by antiphlogistic treatment. At that time (now many years 
ago) I did not possess the knowledge of the power of mercury in inflammation of 
the retina, which subsequent experience has given me. I directed a full bleeding 
from the arm, free purging, low diet, repose of the organ, and general rest. At the 
end of two days the sight was worse : cupping and a blister were now ordered ; but 
there was no improvement at the end of two days more. I now determined on try- 
ing mercury, and ordered two grains of calomel every four hours. Before the 
remedy had affected the system, vision vv^as quite lost, or at least reduced to the mere 
power of distinguishing light from darkness. Full sahvation, which took place in 
about a week from the first application of this patient at the infirmary, suspended 
ail the symptoms ; the sight immediately improved, and was soon completely 
restored," 



AMAUROSIS. 



215 



A soldier, unacquainted with the proper method of observing an edipse of the 
sun, employed for that purpose a piece of opaque glass, with a transparent point in 
its centre. Notwithstanding the vivid and painful impression he experienced from 
the rays that passed through the lucid part of the glass, he continued to look at the 
sun tiJl the eclipse was over, using his right eye. He was soon after seized with 
vertigo, and pain in the right side of the head, and found himself almost entirely 
deprived of the sight of the right eye. Some weeks afterwards, the pain in the 
head continuing, he came under the care of Baron Larrey, who observed that the 
vessels of the eye were injected, the pupil somewhat smaller than that of the other 
eye, retaining, however, its natural freedom of motion ; the vision very obscure or 
almost gone. This man recovered his sight completely after two bleedings, one 
from the temporal artery, the other from the jugular vein ; blisters to the temple and 
nape of the neck ; ice to the head, and moxas.- — (^Mackenzie from the Mhnoires 
de Chirurgie.) 

In the year 1832, a young man standing in a door- way, by a lamp-iron, in a 
thunder-storm, was struck by the lightning, fell backwards, and was convulsed. He 
said afterwards that the hghtning appeared to enter his eye with a scorching sensa- 
tion. During the night, vision was quite lost. The next morning there was no red- 
ness, nor any unusual appearance of the eye. The iris was motionless, however, 
and the patient could not see even the sun. He was treated with calomel, and his 
sight returned ; but the retina remained extremely irritable, and unable to bear the 
light. A month afterwards, when this account was written, he could see distinctly 
enough, but he could not use his eyes without the protection of blue glasses. — 
{Lawrence.) 

In these cases the nervous apparatus that ministers to vision is not, I believe, in 
general, the only part of the nervous system that is injured. In August, 1839, 
Phoebe Judge, a delicate-looking girl, eleven years old, became my patient in the 
Middlesex Hospital. She had lost, in a great degree, the power of using her legs : 
when she attempted to stand they separated, and she sank down. She had not per- 
fect control over her bladder. The desire to make water was frequent, and if not 
immediately attended to, the urine escaped in spite of her efforts to retain it. The 
same urgency, and inability to wait, occurred whenever her bowels were about to act. 
Sensibility in the legs and thighs was impaired, but not extinct. 

Her parents informed me that some time previously, while stooping to raise up a 
sister in a room at Hampstead, she had been struck by lightning, fell backwards, 
became bhnd, and remained so for ten days. She did not lose her consciousness, 
but complained immediately that the lightning had hurt her eyes. They presented 
no visible injury or defect, but the upper hds fell, and she was unable to raise them. 
It was soon found, however, that when pressure was made on the right eyelid she 
could open the other eye. The palsy of her limbs commenced, by degrees, two 
or three days afterwards. The power of vision returned suddenly, and at the same 
moment the power of moving her limbs was restored ; but it gradually went again. 
When she lay down, her hmbs were still ; but they began to tremble, and to be 
agitated as soon as she sat up. Even when lying in bed, she had occasionally a 
sensation and dread, as if she were falling down. She had been in this state nearly 
three weeks. 

She was put upon steel, and a tonic plan of treatment, and in ten days she could 
walk, dragging her left leg a httle after her. In ten days more she was dismissed 
quite well, and able to run from one end of a long ward to the other. 

The greater number of the cases of amaurosis depending upon a morbid condition 
of the retina itself, belong to the class that I have now been mentioning : there 
is congestion of the vessels of the retina ; or inflammation, chronic or acute. In a 
few instances a totally opposite condition of the blood-vessels is presumed to exist. 
I say presumed to exist, because our judgment of this matter is founded, as before, 
upon the nature of the circumstances that have caused the affection, and upon the 
nature of the treatment that removes it. On these grounds some cases of amaurosis 
(few in number, speaking comparatively) may fairly be ascribed to a deficient supply 
of blood to the vessels of the retina. We know that a temporary defect of sight may 



I 
I 



216^ DISEASES OF THE EYE. I 

I 

be produced by a diminished circulation through the retina, as in approaching syn- 
cope under hemorrhage ; and we can therefore the more readily believe that more- 
permanent amaurosis may be occasioned by causes that gradually lessen the quantity 
of blood circulating in the body, and debilitate the whole system. " It is well known; 
(writes the late Dr. Gooch) that large losses of blood enfeeble vision. I saw a- | 
striking instance of this in a lady who was flooded to death. When I entered the- ; 
chamber she had no pulse, and she was tossing about in that restless state which is ' j 
so fatal a sign in these terrific cases. She could still speak; asked whether I was^ [ 
come ? (she knew I had been sent for), and said, ' Am I in any danger ? — How dark- 
the room is ! I can't see.' The shutters were open, the blind up, and the hght> 
from the window facing the bed fell strong on her face. I had the curiosity to lift^ 
the lid, and to observe the state of the eye. The pupil was completely dilated, and* 
perfectly motionless, though the light fell full upon it. Who can doubt that here . 
the insensibility of the retina depended on the deficiency of its circulation?" j 

One might ask, also, who can doubt that the retina may become insensible from a 
similar state of the circulation in it, brought on by some long-continued drain upon* 
the system ? Amaurosis of this kind, proceeding from too profuse and protracted a 
secretion (which may be considered a sort of hemorrhage), is sometimes noticed in 
nurses. Mr. Lawrence describes the case of a young mother of slender make, who" 
suckled her first child, which was strong, and took the breast very often ; her milk • 
was abundant. After two or three months she began to feel very weak, could not-" 
lift a weight, and cried frequently, without having any moral reason for grief. She! 
became totally blind, and was led to his house by a friend. He found her pallid, 
with a small feeble pulse. The pupils were of middle size, and the irides moved 
shghtly. The retina was completely insensible. She could not discern the situation 
of the window, nor see a lighted candle held close to her. After weaning the child, 
and using generous diet, she got perfectly well. Some counter-irritation was em- 
ployed in this instance, but I question whether it had any thing to do with the' 
recovery. Such cases are not uncommon, and their well-known occurrence has 
probably tended to encourage the notion — too prevalent among both patients and 
practitioners — that amaurosis is always essentially a disease of debility, and requires 
tonic and stimulant remedies ; bark, and high feeding, and strychnia, and electricity. 
"Our eyes are weak,'"* say they, "and we require strengthening medicines." You 
must perceive from what has already been said, how necessary it is to discriminate 
in such cases : to look closely into all the circumstances under which the disease has - 
occurred. 

When amaurosis is the result of pressure or of disease, in the course of the optic 
nerve, or in the sensorium, the complaint is generally less within the power of reme- 
dial measures. We cannot say, indeed, in many instances, where the cause of defect- 
lies : and in obscure cases, I should always advise a trial of the mercurial plan. I 
have again and again seen slight palsy of some of the voluntary muscles, evidently 
depending upon some morbid condition of the brain, clear away rapidly upon the 
affection of the gums by mercury ; and the lost power of the retina will sometimes' 
return under similar treatment. ' 

There is something very peculiar in the expression of countenance, and in the- 
gait, of an amaurotic person, by attending to which alone, you may almost recognize; 
his disease. He comes into a room with an air of uncertainty in his movements ; 
the eyes are not directed towards the surrounding objects ; the eyehds are wide^ ■ 
open ; to use a strange but common and intelligible phrase, the patient seems gazing'i 
upon vacancy — has an unmeaning stare ; and there is a want of that harmony of 
movement and expression which results in a great measure from the informatiorr- 
obtained by the exercise of vision. This seeming stare at nothing at all, is not 
observed in patients who are blind in consequence of opacity of the crystalline lens^ j 
or its capsule, i. e., in consequence of cataract. They, on the contrary, while they i 
cannot see, still seem to look about them, as if they were conscious that the power- '' 
of sight remained to the retina, although light was shut out from it. '■■ 

When the amaurosis is incomplete, the motions of the iris are sluggish, and the ' 
pupil is larger than ordinary. When the blindness is total, the commonest condition- , 



I 



AMAUROSIS, 



217 



of the eye is that of great dilatation of the pupil, with complete immobility of the 
iris. A mere ring of iris is all that is visible, and no change takes place in the 
diameter of the pupil, under the greatest variation of the hght that falls upon it. 

Sometimes, on the other hand, though the amaurosis be total, the iris is as active 
as ever; and this is a very interesting circumstance, and may help us, in some 
degree, to conjecture the actual seat of the malady. When the amaurosis is con- 
fined to one eye, this may happen. You examine the diseased eye, and you find 
that the pupil enlarges, or contracts, as you diminish or increase the light. But the 
other eye is open. Shut the sound eye, and try the amaurotic eye again, and jo\i 
find the pupil fixed, although you vary the Hght. The motion you formerly noticed 
was sympathetic of the motion of the iris in the healthy eye. We express this 
otherwise by saying that the associated movements of the iris w^ere natural and 
fively, but its independent movements were lost. But sometimes the independent 
movement is unaffected : nay, the motions of both irides may be perfect, although 
both eyes are completely amaurotic. I may state, by the way, that ceteris paribus, 
when both eyes are affected, that is a ground for supposing the cause of the disease 
to be situate within the cranium. And I should come to the same conclusion if, in 
the case where one eye alone was amaurotic, I found the independent motion of the 
iris of that eye unimpaired. We know that in the healthy condition of the parts, , 
the brightness of the light admitted to the retina determines the size of the pupil;, 
but the motions of the iris do not depend solely or directly upon the retina. It has 
been ascertained, by experiments made upon animals, that the pupil may be made to 
contract either by mechanical irritation of the optic nerve within the cranium, or by 
irritation of the third nerve ; a motor nerve which sends filaments to the ophthalmic 
ganglion, whence the ciliary nerves, passing to the iris, are derived. Now the optic 
and the third nerves have some hnk of connection within the brain ; and if the 
morbid condition upon which the amaurosis depends is situate deeper than the point 
of connection, we may understand, I think, how disease so placed may destroy the 
power of vision, and yet leave the connection between the retina and the third pair 
unaffected: and then the influence of light falling on the retina, though it fails to 
create a perception in the mind, will be reflected back upon the third pair of nerves, 
and so continue to govern the motions of the pupil. In conformity with these views, 
M. Andral relates cases in which amaurosis connected with disease in the cerebellum 
was attended with brisk movements of the iris. . 

There are other causes of amaurosis besides those that I have already adverted to. 
It is sometimes produced by the presence of worms in the alimentary canal. 

[That amaurosis is frequently dependent upon irritations seated within the storhach and 
bowels, and upon derangements of the digestive organs generally, there can be little doubt. 
We have met with many cases of this kind, and they are repeatedly referred to, more espe- 
cially by the German writers on the disease. Children confined in ill-ventilated and ill- 
lighted apartments, and supplied with coarse and indigestible food, are often alfected with a 
certain degree of amaurotic blindness, which is readily removed by a proper hygienic treat- 
ment, and such remedies as are adapted to restore the regular functions of the stomach and 
alimentary canal. We have observed the disease, also, in children who ftave been at too 
early an age, confined in crowded school rooms for many hours of the day, while their minds' 
were compelled to the performance of tasks beyond their powers. Complete blindness, we 
have known suddenly to occur in consequence of the presence of indigestible food in the 
stomach, and to be as quickly removed upon its expulsion. For further information on this 
subject, the reader is referred to the chapter on amaurosis by Dr. Taylor, in the 2d volume 
of Tweedie's Library, Philadelphia edition, page 515, and to the very able paper of Dr. Jacob 
on the same subject in the Cyclopaedia of Practical Medicine, Philadelphia edition, vol. i. 
page 78.— C] 

It has some obscure connection with teething, probably through irritation of the 
facial branches of the fifth pair. A physician of my acquaintance, residing in Lon- 
don, has a young son, who on two or three occasions has caused him great uneasi- 
ness, by becoming blind in one eye without any obvious cause, and with no visible 
change in the organ ; but the blindness on each occasion has gone off again, appa- 
rently in consequence of the extraction of some teeth which had grown irregularly. 
I am assured by Dr. Ashburner that such cases are common. Mr. Lawrence relates 

T 



218 



DISEASES OF THE EYE. 



a very singular instance of dental irritation giving rise to amaurosis. A rnan, thirty 
years old, was suddenly attacked with violent pain in the left temple near the eye, 
and in that side of the face generally. The pain continued to recur from time to 
time, and at length he discovered that he was blind in the left eye. By and by the 
cheek swelled, and some spoonfuls of bloody matter were discharged by a spontaneous 
opening in the lower eyehd, and then the pain subsided ; but after some months it 
returned with great severity. The patient then went to Wilna, with the intention 
of having his eye extirpated, and consuked Professor Galenzowski, who found the 
left eye totally insensible to light, with the pupil dilated, and no other visible altera- 
tion. He ascertained, however, that the first molar tooth on that side was carious : 
it had never caused the patient much uneasiness ; and the toothache which he had 
occasionally suffered had not been coincident, in point of time, with the pains in the 
head and eye. Dr. Galenzowski thought fit to extract this tooth, and was greatly 
surprised at seeing a small substance protruding from the extremity of its fang. This 
proved to be a little splinter of wood about three lines in length, which had perforated 
the centre of the tooth, and had probably been introduced in using a wooden tooth- 
pick. A probe passed from the socket into the antrum, from which a few drops of 
a thin purulent fluid escaped. The pain ceased almost entirely, and on the same 
evening the eye began to be sensible to light. The vision gradually improved, and 
on the ninth day from that time, after thirteen months' bhndness in that eye, he was 
able to see with it as perfectly as with the other. M. Galenzowski has since been 
in England, and he showed Mr. Lawrence the tooth, and the spHnter of wood. 
Doubtless he felt some pride in exhibiting these trophies of his exploit. 

Amaurosis is said also to occur as an hysterical affection; and I am certain that I 
have seen this myself. An unmarried lady, of a very nervous and susceptible habit, 
came to town in great apprehension about her eyes, the sight of one of them being 
quite gone. I could perceive no defect in the eye itself. I saw her in consultation, 
with Mr. Travers, who took an unfavourable view of the case, and thought the 
chance of recovery was very slender. I had one reason for hoping a better result, 
in the knowledge of some facts which Mr. Travers was not aware of till I mentioned 
them to him. I had been acquainted with this lady for some years, and during that 
period she had several times almost entirely lost, and again recovered, the use of her 
lower extremities. On two occasions she had been affected with aphonia, and unable 
to speak, except in a whisper, for months together ; and then, on a sudden, without 
any apparent cause, her voice returned. I trusted, therefore, that this suspension of 
the power of vision in one eye might be a similar freak ; and so it turned out. After 
a few weeks the sight returned, she knew not how ; and she has since lost it a 
second time, and a second time regained it. 

Certain poisons will produce temporary amaurosis ; and the suppression of certain 
natural evacuations, as of the perspiration, of the menstrual fluid, and of the bleeding 
from piles, and the repulsion of certain eruptions, have been charged, by authors, 
with producing the same complaint. 

In those case* in which amaurosis creeps on slowly and insidiously, as it is apt to 
do from various causes : and more particularly when it depends upon a low and 
chronic inflammation, engrafted upon habitual congestion of the vessels of the inter- 
nal tunics of the eye ; its approach is marked by sundry curious affections of the 
vision. The eye feels full or stiff, and sometimes there is pain of the head in its 
neighbourhood; the patient complains that he sees things through a fog or mist, or 
as if a thick piece of gauze were interposed between his eye and the object he is 
looking at. In the dayhght, the gauze or fog seems dull and murky, but in the 
dark it often appears shining, reddish and fiery : the flame of a candle is seen sur- 
rounded with a halo of prismatic colours. That amaurosis of this kind is often really 
dependent upon local congestion we are taught by the Icedentia, by the circumstances 
that aggravate it : thus straining of any kind, which augments for the time the full- 
ness of the vessels about the head, will make the mist appear more dense : the same 
effect may be produced by tyeing the neckcloth tight ; or even by stooping. Boerhaave 
relates the case of a man who, whenever he was intoxicated, laboured under com- 
plete amaurosis : it came on by degrees, increasing according to the quantity of 



AMAUROSIS. 



219 



i wine he drank ; and after the drunkenness went off, his vision returned. Surely 
these phenomena are very illustrative of the way in which nervous disorders may 
arise, or be made worse, from mere local plethora, in almost any part of the body. 

Sometimes the perfect amaurosis is preceded by a remarkable diminution of the 
apparent size of the objects looked at. A patient told Dr. Farre that a carriage, 
which happened to pass the window, seemed to him as small as a wheelbarrow, and 
the horses no bigger than dogs. More commonly ocular spectra become visible : 
that is,^arts of the retina lose their power, or perhaps are eclipsed by turgid vessels : 
the patient sees flies in the air, muscae volitantes, particles of soot, blacks, as we, 
who live in London, call them, which always float before his eyes, and seem to fol- 
low their motions ; and which are especially plain and troublesome when he is look- 
ing upon a white surface. They multiply in number till the whole becomes dark. 

Do not, however, suppose that the appearance of these muscae voHtantes, even 
when they are permanent, necessarily implies the approach of amaurosis. I should 
be sorry if it were so, for I see two of them every morning, when my eyes are 
directed towards a white basin, while I am washing my face. I can find them at 
other times if I look for them ; else I am not sensible of their presence. They bode 
no further evil, if they are associated with no other defect, in function or in appear- 
ance, of the instrument of vision. 

It is obvious that no particular rules, no rules, that is, which will fit all cases, can 
be laid down for the treatment of so multiform a complaint as amaurosis. When it 
manifestly results from disease of the brain, as when it accompanies hydrocephalus, 
or remains after a stroke of apoplexy, our attention must be directed to the disease 
from which it has sprung. When there is any reason to suppose that congestion or 
chronic inflammation of the internal tunics of the eye itself is concerned in the pro- 
duction of the amaurosis, we must adopt the measures that I have already described, 
as the most hkely to remove the congestion; and especially the mercurial plan. 
When there is ground for suspecting that the bhndness takes its rise in vascular 
exhaustion, or nervous debility, we must have recourse to tonics ; bark, preparations 
of iron, nourishing diet, the cold bath. 

After all, you wall find too many cases which will baffle your best-directed attempts, 
and in which you will be required and warranted to try other expedients. When 
what I may call rational measures have been expended in vain, you may have 
recourse to such as are empirical and tentative. There are various stimulants which 
have occasionally been found serviceable ; but most of them, I believe, fail much 
oftener than they succeed. Electricity is one of these : it is applied by taking small 
sparks from the eyelids, and from the integuments, round the orbit. The object of 
this is to rouse the dormant energies of the impassive nerve : and it appears some- 
times to do this for the retina, as well as for the nerves supplying voluntary mus- 
cles. Mr. Ware tells us that electricity is most beneficial in those cases in which 
amaurosis has succeeded a stroke of lightning. You must take great care not to 
employ this remedy when there is any inflammatory action at the bottom of the 
complaint : it should seldom be tried therefore when the affection is recent. 

Strychnia has, of late years, been used for the cure of amaurosis. I shall here- 
after take an opportunity of telling you the ordinary effects of that substance upon 
the body, when given in a certain dose — what is its poisonous operation, and what 
may sometimes be hoped from it as a remedy. In amaurosis it does good, when it 
is useful at all, by stimulating the exhausted or atonic nerve into action. With 
respect to this remedy also I may say — first endeavour to ascertain that it is not 
likely to do harm ; as it will be if the blindness depend upon any condition akin to 
inflammation. Mr. Middlemore, of Birmingham, has probably given this remedy 
an ampler trial than any other person, and he speaks very favourably of its effects 
in certain cases : in others he found it to produce so much pain, and spasm, and dis- 
tress, that he was obhged to discontinue its use. It is not given, in these cases, by 
the mouth, but applied locally ; and Mr. Middlemore considers that it is most efficient 
when placed over the supra-orbitary nerve. He puts a narrow blister above the 
eyebrow ; when it has risen he cuts off the cuticle, and applies a piece of hnen, for 
half an hour, to absorb the serum that continues to ooze forth ; then he sprinkles the 



220 



DISEASES OF THE BRAIN 



strychnia, finely powdered, upon the raw part, and covers it with linen smeared with 
the unguentum cetacei. He repeats this every twenty-four hours, cautiously increas-' 
ing the dose till the vision improves, or some sensible evidence of the agency of the 
strychnia becomes apparent. He commences with the sixth part of a grain. 

I must here leave the subject of diseases of the eye. 

In addition to the lessons which I pointed out before as capable of being learned 
by attending to the disorders of this small organ, I may now mention a few ©thers, 
of no little moment, since we shall meet with their application again and again, as 
we proceed to investigate the morbid conditions of other parts. We have seen 
enough to convince us that mercury, properly administered, has the invaluable 
power of stopping adhesive inflammation ; of arresting the effusion of coagulable 
lymph from the blood-vessels : that inflammation of a given part may be sensibly 
modified by the simultaneous agency of some specific poison upon the system, as 
that of syphilis ; or by the presence of constitutional tendencies to disease, such as 
are observable in gouty and rheumatic people. And we have seen that the func- 
tions of a nerve may be perverted, suspended, or abolished, in various ways : by 
pressure made upon it ; by a plethoric state of its blood-vessels, or by an empty 
state of them ; by inflammation of its texture, chronic or acute : and even, in some 
mysterious, or hitherto unexplained manner, by mere irritation of a distant part ; by 
worms, for example, in the alimentary canal ; by poisonous substances introduced 
into the stomach ; and by what, in our ignorance, we denominate the freaks and 
caprices of hysterical disorder. All these lessons we shall find repeated, as the 
course advances. 



LECTURE XXI. 

Diseases of the Brain and Nervous System. Difficulties of the subject. Short 
Review of some points in the Physiology of the Brain ana Nerves. Peculiarity 
of the Cerebral Circulation. Pressure. 

Having considered some of the most important disorders of the eye, because they 
afforded me the means of illustrating many of the doctrines and principles, which \\ 
had previously endeavoured to lay before you, of general pathology ^ I go next to the, 
diseases of that portion of the body, which, though it includes many distinct parts, 
is called, collectively, the head. I pass over the maladies to which the integuments* 
of the head are liable, because they will fall more naturally and conveniently into^ 
the class of cutaneous disorders ; and I come at once upon one of the most interest-, 
ing, and at the same time most difficuh and obscure subjects of special pathology—, 
that which embraces the diseases of the brain and nerves. Though it will be a, 
slight departure from the plan I have proposed of taking diseases as they affect dif-. 
ferent parts of the body from the head downwards in succession, I shall speak of 
diseases of the spinal cord, and of the nervous system generally, in connection with, 
those of the brain. To disunite them would neither be easy nor useful. 

The study of the maladies and disordered conditions of the brain and nervous sys-, 
tem, is surrounded with peculiar difficulties : and, accordingly, our knowledge of 
these diseases is less precise than of the diseases of most other parts of the body. 

1 . One source of difficulty lies in the circumstance, that the structure of the ner^ 
vous system has no perceptible or understood subservience to its functions. We dc 
not discover in the mechanism of this system that adaptation of means to an end, 
which is so conspicuous in many other parts of the body : and consequently, though 
such adaptation doubtless exists, we are not able to trace the reason or the manner 
of its interruption. We find in the lungs an apparatus of tubes and cells fitted for 
the reception of air, upon the expansion of the chest by the contraction of certain 
muscles ; of which muscles also we can see and understand the action. If we meet 
with any obstruction of those tubes, or any obvious impediment to the play of those 



AND NERVOUS SYSTEM. 



221 



'^muscles, we perceive at once how and why the function of respiration is deranged. 

'■ But no alterations that become visible, after death, in the brain or spinal marrow, 
afford us any explanation of the interruption of their proper functions; which are, 
in three words, sensation, thought, and motion. An apoplectic cell has no relation, 
direct or inverse, that we are capable of appreciating, with a sentiment ; nor a dis- 

• tended lateral ventricle with the exercise of the will. The morbid anatomy does not 

' in any degree elucidate the disorder, simply because the natural structure throws no 
light upon the healthy office of the parts concerned. 

2. It is a further source of difficulty, that physiologists have not yet been', able to 
determine, with any thing like precision or certainty, what share the several parts 
of the brain and spinal cord have in regulating, respectively, the functions which all 
physiologists acknowledge to belong to the nervous system in the aggregate. There 
are many and convincing reasons, for believing that the brain is a complex organ; 
but we can seldom put our finger upon this or that portion of the nervous matter 
which composes it, and say, here resides the influence that governs this or that par- 
ticular function. 

3. Again, the brain and cranio-spinal axis are so encased by their bony coverings, 
that, in the hving body, we are unable to ascertain their physical conditions by 
means of any of our senses. Of many parts of the frame we ascertain the state by 
the sense of sight ; and of many parts that we cannot see, we still may recognize the 
changes by the faculty of touch, or by the ear. The brain and spinal cord we can 
neither see, nor hear, nor handle. 

4. Besides these obstacles to the acquisition of information by the exercise of our 
own senses, concerning the organs affected, the very disturbance of the functions of 
the brain cuts us off, in many cases, from that kind of information which we might 
otherwise derive from the statements of the patient himself. 

5. There is a still greater cause of perplexity, with which we have to contend. 
The very same symptoms accompany alterations of the brain apparently of a very 
different, nay of the most opposite kind ; and on the other hand, changes of struc- 
ture, which, as far as we can perceive, are absolutely identical in their nature, are 
associated, in different cases, with totally different symptoms ; and more frequently 
than not, nervous diseases are attended with no alterations of structure, appreciable 
by our senses. 

6. And lastly, we are perpetually asking ourselves, when we find the proper func- 
tions of the nervous system disordered, — is this disorder the result of disease in the 
nervous matter itself? or is it merely sympathetic of disease in other parts ? for there 
are few diseases of any kind which do not, in some degree, modify or disturb the 
due exercise of the offices of the brain and nerves: and it is very difficult often, 
and sometimes it is impossible, to determine whether, and how far, the disturbance 
is primary or secondary. 

With all its difficulties, however, the pathology of the brain and nerves is always 
full of interest. How can it be otherwise, when we reflect that the nervous system 
is the medium through which we hold communion with the world around us ; the 
stage upon which all the phenomena of animal life are transacted : the instrument 
of the mind ? 

And with all its difficulties, there is also a good deal in the pathology of the brain 
and nerves that is fairly made out and well understood ; and we are at present in the 
right way for advancing our knowledge of this intricate and mysterious subject, by 
that careful collection of facts, and rigid induction of particulars, that will lead, at 
length, to a safe and useful generalization. 

I shall endeavour to point out to you what is known of the morbid conditions of 
the nervous system ; I shall also state the conjectures and probabilities by v^^hich our 
judgment and practice must be guided, when absolute certainty is unattainable. 
With mere speculative questions, that have no practical bearing, I shall meddle as 
little as I can. 

Our knowledge, I say, of the exact functions of the different parts of the nervous 
apparatus, is scanty and imperfect. Some certainties, however, we possess ; and 

t3 



222 



DISEASES OF THE BRAIN 



some strong probabilities which almost amount to certainties. Without first ex- 
pounding my creed upon these matters, it would, be impossible for me to explain, as 
it would be for you to understand, the notions I entertain respecting many of the 
diseases of the brain and nerves. 

Omitting the sympathetic nerve and its ramifications (for we know but little of 
its office, and still less of its disorders), the nervous system is made up of certain 
masses of nervous matter, called the nervous centres; and of nerves therewith con- 
nected. 

The nervous centres consist of the cerebrum and cerebellum, the medulla ob- 
longata and the medulla spinalis. 1 shall include the cerebral hemispheres, and the 
lobes of the cerebellum, under the common term, the brain. So I shall speak of 
the oblong and of the spinal-marrow, in the single phrase, the spinal cord, or the 
craniospinal axis ; their endowments appearing to differ more in relation and de- 
gree than in kind. 

I adopt the belief that the gray (which are much the more vascular portions of 
these nervous centres, form the part in which their peculiar powers reside, or are 
generated ; and that their white or fibrous portions are, like the white and fibrous 
nerves, mere conductors of the nervous influence. 

I incline, also, to the opinion (recollect, if you please, that I do not press these 
opinions of mine upon you as being necessarily correct) that the influence which 
originates in the gray matter, and is transmitted by the white, will at last be found 
to consist in, or to be closely connected with, some modification of electricity. We 
know that some of the effects of this influence may be very exactly imitated, in ani- 
mals recently dead, by galvanism. 

The functions of the brain and nerves are sensation, thought, vohtion, and the 
power of originating motion. Other functions indeed there are ; but these four are 
all that we need, at present, concern ourselves with. 

Now, it is a part of my creed, that the faculties of sensation, of thought, and of 
the will, belong to the brain : in all probabihty to the cerebrum alone. The precise 
office of the cerebellum is involved in much obscurity and dispute. Some of the 
opinions that have been formed respecting it, I shall notice hereafter. 

The chief grounds for beheving that the brain proper is, exclusively, the instru- 
ment of the mind, are these : — 

1. Because this portion of the nervous centres is superadded to the cranio-spinal 
axis, in the greatest bulk and most complicated form, in man : and after him, in those 
of the inferior animals which show the largest share of reason. 

2. Because, in inferior animals which evince a certain amount of mental endow- 
ment, all manifestation of intellect ceases upon the gentle and gradual removal of 
the cerebrum and cerebellum: the animals continuing to live, for a long time, not- 
withstanding this mutilation. 

Again, it forms part of my creed on these subjects that the motive power resides 
in the spinal cord. 

The muscles furnish the instruments of motion. 

Now there is a certain class of muscles which contract without our willing their 
contraction : and generally without our being conscious that they are contracting. 
Such are the heart, the muscular fibres of the ahmentary canal, and of the bladder. 
These are, therefore, called involuntary muscles. 

There is another large class of muscles which obey the bidding of the will, and 
.serve the purposes of prehension, locomotion, and bodily effort. These are consi- 
dered and called voluntary muscles. 

There is still another distinct set of muscles, of which the habitual action is invo- 
luntary, yet which submit also to the interposing control of the will. You will 
(all to mind at once the muscles of respiration, which act while we are asleep, or 
otherwise unconscious ; and the sphincters, which regulate the entrances and outlets 
of the body. Here, I say, the habit is involuntary, but the occasional action is 
prompted and governed by volition. But sometimes the involuntary action rebels 
against the willed action, and overcomes it. The muscle contracts in spite of tho 
will. 



AND NERVOUS SYSTEM. 



223 



Nay, those muscles which, ordinarily, move only in obedience to volition, do 
sometimes, under the influence of strong emotion, or of disease, contract independ- 
ently of any effort of the will, and even in opposition to, and defiance of, the volun- 
tary power. 

Under certain circumstances the limbs move with much briskness and force in 
decapitated animals, in which sensation and volition are extinct. Some physiologists 
hold, indeed, that sensation and volition are properties of the spinal cord ; and they 
would object to these cases, that no one is warranted in affirming the movements in 
question to be independent of the will. The animal has no means of informing us 
whether it feels or not, any more than the human head that has been severed by the 
axe or the guillotine. 

This point, however, has been settled by certain phenomena which are observed 
to occur, in the human body, under disease. Limbs completely palsied as to volun- 
tary motion, and quite dead as to sensation, do yet, under certain conditions, contract 
and move when the integuments are pinched ; the rational patient not feehng the 
pinch, and not being conscious of the movement. 

Whence does the impulse that leads to motion in these cases proceed — how is the 
motive power awakened ? 

The answer to this physiological question has a most important bearing upon the 
pathology of the nervous system. 

It is no part of my purpose to enter into any history of the steps by which this 
curious problem has been worked out. Its solution is an achievement of our own 
time ; and I may add, of our own country. I profess no more than to sketch, in 
mere outline, the leading facts that have been ascertained ; yet I must, in passing, 
pay the tribute due to one indefatigable labourer in this department of science, 
whose sagacity has enabled him to seize the clue, and in a great measure to unfold 
the mazes of the labyrinth in which this part of the physiology of the nervous system 
was so long entangled. Dim and uncertain glimmerings of the truth appear in the 
writings of bygone authors, but it was never clearly discerned, and plainly stated, 
and successfully applied to the elucidation of a large class of disorders, until the 
pubhcation, in 1832 or 1833, of Dr. Marshall Hail's ingenious and most interesting 
researches into " the functions of the medulla oblongata and spinal cord." Similar 
views appear to have suggested themselves, about the same time, to Professor Miiller 
of Berhn. I must recommend you to study the works of these authors ; and I may 
also point out, as fit writings for your perusal (since the doctrines I am now speaking 
of are comparatively . new), Dr. Grainger's Observations on the Structure and 
Functions of the Spinal cord; Dr. Carpenter's two works. Principles of General 
and Comparative Physiology, and Principles of Human Physiology : and a very 
able paper on the Pathology of the Spinal Cord, by Dr. William Budd, in the 22d 
volume of the Medico-Chirurgical Transactions. 

If, on the other hand, you wish to see how nearly the idea, which has been so 
happily simphfied into an intelligible principle by Dr. Hall, was reached by earher 
observers, you may consult the writings of Dr. Whytt, upon nervous diseases. 

What, then, respecting this intricate subject, are the main facts and doctrines 
which modern research has made clearer ? 

It seems ascertained, that the movements of those muscles which acknowledge the 
empire of the will, depend esseniially upon some momentary change in the condi- 
tion of the spinal cord. This change (whatever may be its nature) is capable of 
being effected in three several ways. 

First, vohtion, or emotion, originating in the brain, may send down an influence 
which travels with electrical rapidity to the spinal cord : whence, the requisite change 
having been instantly produced, the motive influence passes, with proportional speed, 
along the nerves which connect the cord with the muscles to be moved. 

Secondly, the change productive of motion may be wrought in the cord, whether 
the brain be attached to it or not, by mechanical, chemical, or electrical agencies, 
operating directly upon the cord itself. 

Thirdly, the change productive of motion may be wrought in the cord, by an 



224 



DISEASES OF THE BRAIN 



influence carried to the cord, not from the brain, but from the extremities of nerves 
distributed upon the internal and external surfaces of the body, 

The action of this nervous circle, whereby, I say, an influence is first carried from 
the surfaces of the body, along nerves to the spinal cord — whence again an influence 
is transmitted, or reflected, as it were, to certain muscles along certain other nerves- 
has been called by Dr. Hall the reflex function of the spinal cord. The apparatus 
subservient to this function is named by him the excito-motory system; the nerves 
which carry the impression to the cord are incident or excitor nerves ; those which 
convey the motive impulse froin the cord, rejiex or motor nerves. Dr. Carpenter's 
terms (which I like better, except for their similarity in sound) are afferent and 
efferent nerves. 

Mr. Grainger beheves that physiology indicates, and anatomy can exhibit, four 
sets of fibres belonging to the nerves and the nervous centres. Sensiferous, and 
volition nerves, connected with the gray substance of the cerebrum and subordinate 
to the exercise of feeling and of the will ; and incident and reflex nerves, connected 
with the gray matter of the cord, and belonging to the excito-motory system. 

Whether this be the true state of the case, or whether the efferent fibres be the" 
same, while the afferent fibres are different ; the latter coming to the spinal marrow 
both from the brain and from the various surfaces, just as two trains may arrive at 
Euston Square ultimately by the same rail, although the one starts at Derby and the 
other at Birmingham ; or (which is perhaps the better illustration) just as, in some 
houses, the same bell is made to ring in the servants' hall by pulling, indifferently, 
the dining-room or the drawing-room rope : — which of these two hypotheses is the 
more correct, I am not competent to determine. 

This reflex action, independent of the will, and although attended often by con- 
sciousness and sensation, yet often also exercised when there is neither, governs the 
orifice by which air and food are introduced, and excrements are voided. The 
infant breathes and sucks by it ; the aduk uses his will for bringing nutriment into i 
his mouth ; in both, the act of deglutition, after the food has reached a certain point, | 
is involuntary. The expulsion of the feces, the urine, the semen, and the fostus, is i 
regulated by the same function. Nevertheless, most of these muscular acts are ' 
capable of being moderated and directed by vohtion. The reflex power, on the 
other hand, extends, both in health and in disease, to the entire system of the strictly 1 
voluntary muscles ; during health it is manifested only in the maintenance of what I 
is called their tone, their natural tension and firmness : in disease, as we shall here- | 
after see, it sometimes acts upon them with terrific energy. ; 

Some of the difficulties which I enumerated in the beginning of the lecture, as I 
impeding our researches into the diseases of the nervous centres, are insurmount- { 
able. One or two of them, however, appear to caU for a more attentive consideration. 1 

I say we often fail to discover any deviation from the natural condition of these 
nervous centres, or of their appendages ; even when the disorder of their functions ' 
has been broadly displayed. 

We are not to infer, from this, that no change has taken place in these parts. 
The only legitimate conclusion is, that the nervous functions are liable to be deranged, 
impaired, or suspended, by altered conditions, not traceable by our senses, or at least 
not yet discovered by us, of the organs which minister to those functions. 

There may be only one such undiscovered disturbing cause, variable in degree in 
different cases ; or (what is more probable) there may be several such conditions 
differing in kind. A blow or fall, which jars the brain ; a sudden mental emotion; 
an electric shock ; a teaspoonful of prussic acid ; any one of these causes may de- ' 
stroy life, yet leave no vestige of its action in the nervous substance upon which it 
operates. It is probable that the fatal condition is not, in each case, the same. 

We may even form a reasonable conjecture of the manner in which the invisible i 
changes are sometimes brought about. We can conceive, for example, that undue 
pressure upon the nervous pulp on one hand, or insufficient pressure on the other, 
may constitute conditions of the kind we are in search of; and I shall be able, I 
think, to convince you that such is sometimes the case. Again, we can conceive 



I 



AND NERVOUS SYSTEM. 



225 



tbat such conditions may be furnished by the varying state of the cerebral circulation. 
In point of fact, we- knorv of some changes in the circulation through the brain 
which have the effect, invariably, first of modifying, and at length, if they are con- 
tinued, of arresting, the cerebral functions. If no blood be sent through the arteries 
of the brain, death in the way of syncope ensues ; if venous blood circulates in those 
vessels, it leads to death by coma. 

But whatever may be the nature of the unknown, and perhaps fugitive, physical 
conditions of the nervous centres, thus capable of disturbing or abolishing their func- 
tions, it is useful to keep in our minds a distinct and clear conception of the fact that 
there must be some such physical conditions. By steadily retaining this idea of 
their real existence, we may hope, at length, to get some insight into their nature ; 
which we are the less hkely to obtain, if we dwell only on the obvious and visible 
injuries effected in the nervous substance ; associated, as they are apt to be, with so 
perplexing a diversity of symptoms. Indeed, by the help of this distinct conception, 
we are at once enabled to reconcile some of the seeming anomalies and inconsisten- 
cies to which I before adverted. The same symptoms, I repeat, have been found to 
accompany physical lesions of the nervous centres, apparently different in kind, 
place, and degree : and, on the contrary, physical lesions, apparently identical in 
their nature, extent, and situation, are attended by different and contradictory symp- 
toms. We must not attribute the symptoms, in such cases, to the visible physical 
lesions, but to some unperceiyed condition of the nervous centres, concomitant with 
those lesions. The proximate cause of the symptoms escapes our notice. The 
obvious physical changes may be remoter causes of the symptoms — causes of this 
proximate cause : but they may also be merely cotemporaneous effects of some other 
remote agency. 

I have adverted to deviations from the natural and healthy circulation of the blood 
through the brain, as being capable of modifying the nervous functions. Of such 
deviation, one mode which is conceivable, and which has been assigned as a pre- 
sumed cause of morbid phenomena, is a variation in the relative quantity of blood 
contained respectively in the arteries and veins that he within the cranium. And it 
seems probable enough that a healthy condition of the cerebral circulation may imply 
and require a certain balancing and adjustment of the amount of blood carried in 
these two sets of vessels. But with this theory — that disturbance of the functions 
of the brain may resuk from an altered ratio of the arterial and venous blood therein 
— has been associated another; namely, that although the blood may, at different 
times, be variously distributed between the cerebral veins and arteries, yet that the 
absolute quantity of blood circulating within the cranium is always and necessarily 
the same, or nearly so. 

This notion, broached by the second Monro of Edinburgh, and upheld (as it then 
seemed) by experiments performed upon animals by Dr. Kellie, received at a later 
period the sanction and approval of Dr. Abercrombie. And, resting upon such 
authority, I have been in the habit of dehveringthe same theory, not, however, with- 
out some misgiving as to its soundness, in these lectures. It has been completely 
overthrown, of late, by Dr. George Burrows. 

The doctrine was this. The brain is closely shut up in an unyielding case of 
bone. Its surface must therefore be exempt from the influence of atmospheric 
pressure. Hence, supposing its substance to be unaltered and incompressible, it 
would seem impossible to empty the blood-vessels of the brain. The cavity being 
completely full, the blood which circulates in those vessels can neither be materially 
increased, unless something is displaced or compressed to make room for the addi- 
tion ; nor materially diminished, without the entrance of something to supply the 
place of the blood substracted. 

Dr. KeUie noticed that while, in animals bled to death, the other organs of the 
body were emptied of their blood, and blanched — the brain presented its ordinary 
appearance, and even seemed to contain more blood in its superficial vessels than 
usual. Having satisfied himself upon this point, he varied his experiment. He first 
made a small opening in the skull, by means of the trephining instrument, taking 



226 



DISEASES OF THE BRAIN 



away a little circular piece of bone, and then he bled the animals until they died : 
and in these cases he found that the brain was as completely drained of red blood as 
the rest of the body. He did that with respect to the cranium which housekeepers 
do when they tap a barrel of beer. You know that if the barrel be quite full, you 
may introduce a fawcet at its lower orifice, but no beer will run out through it. The 
pressure of the atmosphere operates upon that portion only of the fluid which is now 
exposed to the air, and its effect is to keep the beer in. But if you bore a small hole 
Mnth a gimlet through the top of the cask, and so admit air to the upper surface of 
the beer, it will then flow readily through the lower outlet. Dr. Kelhe imitated this 
process of making a vent-hole, when he trepanned the skulls of sheep, and admitted: 
air to the yielding membranes of the brain. 

He availed himself, also, in these researches, of what he considered the converse 
experiment. He desired to ascertain whether, under circumstances calculated to 
gorge the vessels of the head, those of the brain were or were not made really more 
full than usual. With this object he examined the brains of two men who had 
been hanged. When the scalp in these cases was divided, a great quantity of blood 
escaped; marking plainly enough the congestion of the vessels exterior to the cra- 
nium, but there was no such congestion observable within. " The sinuses contained 
blood, but in no extraordinary quantity ; the larger vessels on the surface and be- 
tween the convolutions were but moderately filled ; and the pia mater was, upon the 
whole, paler, and less vascular than we often find it in ordinary cases." Similar 
appearances have been noticed by myself. I paid particular attention to the condi- 
tion of the head during the examination, helow-stairs, of the body of Bishop, the 
murderer of the Italian boy. When the corpse was brought hither after the execu- 
tion, the eyes were blood-shotten, and the hps and countenance turgid and hvid. The 
inner surface of the scalp, when it was turned back, and the exposed surface of the 
skull, were very red and bloody; and in one part, on the right side of the head, 
there was some blood extravasated. But when the bone had l)een sawn through, 
and the skull-cap removed, the large veins of the brain did not appear unnaturally 
full. 

In the year 1826 I was present in St. Bartholomew's Hospital, at the opening of 
the head of a woman who had been hanged the day before, for murder. I find the 
following statement in a note which I made at the time. " The scalp was bloody, 
but the brain was of very natural texture and appearance, and not more than com- 
monly full of blood." 

Among the propositions deduced by Dr. Kellie from his observations and experi- 
ments were the following : — 

1. That in the brains of animals that have died of hemorrhage, there is no lack 
of blood, but, on the contrary, very often a state of venous congestion. 

2. That congestion of the cerebral vessels is not met with in those cases in which 
we should most expect to find it; in persons, for example, who die strangled. 

3. That the quantity of blood in the cerebral vessels is not affected by gravitation: 
in other words, that it remains the same, whatever may be the posture of the body, 
and the position of the head. 

Dr. Burrows, distrusting the whole theory, and unsatisfied with the experiments 
by which it was fortified, determined to repeat them, taking care as much as was 
possible, to exclude every conceivable source of fallacy : and he has shown, most 
convincingly, that Dr. Kellie's conclusions were erroneous. 

First, he demonstrated that hemorrhage has a most decided effect in depleting the 
cerebral blood-vessels, and in reducing the quantity of blood within, as well as upon 
the outside of the cranium. Two well-grown rabbits were killed : the one (A) by 
opening the jugular vein and carotid artery on one side of the. throat ; the other (B) 
by strangulation. Round the throat of the first, as soon as it was dead, a ligature 
was tightly drawn, to prevent any further escape of blood from the vessels of the 
head. 

" The contrast between the two brains in point of vascularity, both on the surface 
and in the interior, was most striking. In the one, scarcely the trace of a blood- 
vessel could be seen ; in the other, every vessel was turgid with blood." 



AND NERVOUS SYSTEM. 



227 



He next investigated the effect of posture upon the condition of the intercranial 
vessels. 

" Two full-grown rabbits were killed by prussic acid ; and while their hearts 
were still pulsating, the one (C) was suspended by the ears, the other (D) by the 
hind legs. They were left suspended for twenty-four hours ; and before they were 
taken down for examination, a light hgature was placed round the throat of each 
rabbit, to prevent, as effectually as was possible, any further flow of blood to or from 
the head, after they were removed from their respective positions. 

"In the rabbit (C) the whole of the external parts of the head, the ears, the eye- 
balls, &c., were pallid and flaccid ; the muscles of the scalp and bones of the cra- 
nium were also remarkably exsanguine. Upon opening the cranium, the membranes 
and substance of the brain were palhd, the sinuses and other vessels were exsanguine 
— anaemic beyond my expectation. 

" In the rabbit (D), the external parts of the head, the ears, eyeballs, &c., were 
turgid, hvid, and congested. The muscles and bones of the cranium were of a dark 
hue, and gorged with blood, which at some parts appeared extravasated. Upon 
opening the cranium, the membranes and vessels were dark, and turgid with liqi*id 
blood ; the superficial veins were prominent, the longitudinal and lateral sinuses 
were gorged with dark blood, and there was straining of the tissues, if not extrava- 
sation of blood into the membranes. The substance of the brain was uniformly 
dark, and congested to a remarkable extent." 

From these experiments. Dr. Burrows draws the logical inference, that " the 
principle of the subsidence of fluids after death operates on the parts contained 
within the cranium, as well as upon those situated in the thorax or abdomen." 

And of that absence of vascularity sometimes observed within the skulls of 
persons who have died of strangulation, he offers a very satisfactory explanation. 

In the first place, the cerebral vessels are, in some instances, highly congested. 
Something will depend upon the position of the rope; which may press unequally 
upon the jugular veins on the opposite sides of the neck, leaving one of them more 
or less pervious. 

" But there is another still more efficient cause of the occasional absence of con- 
gestion of the cerebral vessels after death by hanging. It is the subsidence of the 
fluid blood after death, while the body is yet suspended, through the cervical 
vessels which are not completely obliterated by the pressure of the cord. And, it 
should be recollected, there are some channels which are scarcely, if at all, affected 
by the compression of the rope. These other channels are the vertebral sinuses, 
and special plexus of veins, so ably delineated by M. Breschet." 

Moreover, the manner in which the corpse is generally examined, proves an ad- 
ditional source of fallacy. All the great vessels of the neck are usually cut across, 
and the viscera of the thorax removed from the body, before the skull is opened. 
Then, while the head is elevated, during the operation of taking off the calvarium, 
and examining the brain, the blood, still fluid (as it almost always remains, after 
sudden death of any kind,) "gravitates from the cranium, and pours from the 
divided cervical vessels into the chest." 

By this refutation of a prevalent error, not unlikely to warp or mislead our 
practice in some cerebral disorders, Dr. Burrows has done the science of medicine 
an essential service. 

The theory which he has demolished involved probably more than one erroneous 
assumption. Dr. Burrows thinks that the anatomical structure of the human cra- 
nium does not warrant the opinion that its contents are withdrawn from the pressure 
of the atmosphere. " The numerous fissures, and foramina, for the transmission of 
vessels and nerves through the bones of the cranium, appear to me (he says) to do 
away with the idea of the cranium being a perfect sphere, like a glass globe, to 
which it has been compared by some writers. If there were not always an equi- 
librium of pressure on the parts within and without the cranium, very serious 
consequences would arise at the various foramina of the skull." 

We fall back, therefore, upon another principle, whereby some of the difficulty 
and obscureness which attend certain affections of the brain and nerves may be 



228 



DISEASES OF THE BRAIN. 



explained. I mean the principle of varying pressure upon the nervous substance. 
Physiologists say that the cerebral matter is incompressible. This is another of the 
questionable assumptions implied in the foregoing theory. Upon what grounds the 
opinion may rest, T am ignorant : but whether the brain be compressible or not, 
whether, that is, it be or be not reducible by pressure into a smaller compass, it is 
clearly capable of having different degrees of pressure applied to it, and of being 
pressed out of its ordinary form. We shall see, hereafter, that by pressure exercised 
from within, by the distension of what are called the ventricles of the brain, the 
convolutions on its surface are sometimes flattened, and the natural furrows between 
them nearly effaced. Pressure there certainly is in what I shall have to describe 
to you as hypertrophy of the brain. There must be considerable pressure on the 
nervous pulp when blood is poured out within it from a ruptured artery in cerebral 
hemorrhage. But the phenomena noticeable when a portion of the skull has been 
removed by the trephine, show very clearly that the encephalon sustains pressure 
from the varying states of the circulation during perfect health. The surface of the 
brain, seen through the circular opening in the bone, is observed to pulsate ; and to 
piSlsate with a twofold motion. With every systole of the heart, the surface pro- 
trudes a Httle ; and it again subsides with the succeeding diastole. This shows 
that the tension of the arteries, produced by every contraction of the ventricles of the 
heart, exerts a degree of pressure upon the contents of the cranium. But the brain 
has an alternate movement also, corresponding with the movements of the thorax in 
breathing ; rising with every act of expiration, and sinking with ever};^ act of inspi- 
ration. Now, during expiration, the blood escapes less freely from the head through 
the veins ; and thus again vascular fulness is found connected with evidence of pres- 
sure on the parts within the head. In further proof of this, if any were needed, I 
may again refer to Dr. Kellie's experiments. He removed a portion of the cranium 
of a dog by the trephine. The brain was observed to rise and fall alternately, but so 
as always to fill the cranium ; the rise being marked by a sort of protrusion through 
the hole that had been made. One of the carotid arteries was now opened, and in a 
minute or two afterwards there was an evident gradual sinking and receding of the 
brain from the margin of the bone. So, likewise, when the blood was flowing from 
the rabbit (A) in Dr. Burrows' experiment, "the conjunctiva was observed to 
become pallid, and the eyeballs to shrink within the socketsy 

It is certain then that, whether the cerebral pulp yields to it or not, there is a 
constant alternation of a greater and a less compressing force, exerted upon it, during 
life. It is not improbable that this continual variation of the compressing force may 
be essential to the performance of the cerebral functions. May not the brain 
be thus incessantly charged, if indeed it be (as has been suggested by no less a 
philosopher than Sir John Herschel) "an electric pile, constantly in action," dis- 
charging itself by the nerves, at brief intervals, " when the tension of the electricity 
developed reaches a certain point ?" However this may be, it is equally certain that 
the compressing force may transgress its natural limits, in either direction ; may be 
too great or too little. The functions of the nervous centres may be perverted, or 
lost, when the pressure becomes excessive : or, on the other hand, when the pressure 
is insufficient. 

It is plain that excess of pressure may cause fatal com.a, or defect of pressure fatal 
syncope, and yet no evidence of the operation of these causes be left in the dead 
brain. And we may explain, by the help of this same theory of pressure, a very 
singular phenomenon observed in certain forms of cerebral disease ; I mean the 
occasional recurrence only of the symptoms, although the organic disease itself be 
permanent. For example, we see continually persons who are epileptic : that is, 
they have fits of convulsion and stupor noiv and then, and appear perfectly well in 
the intervals. After the death of such patients we sometimes find organic disease of 
the brain ; a piece of bone perhaps projecting from the cranium, or a tumour, or a 
cyst : and this we are apt to consider as a sufficient explanation of the preceding 
disease; but we are always pressed with this difficulty; if the tumour or piece of 
bone was the cause of the paroxysms, why had the paroxysms any cessation ? 

It seems probable, or not improbable, that in such cases as these, and in many 



SYMPTOMS OF CEREBRAL DISEASES. 



229 



others, the permanent morbid condition is a predisposing cause only of the occa- 
sional symptoms ; rendering the diseased organ more sensible to variations in the 
circulation; to accidental circumstances which determine an undue amount of com- 
pressing force, or a deficient amount ; and I think Dr. Abercrombie has gone too 
far when he says "we may safely assert that the brain is not compressible by any 
such force as can be conveyed to it from the heart through the carotid and vertebral 
arteries." 

Dr. Kelhe narrates the following curious circumstance : — "Mr. G., with a nume- 
rous train of distressing symptoms, which too well marked the existence of enlarge- 
ment of the heart, and the violent propulsive energy of that viscus, had only one 
characteristic of any disturbance within the head. On looking upwards to the 
whitened ceiling of a room, he saw a darkened spectrum, which vanished and reap- 
peared with great regularity. It was soon discovered that the appearance of this 
umbra was synchronous with the systole of the heart, so that he used often, in my 
presence, to count his pulse with the utmost precision, by keeping his eye fixed on 
the ceiling, and numbering every appearance of the spectrum." In this case it is 
presumable that by each contraction of the left ventricle of the heart, plethora of the 
cerebral blood-vessels was produced, and therefore an excess of pressure upon the 
cerebral substance. In that which I am about to quote it seems, on the other hand, 
probable that comparative -emptiness of the vessels of the brain, and a consequent 
defect of the requisite degree of pressure, occasioned the morbid phenomenon. 

A gentleman, thirty years old, was reduced to a state of extreme weakness and 
emaciation by some complaint of his stomach. As the debility advanced he became 
very deaf ; and this symptom varied in the following instructive manner. He was 
very deaf while sitting erect, or standing ; but when he lay horizontally, with his 
head quite low, he could hear very well. If, when standing, he stooped forwards, 
so as to produce flushing of the face, his hearing was perfect ; and upon raising 
himself again into the erect posture, he continued to hear distinctly as long as the 
flushing continued : as this went off the deafness returned. — (Abercrombie.) An 
old clergyman, who is sometimes my patient, is troubled by two grievances : deaf- 
ness and an intermitting pulse. They are both always benefited by quina. 

Objections, I should tell you, have been raised against this theory of pressure 
affecting the functions of the nervous centres ; but I think the objections are sus- 
ceptible of a satisfactory answer. I must content myself, however, for the present, 
with having pointed out the main grounds upon which the theory rests. The diffi- 
culties that attend it, and the considerations which diminish the force of those diffi- 
culties, will come necessarily before us on a future occasion. 



LECTURE XXII. 

Symptoms of Cerebral Diseases. — Inflammation of the Dura Mater and Arach- 
mid, from external injury ; from Disease of the Bones of the Ear, and of the 
Nose. — Inflammation of the Pia Mater, 

The functions of the brain, summarily expressed, being sensation, thought, and 
voluntary motion, we naturally look for disturbances of those functions whenever 
the orfjan suffers disorder or disease. And experience has made, us familiar with 
various forms of disturbance to which these same cerebral functions are liable. Let 
us pass them shortly in review. 

1. The faculty of sensation may be morbidly keen, or morbidly obtuse ; or it may 
be perverted : in other words, it may deviate in degree, or in kind, from the healthy 
standard. 

The sensations referred to the several surfaces and structures of the body, and to 
the organs of sense, may (without any fault in those parts and organs) be preternatu- 
rally acute. Tenderness ascribed to different parts, their natural sensations being 

u 



230 



DISEASES OF THE BRAIN. 



heightened into pain ; a general state of irritability ; intolerance of light, and of 
noise ; are so many instances of this over-sensitiveness of the percipient organ. 

Under the head of diminished or defective sensation may be ranked, numbness in 
all its degrees, up to total loss of sensibility or ansesthesia ; dullness of hearing, deaf- 
ness ; dimness of sight, blindness ; failure, or absolute extinction of the senses of 
taste and of smell. 

Perverted sensations, sensations unnatural in kind, are very numerous. To men- 
tion a {ew : giddiness ; nausea ; ringing in the ears ; ocular spectra ; ill smells in 
the nostrils ; false tastes on the palate ; itching ; and sundry uneasy feehngs, many 
of which are indescribable. Various kinds of pain belong to this class ; spirits vio- 
lently high ; causeless depression, anxiety, and dread. 

2. Innumerable degrees and varieties of disturbance of the faculty of thought are 
met with. Dehrium in all its shades ; dullness and confusion of intellect ; sundry 
defects of memory ; incapacity of judgment ; and every degree of stupor up to com- 
plete coma. 

3. Of the function of voluntary motion there are also various kinds and grada- 
tions of derangement : twitchings of the muscles ; tremors of the hmbs ; rigidity 
from spasm ; irregular and involuntary jactitation ; convulsions ; muscular debihty ; 
palsy. 

Now, as I stated before, there is, and there can be, no physical exploration of the 
living brain. We are limited, therefore, in studying its diseases, to the rational 
symptoms. It becomes our task to interpret the import of the multiform disturbances 
of function just enumerated, in every case in which more or fewer of them appear; 
and when you are told that these symptoms are apt to present themselves in almost 
every conceivable order and combination, and, moreover, that many of them may be 
sympathetic of diseases of other parts than the brain, you will scarcely need to be 
further informed, that the language they speak is often very hard to construe ; that 
we frequently fail to reach and discover, by these outward signals, the inward things 
they denote. 

I am about to consider, in the first place, some of the inflammatory affections of 
the brain, and some which may easily be mistaken for inflammatory affections ; and 
I warn you beforehand, that, in respect to exactness of diagnosis, we are sadly bar- 
ren of certainties in these matters. Hints, sketches, approximations, are nearly all 
that I can promise concerning not a few of the many diseased conditions to which 
the brain and its appendages are obnoxious. 

In the brain, as in other composite organs, inflammation may be general or par- 
tial. It may attack certain tissues only : it may be seated in the substance of the 
cerebral mass ; or in the membranes that envelop it. 

I need not tell any of you that the membranes which invest the brain are three in 
number; the fibrous dura mater, the serous arachnoid, and the pia mater, which is 
composed of blood-vessels held together by a web or areolar tissue. 

Speaking generally, inflammation of the cerebral substance alone, is perhaps more 
common than inflammation of the investing membranes alone. The central parts of 
the nervous mass may and do suffer inflammation, while the membranes escape. 
But it seems to me scarcely possible that inflammation of the pia mater should take 
place without implicating also the surface of the convolutions with which it has so 
close a relation, and so intimate a vascular connection. 

Again, with respect to the membranes themselves, the dura mater may be inflamed 
while the pia mater remains unaffected. I beheve also that the arachnoid may suffer 
inflammation, and leave the subjacent pia mater untouched. Whether the arachnoid 
ever escapes participating in the inflammation of the dura mater on the one side, or 
of the pia mater on the other, is to be doubted. 

.Can we separate and distinguish these several inflammations by assigning to each 
its proper external phenomena ? Seldom ; scarcely ever. Doubtless each has its 
pecuhar symptoms ; and if inflammation were often strictly hmited to the one mem- 
brane or the other, and if the course and events of the inflammation did not modify 
the condition of the brain itself, by pressure, or by affecting the circulation of blood 
through it, then we might expect greater uniformity, and might hope by careful and 



DURA MATER AND ARACHNOID. 



231 



repeated^ observation to seize upon the desired distinctions. But this simplicity is 
not exhibited by the inflammatory affections of the parts within the cranium. Inflam- 
mation commencing in one membrane is apt to spread readily and rapidly to the 
rest, and to the cerebral substance ; and the complication of diseased conditions 
coexisting within the skull at the same time, throws confusion over the whole sub- 
ject. This uncertainty of exact diagnosis is however of the less consequence, inas- 
much as when we have learned that inflammation is going on in any part of the 
encephalon, we have learned enough to direct us as to the general plan of treatment 
to be adopted. 

After all, certain symptoms do present themselves more frequently when one part 
is inflamed, and certain other symptoms more frequently when another part is 
inflamed; and it will be proper and convenient to contemplate certain forms of 
meningeal inflammation separately. 

Let us, first, then, consider inflammation as it is confined, occasionally, to the dura 
mater — or to the dura mater and arachnoid. 

This very rarely happens as an idiopathic or spontaneous disease ; but it is not at 
all uncommon as a result of external injury. And we may advantageously trace its 
ordinary phenomena and consequences, by attending to these instances of traumatic 
inflammation of the dura mater. They were excellently well described many years 
ago, by Mr. Pott. A man receives a blow on the head ; the blow stuns him per- 
haps at the time, but he presently recovers himself, and remains, for a certain period, 
apparently in perfect health. But after some days he begins to complain ; he has 
pain of the head, is restless, cannot sleep, has a frequent and hard pulse, a hot and 
dry skin, his countenance becomes flushed, his eyes are red and ferrety ; rigours, 
nausea, and vomiting supervene ; and, towards the end, delirium, convulsions, or 
coma. Meanwhile the part which was struck becomes puffy, tumid, and somewhat 
tend-er ; and if this tumid portion of the scalp be cut through, the pericranium beneath 
it is found to be separated from the bone ; moreover, the bone itself is observed to be 
altered in colour, whiter and drier than the healthy bone ; and if a piece of this bone 
be removed, it is also seen that the dura mater on the other side of it is detached 
from the cranium, and sometimes smeared with lymph or puriform matter. This is 
a form of disease very often met with by the surgeon. I have watched, with much 
interest, several such cases under the care of my hospital colleagues. One or two 
of them I will briefly describe. 

In J;he year 1833, during Christmas time, the coachman of a lady living in my 
neighbourhood fell, being intoxicated, into a cellar or area, struck in his fall one side 
of his head, and tore up the scalp over a considerable space. He was carried to the 
hospital, where the loose flap of integuments was cleansed and replaced. After 
some days erysipelas came on, and then a much larger portion of the scalp sloughed 
away, so that the bone was laid bare to a frightful extent, and looked, at a little dis- 
tance, as he sat up in bed, like the tonsure of a monk. Nevertheless the man seemed 
wonderfully free from suffering or distress : his pulse, indeed, was frequent, but it 
was said to be so during health. His intellect was clear, and he had no head symp^ 
toms ; or rather, no brain symptoms. 

In the early part of February, 1834, he had a shivering fit, which was followed 
by convulsions of the right side of the body, and subsequently by paralysis of the 
right arm and leg, and by stupor, from which he could easily be roused. He would 
put out his tongue when desired to do so; but to every question he answered "3^es." 
A portion of the left parietal bone was evidently dead : here the trephine was 
applied ; and a piece of bone being removed, the dura mater Avas exposed. It 
looked as if it had lost its vitahty. Some pus lay upon it. No relief followed the 
operation. 

On the 10th of February fluctuation was detected beneath the dura mater, which 
was then slit open. About three drachms of puriform fluid escaped. The patient 
died soon afterwards, having had no active delirium throughout. 

The surface of the dura mater was found to be nearly of its natural appearance, 
except where the trepanning had been performed. At that spot it was dry and 



232 



DISEASES OF THE BRAIN. 



sloughy. Over the whole of the anterior and lateral surface of the left hemisphere 
there lay, upon the arachnoid, a thick coating of coagulable lymph, smeared with 
pus : this extended down the posterior part of the hemisphere also, nearly to its 
base. There was no other morbid appearance ; no fluid in the pia mater, nor in the 
ventricles. The substance of the brain was everywhere perfectly sound and healthy: 
it was divided in all directions in search of an abscess, but nothing unnatural could 
be delected. 

Another man came to the hospital to have a small incised wound of the scalp 
looked at. The injury appeared to be trivial ; the cut was dressed, and the man 
made an out-patient. A few days afterwards he came again, incompletely paralytic 
on one side of his body. I saw this man's skull trepanned ; he was perfectly calm 
and collected : that part of the dura mater which corresponded to the wound was 
found to be inflamed ; and there was pus diffused over the arachnoid covering the 
cerebral convolutions on the same side. He sank quietly into a state of coma, and 
so died. Not the slightest incoherence or delirium had been manifested : there 
had been no convulsions, nor was there any other morbid appearance within the 
cranium. 

I mention these cases to show you the grounds of my own opinion, that inflam- 
mation, beginning in the fibrous membrane, may affect the arachnoid, without neces- 
sarily extending to the pia mater; just as inflammation may overspread the pleura, 
or the pericardium, without touching the lung or heart which those serous mem- 
branes respectively clothe. Here no sensible traces of inflammation were discovered 
deeper than the free surface of the arachnoid ; and there had been no disturbance, 
till towards the end, of the proper functions of the brain. I conclude that the disease 
did not pass beyond the serOus membrane ; for I can scarcely conceive inflammation 
of the pia mater to exist without involving, in some degree, the^ surface of the brain; 
nor inflammation of the surface of the brain to exist without some manifest derange- 
ment of the cerebral functions. In the instances that I. have been relating, the final 
stupor and palsy may reasonably be ascribed to pressure resulting from the events 
of the inflammation of the arachnoid : from the effused pus and lymph. 

Inflammation of the dura mater is very rare as a simple and idiopathic affection. 
Dr. Abercrombie relates one instance of it, as the only one he had seen ; and even 
that was not a pure case of inflammation of the dura mater. There was pus upon 
that membrane, which adhered to the cranium over a space as big as a crown-piece, 
and at that spot was ulcerated. But there was also found an adventitious m.embrane 
beneath the arachnoid where it covers the brain. 

Speaking generally, this complaint is marked by pain of the head, by fever, and 
by rigors which intermit ; and so regular sometimes are the intermissions, that the 
practitioner may be tempted to believe that he has got an aguish patient, and to 
administer bark. The intellectual faculties, especially at the outset of the disease, 
are but little affected ; which is just what we might expect. The dura mater and 
the arachnoid lying apart from the sensorium, their inflammation can have no other 
than an indirect influence upon its functions. 

Although inflammation of the dura mater is very uncommon as an idiopathic or 
primary disorder, we very frequently meet with it as a secondary affection ; and 
then there are few diseases more surely fatal or less within the reach of remedies. 
It is as a consequence of what is called otitis, that physicians are chiefly accustomed 
to encounter inflammation of the dura mater. It results from disease of the internal 
ear, and of the petrous portion of the temporal bone. Sometimes acute inflammation 
arises within the tympanum, when there has been no previous disease : the patient 
has severe headache ; at length a gush of matter comes from the external meatus, 
but the pain does not, as it usually does in such cases, cease ; it continues, or even 
increases in intensity ; the patient begins to shiver; he becomes dull and drowsy ; 
slight delirium, perhaps, occurs ; and by degrees he sinks into stupor. In some 
instances no pus issues externally. More commonly symptoms of the same kind 
supervene upon a chronic discharge of purulent matter from the ear. It is scarcely 
possible to sketch an accurate general picture of this insidious but most dangerous 
complaint. Next to seeing and watching actual cases of it, the best way of becoming 



DURA MATER AND ARACHNOID. 



233 



I acquainted with its phenomena is by attending to recorded instances. I will bring* 
I before 3'ou, therefore, some examples of inflammation of the dura mater, occurring 

in connection with disease of the interior of the organ of hearing. 
' A youth, sixteen years old, applied to the late Dr. Powell (who has related the 
case in the fifth volume of the Transactions of the College of Physicians) on account 
of an eruption, with an acrid discharge behind the right ear. He had become deaf 
1 five years before, after scarlet fever, but no discharge took place at that time from 
I the ear. In the following year, however, he had the measles, and then an abscess 
I formed in the right ear ; and after giving him much pain, it burst. He had again 
' suffered, three days before Dr. Powell first saw him, a sudden attack of very severe 
! pain in the same ear. The pain quite deprived him of rest ; but he had no fever, 
nor deJirium, nor coma. He slept, indeed, a great deal, but that was the effect of 
opiates, which he took to relieve the pain. This symptom was quieted by the opium ; 
but it always returned with severity if the medicine was suspended. A foetid dis- 
charge came from the ear. On the tenth day of this attack, after a most violent 
paroxysm of pain, his strength rapidly declined, and he died. 

"When the head was examined, the structure of the dura mater was healthy and 
natural, but beneath this membrane the whole superior surface of the right hemi- 
sphere was covered with a layer of coagulable lymph and pus. The vessels of the 
substance of the brain were not more numerous or loaded than usual, and the brain 
itself was healthy in every part. In the base of the skull the dura mater adhered 
to the bone, except at one part, of about half an inch diameter, just over the petrous 
portion of the temporal bone, where it was black and sloughy. The subjacent 
portion of the bone itself was carious, black, and crumbling ; and contained foetid 
pus." 

In this case, you will observe, there was no symptom to mark the extensive mis- 
chief within the head, except the pain : the pulse never exceeded 72 ; the skin 
was warm and moist ; there was neither fever, nor dehrium, nor convulsion, nor 
coma. 

_ A girl, aged nine, (I take this case from Dr. Abercrombie, whose volume on the 
diseases of the brain is full of practically instructive examples,) had been liable to 
attacks of suppuration of the ear, which were usually preceded by severe pain, and 
some fever. She suffered one of these attacks in the left ear, in July, 1810. Upon 
the discharge of matter from the ear she did not obtain ease, as she had done on 
former occasions; but continued to be affected. with pain, which extended over the 
forehead. When Dr. Abercrombie saw her, he found that, besides the pain, she 
had some vomiting, and impatience of light. Her look was oppressed ; the pulse 
84, Blood-letting, purging, blistering, and mercury, were employed without relief. 
Tavo days afterwards there was slight and transient delirium, a degree of stupor, and 
slight convulsions. She lay constantly with both her hands pressed upon her fore- 
head, and moaning from pain, of which there had not been the least alleviation. On 
the fifth day from the commencement of the discharge, she continued sensible, and 
died suddenly in the afternoon, without either squinting, blindness, or coma, the pulse 
having been always under 90. A considerable quantity of colourless fluid was 
found in the ventricles of the brain, which, in other respects, was healthy. In the 
left lobe of the cerebellum there was an abscess of considerable extent, containing 
purulent matter of intolerable foetor. The dura mater, where it covered this part of 
the cerebellum, was thickened and spongy, and the bone corresponding to this portion 
was soft, and shghtly carious on its inner surface ; but there was no communication 
with the cavity of the ear. 

Here again the pain was the most prominent symptom, and probably resulted from 
the partial inflammation of the dura mater. It is interesting to mark these two 
points : — that the disease in the bone imparted disease to the dura mater, although 
• no passage was opened from the tympanum ; and that this inflammatory state of 
the external membrane of the brain led (apparently) to deep-seated suppuration 
in the cerebellum; the parts lying between the abscess and the dura mater 
escaping. 

This last, and somewhat singular circumstance, might have been owing, (so at 

u2 



234 



DISEASES OF THE BRAIN. 



least I conjecture), to the extension of the inflammation from the suppurating ear to 
some of the veins of the skull; and the consequent formation in the cerebellum of 
one of those secondary abscesses so connmonly noticed in uncircumscribed phlebitis. 
Two very remarkable instances of diffused inflammation of veins, and of its terrible 
effects, occurring in connection witk purulent otorrhoea, have fallen under my own 
observation ; one of them in private practice, the other in the hospital. As I am not 
aware that such consequences as supervened in these cases upon otitis, have received 
much attention, I will briefly describe them. 

The first of these two patients was a boy, eleven years old, whom I attended with 
Dr. Maclntyre and Mr. Arnott. He had had a discharge of oifensive purulent 
matter from his ear since the time when, four years before, he had gone through 
scarlet fever. In August, 1833, he went, for a walk, into Kensington Gardens, and 
there lay down, and slept upon the damp grass. The next day he was attacked 
with headache, shivering, and fever. Strong rigors, followed by heat and perspi- 
ration, occurred very regularly for two or three days in succession ; suggesting the 
suspicion that his complaint might be ague : but then pain and swelling of some of 
the joints came on, and were, at first, considered rheumatic. However, the true and 
alarming nature of the case soon became apparent. Abscesses formed in and about 
the aflected joints ; and one of these fluctuating swelhngs was opened, and a consi- 
derable quantity of foul, grumous, dark-coloured matter let out. After about a fort- 
night the child sunk under the continued irritation of the disease. The hip-joint 
presented a frightful specimen of disorganization ; it was full of unhealthy sanious 
pus, the ligamentum teres was destroyed, the articular cartilages were gone, and 
matter had burrowed extensively among the surrounding muscles. The knee and 
ankle joints of the same limb were in a similar state. It is curious that the destruc- 
tive disease of the joints was limited to those of the right lower extremity, while the 
primary suppuration was in the left ear. Unfortunately the head was not examined ; 
but that the fatal disorder had penetrated from the ear to the dura mater, I entertain 
no doubt : in all probability the inflammation had involved the veins or sinuses of 
the head. 

The second case had many points of similarity with this. 

William Marriott, aged 19, was admitted under my care into the Middlesex Hos-; 
pital, on the 18th of October, 1834, having pain and tumefaction of the right shoulder, 
wrist, and foot, with redness of the latter. He complained also of headache, vertigo, 
drow^siness, and of an occasional feehng of stupor. His skin was hot and dry, his 
face flushed, his tongue furred, his pulse frequent (112), and his bowels were re- 
laxed. A puriform discharge came from his right ear. 

He had been suddenly seized, a w-eek before, with sharp pain in that ear, which 
lasted twenty-four hours, when the discharge commenced, and the pain was relieved. 
He then began also to have headache, which had never left him, and to be sometimes 
dizzy. Three days previously to his admission the rheumatism (as he supposed it 
to be) commenced in the foot. When this part was examined, the redness was 
found to be circumscribed, somew^hat livid, and limited to the great toe. It had much i 
the appearance of gout. 

He soon began to be troubled with shivering fits, which recurred regularly every , 
morning about the same hour, and were followed by burning heat of the skin, but 
no sweating. An abscess formed near the toe, and was opened by Mr. Mayo, and 
some healthy-looking pus evacuated. Next a large fluctuating tumour near the 
shoulder was punctured, and three ounces of pus, mixed with blood, came out. 
After this incision the rigors ceased ; but the abscesses continued open, and the dis- , 
charge had an offensive smell. On the 14th of November it was discovered that 
matter had collected in the left hip : this also was emptied by puncture. On the 1st 
of December, a very large quantity, not less than three pints, of unhealthy and 
grumous pus, was let out from a vast abscess which had forn:ied in the loins : and 
pus was noticed in his stools. The discharge from the shoulder came at last to 
resemble the lees of port wine. 

During all this while the patient remained feverish, with a dry parched tongue, 
and a rapid and feeble pulse. The diarrhoea continued, more or less, throughout. 



DURA MATER AND ARACHNOID. 



235 



For some time before his death, which happened about the middle of the month of 
i December, the left leg and thigh had been much enlarged by cedema. 
I I was not able to be present at the inspection of the body ; and 1 have to regret 
ji that in the report which I received of it, the condition of the brain, of its membranes, 

and of its veins, was not noted. 

The right shoulder-joint was extensively diseased ; the cartilages were destroyed 
I by uiceration over a considerable space. Those of the left hip were entire, but the 

synovial cavity was fuJl of foul matter. The joint of the great toe w^as implicated 

also in the abscess which had formed there. The femoral vein, on the left side, was 
I plugged up, throughout its whole extent, by a coagulum, which was firm and of a 

reddish brown colour at the upper part of the vessel, Joose and darker towards the 

ham. The saphena was pervious : the ihac was free from disease. 

The lungs had undergone partial disorganization. Several distinct portions of the 

pulmonary tissue were nearly solid, while the tissue immediately around them was 

crepitant and heahhy. From these small sohdified portions, purulent matter could 

be made to ooze by gentle pressure. 

The mastoid cells of the right temporal bone were filled with pus, and there was 

a sht-like opening in the membrana tympani. The small bones of the ear were 

sound. 

I much lament that in these instances, the direct hnk of connection between the 
disease of the ear and the disorganization of the joints was not demonstrated : for 
seeing (they say) is believing. Yet the pain of the ear, the discharge of pus from 
the external meatus, the subsequent pain of the head, coming on with fevers and 
rigors, and followed after a short interval by destructive suppuration in several dis- 
tant parts, and, in the last case, the actual femoral phlebitis : these circumstances 
form a chain of presumptive evidence, amounting, in my judgment, to moral cer- 
tainty, that the fatal mischief, in each case, found entrance through " the porches of 
the ear ;" and that the dura mater underwent inflammation. The same evidence is 
scarcely less affirmative of the complication of cerebral phlebitis. Perhaps the veins 
of the diploe, which in the cranial bones are of considerable magnitude, were 
involved in the inflammatory mischief ; perhaps the large sinuses of the brain. The 
close vicinity of the lateral sinus to the diseased bone, and its formation by a dupli- 
cature of the dura mater, would seem to render such a complication highly probable. 

These views, which were brought forward in my first course of lectures here, in 
1836, have been confirmed by the pubhcation, very recently (1841) in the Medical 
Gazette, by Dr. Bruce of Liverpool, of two cases witnessed by himself, of " Phle- 
bitis of the cerebral sinuses as a result of purulent otorrhea." Pie refers to several 
other instances of the same kind recorded by different authors. This combination 
of disease is doubtless more common than had been heretofore supposed : and the 
important pathological considerations connected with it wiU probably receive further 
illustration, now that the attention of the profession has been called to the subject by 
Dr. Bruce's paper. 

Dr. Griffin has published, in the Dublin Journal of Science, two examples of 
otitis attended with symptoms exactly resembling those of intermittent fever. One 
of them is as follows : — A young man, previously healthy, was attacked with fits of 
shivering, accompanied by pain in the left side of the head. At first the paroxysms 
were rather irregular, but they soon assumed the form of tertian ague ; coming on 
every other day, at about the same hour ; the cold fit commencing at noon, and 
lasting about half an hour, followed by a hot stage of somewhat longer duration, 
and then a profuse sweat. In the intermissions the pain in the head was trifling: 
there was no thirst nor heat of skin, but he did not sleep. A tumour formed over 
the mastoid process of the left side, and was opened, and a quantity of extremely 
ofTensive brownish pus sprang out with great force. This gave much rehef. The 
bone was carious over a space as big as a shilling. After about ten days, the pain 
in the head and in the mastoid process became very severe ; the patient had violent 
shivering fits many times in the day, great thirst, heat of skin, vomiting, and deh- 
rium : his face was flushed, and his pulse hard ; and he died within a few hours 
after the accession of these last symptoms. 



236 



DISEASES OF THE BRAIN. 



The most remarkable features in tliis case were the smiilarirv of the fits of shiver 
ing to the paroxysms of ague, their regujar recuiTence at periods of fony-eight hours, ^ 
and the circumstance that they seemei to be checked, for some time, by the treat- 
ment proper in ague : namely, the e5h:b:::on of bark. The occurrence oi quotidian 
paroxysms of the same kind iia.s been nctior i m rehating some of the previous cases. 

I have related them to show you what dinri-n: symptoms nic-y rr^\;_: : intiam- 
marion of the dura mater; and to put you upon vour guard ag:.::".-: cv-r.oikmo; the 
cause from which such indamnjiition does frequently originate. Tne suppuration of 
the tympanum, and consequent disease of the bone, are more C'lmrnin m scrofulous ^ 
persin; than in others : and they are more apt to occur as a seyie: :: scarlet fever , 
tlian in any other way. I conceive that the inflammation of the t::; :j.:, belonging to '. 
that disorder, and often constituting all hs danger, cret^iis along the Eustachian tube , 
into the interior of the ear. In strumous subjects the hre thus hghted smoulders on, ! 
or if It ever c-oes out. is readily rekindled : that part of the temporal bone, in which . 
the organ of hearing is principalh; lod^red, becomes carious : the membrana tympani 
is perforated: the little bone; 'M h.-e ear come away: more or less deaihess ensues; 
and from time to time, or haoituahy it may be, there is a discharge of pus from the 
external orifice. At length the inner surface of the bone participates in the disease ; 
and then the inflammation is apt to be propagated to the dura mater, in the manner 
of which I have given you some instances. It is in the first onset of the inflamma- 
tion in the ear that remedies are most likely to be enicient in preventing this catas- 
trophe, Lerchei a;y:.:rj. -irlv and repeatedly to the mastoid process, especially 
when that pan beconi-s tmder. as it often does in such cases, and counter-irritatioQ 
afterwards, are the best mtans in our possession. 

[T :e ::? ::.: - v which, inflammation of the dm-a mater supervenes npon otitis, espe- 
ci? : . ; : rM be kept constantly in mind; for it is only by a prompt, active, and 
:u. : 5 : > .r \_iist the disease is confined to the internal ear, that we can have any 
li: - : . ::ent — ^when inflammation has extended to the dura mater, the termi- 

na::;:i is Vrry ^r::er?...r latal. — C] 

If symptoms of acute inflammation within the head supervene, the complaint 
requires more vigorous treatment, vrhich I shall describe when I have spoken of in- ; 
flammation of the other membranes of the brain. After what has been said, it is 
unnecessary to point out to you th-at the prtg-nosis in these ca^es is v^rv unfavour- . 
able. But we are not to abandon them in de;i-a::-, TivAt infiammanon of the dura i 
mater may be r-cover-d from, we know, by wna: harp-ns in ctrtain injuries of the 
head: and the i'j..j-":r.g wc i.i seem to be an ini:anc^ o: recovery when the source ■ 
of the mischief was situated m the ear. A yorin:' Ir. h;. afer the usual symptoms j 
in the head, lay for three or four days in a sta:e prrirct coma, and her condition" i 
was thought utterly hopeless. Her medical atitndanis con:inued to visit her as a i 
matter of form ; and one day they were agreeably surprised to find her sitting up, ' 
and free irom complaint : a copious discharge of matter had taken place from the 
ear. v,-i:h immediate rehef : and she continued in good health. — (Abercrombie.) 
"We cannot be sure in such a case that the matier came from the brain; but the 
symptom made tha: supposition exceedingly pro'rarli, The case shows clearly one 
of two things : eiiher that pus may thus i-;ca;:e frrrn the skull, and the patient get 
weU ; or that pus shut up in the cavirv of trie t'.'inpanum may produce the urgent 
symptoms that are known to result frjm cerebral pressure. 

Cases are recorded of analogcus disease communicated from the carious a^thmoid 
bone to the dura mater: the patients liovin;- had pain in th- frrhiead and purulent 
discharge from the nose, and becoming at last forgetful and d-.ir:ous. and dying in 
a state of coma. I have never met with an instance of this kind ; nor of inflamma- 
tion spreading inwards from the socket of the eye : but I make no doubt that each 
may occasionally happen. 

These three, then — idiopathic inflammation of the dura mater — very rare ; in- 
flammation of the dura mater by extension of disease from the sthmoid bone, or 
from the orbit — also infrequent; and inflammation of the dura mater by extension 
of disease from the petrous ponion of the temporal bone — very common: constitute 
those forms of inflammation of the outermost tunic of the brain, which the physician * 



PIA MATER. 



237 



may be called upon to treat. The inflammation is not always — nay, perhaps it is 
seldom, if ever — restricted to that tunic ; but it begins there ; and the essence of the 
disease is inflammation of the dura mater. 

Acute arachnitis— hy which I mean active and uncomhined inflammation of the 
arachnoid membrane — is, I apprehend, a very uncommon disorder; although that 
term is of frequent occurrence in medical writings. I have shown you already that 
inflammation may pass from the fibrous dura mater to the serous membrane reflected 
over it ; and thence (by what is sometimes called contiguous sympathy) to the oppo- 
site portion of the same membrane spread over the surface of the brain. So, hke- 
wise, inflammation may extend from the pia mater to the arachnoid. If simple 
arachnitis, of an acute kind, ever happens, it has not been my fortune to see or to 
recognize it ; and I can tell you nothing about it. In truth, the authors who use the 
word arachnitis do not intend thereby to express unmixed inflammation of the arach- 
noid ; but include under that term inflammation of the pia mater also. Some apply 
the name meningitis to that compound affection ; and the only objection to this 
nomenclature is, that the dura mater is as much one of the meninges of the brain as 
either of the two others. 

In the few remarks which I have to make upon inflammation of the pia mater 
(or, if you will, of the pia mater and arachnoid at once), I shall chiefly follow Dr. 
Abercrombie : because his observations are comparatively recent, and carefully 
made ; because his veracity, and sobriety of judgment, and philosophical turn of 
mind, are well known ; and because his cases (as regards this particular affection) 
are quite to the point, and hi^ descriptions clear and concise. 

But I must premise a word or two respecting the anatomical characters of the 
disease. 

When the upper part of the skull, and the dura mater, have been removed, you 
may frequently see, on the surface of the exposed brain, what seems to be a thin 
layer of a clear gelatinous substance : but this appearance is fallacious. Puncture 
here and there the transparent arachnoid, and a limpid fluid, hke water, trickles out ; 
and the jelly-hke investment of the convolutions is gone. Now this thin serous 
liquid, thus collected in the meshes of the pia mater, may be the event of inflamma- 
tion of that membrane : but it may also be produced, and it very often indeed is 
produced, by simple congestion and re mora in the cerebral veins. Nay, a certain 
am.ount of serosity, in this situation, belongs to the condition of health. We cannot, 
therefore, with any certainty, infer, merely from seeing this serous effusion, that 
there has been inflammation : we judge of its import, by noting the co-existence, or 
the absence, of other traces of inflammation ; and by the character of the symptoms 
that preceded death. 

On the other hand, we may be sure that there has been inflammation of one or 
both of these tunics of the brain when we find false membranes between them ; 
layers, i. e., of coagulable lymph. In the effusion of this substance I conclude that 
the vessels of the pia mater play the main part ; both because it is always, in such 
cases, excessively vascular, while the arachnoid is seldom found to be so in any 
remarkable degree, if at all: and also, because the false membrane commonly, though 
not always, sends down layers between those duplicatures of the pia mater which 
descend into the sulci formed by the convolutions ; where, as you know, the arach- 
noid does not go. In fact, considering the arachnoid as the serous membrane of the 
brain, we should expect that, when inflamed, it would present the events or products 
of inflammation on its free surface ; and we sometimes find them there ; but this is 
very rare ; and for my own part, I look upon those effusions which lie beneath the 
arachnoid, between it and the pia mater, as being furnished exclusively by the ves- 
sels of which the latter membrane is mainly composed. 

Now the inflammation of these membranes (taking them together) commences, 
and declares itself, by no fixed or uniform symptoms. The most common and 
striking phenomena is a sudden and long-continued paroxysm of general convul- 
sions. Sometimes this is the first thing noticed. Sometimes it comes on after a 
few days of discomfort, slight headache, and vomiting. The convulsions recur, and 



"I 

I 



238 DISEASES OF THE BRAIN. ' 

I 

at length end in coma. Sometimes, again, the first attack of convulsions is preceded ^ 
by violent pain in the head, setting in quite suddenly, and attended with screaming i 
Considering, on the one hand, the intimate connection between the pia mater and 
the gray m.atter of the convolutions, and, on the other, the presumed functions of 1' 
that gray matter, we might expect that inflammation of the pia mater would soon be \ 
attended with some manifest derangement of the mental faculties. Accordingly, ti 
deliriimi, often violent and continued, is stated by most authors to accompany and t 
denote inflammation of the membranes ; and especially of the membranes where ! 
they invest the upper surface of the cerebral hemispheres. Yet I do not find that f 
symptom mentioned in any of the various examples of meningitis recorded by Dr. •) 
Abercrombie. He does give cases, indeed, in which there was much delirium ; ; 
but they were not cases of meningitis of any kind. He relates them as instances i 
"of a very dangerous modification of the disease, which shows only increased vas- ; 
cularity." I venture with great humility to question or criticise any opinion of Dr. j 
Abercrombie's ; but I entertain no doubt about the nature of the cases which he so | 
describes ; and I hope to convince jou by-and-by that they are not examples of I 
inflammation at all : they neither show the anatomical characters of inflammation, ! 
nor yield to the remedies of inflammation. Excluding these cases, I do not find 
delirium specified as a symptom of uncombined meningitis. I shall abridge one or j 
two of the well-marked examples of the disease. 

A girl, aged nine, woke suddenly in the middle of the night, screaming from vio- 
lent headache, and exclaiming that some person had given her a blow on the head. 
For the next two days she complained of some, but not much pain in her forehead, 1 
and did not even remain constantly in bed : no alarm was felt about her. On the 
third day she was seized with violent and long-continued convulsions, and imme- 
diately after the convulsions she fell into a state of deep coma ; she remained in this 
state, with a natural pulse, till she died, on the sixth day of the disease. 

When the dura mater had been removed, the other membranes appeared highly j 
vascular, except where this appearance was concealed by a layer of yellow adven- j 
titious membrane, spread out betwixt the arachnoid and the pia mater. This was j 
distributed in irregular patches over various parts of the surface of the brain, but 
was most abundant on the upper part of the right hemisphere. It was as thick as 
a wafer, and in some places dipped down between the convolutions. A considera? i 
ble quantity of it extended over the surface of the cerebellum also. I 

A child two years old was suddenly attacked one morning with severe and long- ; 
continued convulsions. The convulsions recurred many times ; in the intervals she ^ 
was dull and torpid, in a state of partial coma, with occasional starting, and a frequent i 
and feeble pulse. On the fourth day she sank. j 

The surface of the brain, when the dura mater was removed, was covered in many I 
places, betwixt the arachnoid and pia miater, by an adventitious membrane. It , 
was chiefly found above the openings between the convolutions, and in some places | 
appeared to descend a httle way between them. The arachnoid when detached ' 
seemed to be healthy ; but the pia mater was in the highest state of vascularity ' 
throughout ; and when the brain was cut vertically, the spaces between the convolu- 
tions were most strikingly marked by a bright line of vivid redness, produced by 
the inflamed membrane. There w^as no eflusion in the ventricles, and no other | 
morbid appearance. 

In another example, the whole surface of the brain was covered by a continued 
stratum of yellow false membrane, lying between the arachnoid and pia mater, and 
in some parts following the course of the pia mater through the whole depth of the 
convolutions : the pia mater and arachnoid adhered together everywhere, very 
firmly, by means of it: not a trace of it could be found either on the outer surface 
of the arachnoid, or the inner surface of the pia mater : the arachnoid itself, when 
separated, presented no unusual appearance, but the pia mater was everywhere ex- > 
cessively vascular. There was no serous efliision, and the brain and cerebellum were 
perfectly healthy. ) 

Now in this dissection there was unequivocal evidence of acute and extensive 
inflammation of these membranes, or I should say, of the pia mater ; yet the symp- 



PIA MATER. 



239 



toms had been very obscure. The child in whom the disease occurred was conva- 
lescent from a mild attack of scarlet fever. One evening he became very feverish, 
and complained of his belly. Three days afterwards he had frequent vomitings 
followed by stupor, and some convulsive movements of his face and arms, and death 
took place four days and a half after the feverishness began. We learn from this 
case, that general and severe inflammation of the innermost membrane may exist, 
and prove fatal, without giving jise to any violent symptoms at all. 

I must trouble you with one more history, because it affords another example of 
what I have mentioned as being rare; viz., the effusion of the products of inflam- 
matory action upon the outer surface of the arachnoid, — marking therefore very 
distinctly the inflammation of that membrane. It was evidently combined, however, 
with inflammation of the pia mater also. A child, eight months old, died after more 
than three weeks' illness ; which began with fever, restlessness, and quick breathing; 
afterwards there were frequent convulsive affections, with much oppression ; and at 
last severe convulsions, squinting, and coma. At an early period of the complaint, 
a remarkable prominence of the anterior fontanelle was noticed ; in the second week 
this increased considerably ; and in the third week, it was elevated into a distinct 
circumscribed tumour, which was soft and fluctuating, and pressure upon it occa- 
sioned convulsions. It was opened by a small puncture, and discharged at first some 
purulent matter, afterwards bloody serum. No change took place in the symptoms, 
and the child died four days after. 

A deposit of thick flocculent matter mixed with pus was found covering the sur- 
face of the brain to a considerable extent, and lying upon the free surface of the 
arachnoid. There was a similar deposition also between the arachnoid and ftie pia 
mater, and considerable effusion into the ventricles. 

If the sketches I have been giving you afford a true outline of the phenomena 
which attend acute inflammation of the pia mater, or of the pia mater and arachnoid 
jointly, what, you may naturally ask, is the nature of those cases in which there is 
high excitement, and much fever, and great dehrium, and which are sometimes 
spoken of as phrenitis, or as brain-fever ? Why these are instances of acute inflam- 
mation of the whole contents of the cranium ; of the brain and its membranes ; 
of the encephalon in short ; and, therefore, the disease has, not improperly, been 
called encephalitis. Of this formidable malady I shall give you some account 
to-morrow. 



LECTURE XXIIL 

Acute and general inflammation of the Encephalon. Period of Excitement. Modes 
in which the disease mxiy commence. Period of Collapse. Treatment. Deli- 
rium tremens. 

Acute inflammation does sometimes appear to invade at once the whole of the 
parts that are lodged within the skull; or, beginning in one part, it extends rapidly 
to all the rest. As the contents of the cranium are called, collectively, the encephalon, 
so the disorder which I am about to consider has been named encephalitis. It is an 
uncouth appellation, but it will serve its purpose. Cullen, and many others, apply 
the term phrenitis to the same disease. You may choose between these names, 
taking care to remember what they signify. The malady is sometimes described as 
inflammation of the membranes of the brain. I believe this to have arisen from the 
circumstance that the effects of the inflammation, which become visible after death, 
are often more striking and obvious on the surface of the brain, or in its ventricles, 
than in the cerebral substance itself. An abscess in the nervous mass can scarcely 
be overlooked : a softening of the cerebral pulp may escape the notice of a hasty 
or inexpert observer : and those changes of colour, which sometimes denote increased 



240 



DISEASES OF THE BRAIN. 



VEiscularity of the same part, may very easily be passed over Vv'ithout attracting 
much attention^ 

Phrenitis, or encephahtis, or acute and general inflammation of the brain and i.s 
membranes, as it occurs in adults, presents two periods, which are marked by differ- 
ent symptoms, and in most instances are very distinctly observable. In the first 
period what are called symptoms of excitement predominate ; the functions of the 
organ are exaggerated as well as disordered : in the second period those symptoms 
appear which are comprised under the term collapse. Sometimes these two sets of 
symptoms, instead of following each other, are more or less mixed and confounded 
together. But the distinction is real, and requires to be attended to. 

The symptoms that characterize the period of excitement, are pain of the head, 
often intense and deeply seated, or extending over a large part of it ; a sense of con- 
striction across the forehead ; throbbing of the temporal arteries, flushing of the face; 
injection of the eyes, which' have a wild and brilhant look ; contraction of the pupils ; 
preternatural sensibility to external impressions, amounting frequently to impatience 
of light, and of sound; violent dehrium; want of sleep; paroxysms of general 
convulsion ; a parched and dry skin ; a frequent and hard pulse ; a white tongue ; 
thirst ; nausea and vomiting ; constipation of the bowels. 

You are not to look for all these symptoms in every case, nor to cor ,..i*t 
your patient has not inflammation of the brain because the phenomena I . been 
enumerating do not all present themselves, or do not take place in any regular order 
of succession. 

In fact, we find, in actual practice, that encephalitis is apt to come on, to commence 
I mean, as far as symptoms are concerned, in three or four different ways. 

Sometimes there is a sudden alteration of manner, and the patient, complaining 
probably of his head, becomes all at once and furiously dehrious ; and fever is 
lighted up. These are symptoms which cannot pass unnoticed, and which imme- 
diately direct one's attention to the head. They may, however, be fallacious, as we 
shall see by-and-by. 

In other cases the first thing remarked is nausea and vomiting : and these symp- 
toms may soon cease ; or they may continue several days, and even sometimes 
throughout the whole course of the disease. Bitter fluids are brought up, yellow or 
green, and evidently containing a good deal of bile ; and whatever is introduced into 
the stomach, even a small quantity of the most simple drink, is immediately rejected. 
With this state of matters there is generally much constipation, and the bowels refuse 
to act except under the stimulus of strong purgatives. 

It is important to attend to these symptoms ; for, occurring, as they usually do, 
with headache, they may easily deceive a person who is not previously aware of 
what they may portend. If the patient has not been previously subject to sick 
headaches, and if the epigastrium and abdomen be natural, not tender, nor distended, 
as they are apt to be w^hen the stomach itself is in fault, we have the more reason to 
look narrowly into the case, and to suspect that some serious mischief of which the 
nausea is a token, may be going on in the brain. I would observe, by the way, 
that where there is much vomiting of bile, persons are apt, both patients and their 
doctors, to blame the liver, to set down the disorder as bilious ; but you ought to be 
aware, that whenever vomiting is often repeated, or long continued, bile is to be 
expected in the matters brought up : the action of the duodenum, as well as that of 
the stomach, is inverted ; and the bile passes in the wrong direction. If you have 
ever suffered from sea-sickness, you must know that after the puking has gone on 
for a httle while, bile is constantly voided. 

Again, some cases of acute inflammation of the brain set in neither with sudden 
and great disturbance of the intellectual functions, nor with sickness and vomiting, 
but with a paroxysm of general convulsion, such as often ushers in an attack of me- 
ningitis. This symptom, according to Andral, is a much more certain sign of cere- 
bral inflammation, than the occurrence of active dehrium ; and I quite agree with 
him in so thinking. 

It is probable (but I speak conjecturally only) that this diversity of symptoms, 
marking the onset of encephahtis, may depend upon the part in which the in- 



ENCEPHALITIS. 



241 



fiammation begins ; and that it is soon propagated from that part to the whole of the 
organ. I should suppose that when nausea and vomiting are the earhest symptoms, 
tthe inflammation has taken its point of departure in the cerebral pulp ; in the sub- 
stance of the brain ; and that when the attack comes on with a sudden fit of convul- 
sion, the inflammation has commenced in the pia mater or arachnoid. This is con- 
sonant with what we know of inflammation of those parts when they are separately 
aflected. Again, it seems to me presumable that the cases which are characterized 
by early and fierce delirium are cases in which the inflammatory action has invaded 
the whole of the encephalon, substance and membranes, simultaneously. I say I 
ofler these as conjectures of my own : what it is of importance for you to remember 
is, that inflammation of the brain does commence in the three several ways that I. 
have been describing. 

There are some cases, however, that cannot be brought within even this general 
rule. They begin in some irregular or obscure manner, or with some unusual phe- 
nomenon. Andral states that he has seen a few striking instances of inflammation 
of the brain, of which the first sign was a sudden loss of the power of speech ; and 
Dr. Abercrombie relates a very remarkable case in which the same thing happened. 
I CP very remarkable both on account of the singular manner in which the dis- 
' showed itself, and because it furnishes an example of encephalitis produced 
by fi exposure to intense heat of the sun — insolation ; an event very uncommon 
in oui climate. It occurred in the practice of a surgeon at Selkirk, in Scotland : — 

"A young man, aged 16, bathed twice, on the 5th of June, 1818, in the river 
Tweed. After coming out the second time he lay down on the bank and fell 
asleep, without his hat, and with his head exposed to the direct beams of a hot sun. 
On awaking, he was speechless ; but walked home, and seemed to be otherwise in 
good health. He was bled and purged, and the next day recovered his speech, but 
lost it again at intervals several times during the three or four following days. He 
was forgetful, and his look was dull and heavy : he made little complaint, but when 
closely questioned said he had a dull uneasiness at the back of his head. In a few 
days more he had squinting and double vision, and a very obstinate state of bowels, 
and his pulse was 60. After further bleeding the pulse rose to 86 ; but he sank 
gradually into coma, and died on the 30th. 

The substance of the brain in general was found highly vascular, and a very con- 
siderable extent of it was in a state of softening mixed with suppuration. The ven- 
tricles were distended with fluid, and the membranes in many places were much 
thickened. One very curious circumstance (affording perhaps some explanation of 
the readiness with which the inflammation was produced) was, that the cranium was 
of very unequal thickness at its upper part ; in one spot, as big as a sixpence, it was 
as thin as writing-paper, and transparent. 

However, the phenomena which I mentioned at first constitute the common and 
ordinary symptoms of acute inflammation of the brain and its membranes. They 
continue for a variable period ; from twelve hours to tw^o days, or more ; and then 
they are succeeded by others, which characterize the second stage of the complaint, 
or ihe period of collapse, as it is called. These result, I apprehend, from the events 
and products of the inflammatory action ; the violence of which is over or abated. 
The patient ceases to complain of headache ; instead of being excited or wildly deli- 
rious, he mutters indistinctly, and falls into a state of stupor, from which it is diflicult, 
and at length impossible, to rouse him. His vision and hearing are no longer pain- 
fully acute, but dull, or perverted ; strabismus and double vision are not uncom- 
mon ; and the pupil, from being contracted to the size of a pin's head, becomes first 
oscillating, then widely dilated, and ultimately motionless. The patient is not shaken, 
at this period, with violent convulsions ; but twitchings of his muscles, and startings 
of their tendons come on, and some of his limbs are agitated with tremors, or become 
powerless and palsied ; the countenance is ghastly and cadaverous ; cold sweats 
break out ; the sphincters relax : at length the coma becomes profound, and fife 
ceases. 

The disease, when it proves fatal, as it too often does, mostly runs a rapid course. 
It may kill in as short a time as twenty-four or even twelve hours ; or the patient 
16 V 



242 



DISEASES OF THE BRAIN. 



may struggle on for two or three weeks. The morbid appearances met with in the 
dead body are very various. Serous or puriform effusion into the ventricles, and 
into the meshes of the pia mater ; layers of coagulable lymph between that mem- 
brane and the arachnoid ; softening of the cerebral substance, with pus infiltered 
into the softened parts ; or great vascularity, shown by a pink or purphsh motthng 
of its cut surface, giving it a stained appearance. 

Let us next consider the treatment required for this frightful disorder. 
It is quite plain that in an organ so essential to life, and of such delicate organiza- 
tion as the brain, and in which changes so irreparable in their nature as many of 
those I have just enumerated, so readily take place under acute inflammation, we 
cannot hope to be of much service unless we see and treat the case at an early 
period. On this account it becomes exceedingly important to recognize the nature 
of the disease, at its very commencement ; and, therefore, I have taken pains to 
point out to you the various forms which it may assume, while it is yet within the 
reach of remedial measures. 

The principal of those measures are blood-letting, purging, and the application 
of cold to the head. All the particulars of the antiphlogistic regimen are to be 
rigidly observed ; the patient should be kept as much as possible in silence, and 
darkness, \vith his head bieh, and on a firm pillow. And the antiphlogistic reme- 
dies are to be employed with decision and energy. 

With respect to bleeding I can only repeat what I have said before : the blood 
should be drawn in a full stream, and suffered to flow till some -decided impression 
is made upon the pulse ; or until syncope occurs, or is evidentl}^ at hand. After 
the patient has raUied a httle, blood should be taken b}^ cupping or leeches from the 
back of the neck, or the temples, or the mastoid processes ; and these depletory 
measures must be repeated according to the violence or continuance of the symp- 
toms which first demanded them. 

The apphcation of cold to the head is a remedy of great importance in this disease. 
The head must be first shaved, and the mere removal of the hair is sometimes fol- 
lowed by a manifest abatement of some of the most urgent symptoms ; of the pain, 
for example, and of the delirium. In cases such as I am now supposing, it wnll not 
be enough to apply wetted cloths to the head : the application must be colder than 
the ordinar}^ temperature of the cold water ; and it may be made colder by ice ; and 
the best way to ensure a permanent depression of the superficial heat is to put some 
pounded ice with a little water into a thin and flexible bladder, and to lay it on the 
patient's head : there should not be too much ice, or its w^eight may be injurious. 
This is generally very grateful and pleasant to the feelings of the patient ; and we 
often have the satisfaction of perceiving that, wnth the reduction of the external heat 
of the head, there is also an evident mitigation of the violent symptoms; the agi- 
tation and delirium are calmed, and the patient sleeps, or recovers his senses. 

Another excellent and most powerful method of applying cold, is by pouring cold 
water in a slender stream upon the vertex of the head, until it produces some marked 
effect. Of course this as well as all other strong measures, must be adopted w^ith 
great caution, and its influence closely watched : I mean it is not to be left to the 
discretion, or indiscretion, of domestics and nurses. Dr. Abercrombie tells us that 
he has seen a strong man, submitted to the operation of this cold douche, " thrown 
in a very few minutes into a state approaching to asphyxia, w^ho immediately before 
had been in the highest state of maniacal excitement, with morbid increase of 
strength, defeating every attempt of four or five men to restrain him." Of the 
effect of this measure in a somew^hat different morbid condition, he gives an 
instance, which I will quote, because it shows, in the first place, the striking power 
of the remedy ; and, secondly, the simple mode of applying it. A strong plethoric 
child, five years old, after being for one day feverish, oppressed, and restless, fell 
rather suddenly into a state of perfect coma. She had been in that state about an 
hour when Dr. Abercrombie saw her. She lay stretched on her back motionless, 
and completely insensible ; her face flushed and turgid. She was raised into a 
fitting posture, and a basin being held under her chin, a stream of cold water was 



ENCEPHALITIS. 



243 



directed against the crown of her head. In a few minutes, or rather seconds, she 
was completely recovered ; and the next day was in her usual health. 

This measure also is to be repeated, according to the circumstances of the case. 

Some persons recommend that a constant dripping of cold water upon the patient's 
shaven head should be kept up. This may easily enough be managed by means of 
a sponge and funnel placed a little above the head. Andral mentions his attending 
with another physician (M. Recamier) a young man who laboured under all the 
symptoms of acute inflammation of the brain. Cold water was made to drop slowly 
upon his head, and complete recovery took place, although no other active treatment 
of any kind was adopted. 

In strongly recommending this efficient remedy to your notice, you will not un- 
derstand me to advise that it should supersede the use of copious blood-letting ; it 
is to be employed as an auxiliary to the lancet ; not as a substitute for it. 

The third remedy w^hich I named, that is to say, purging, is also of great im- 
portance and efficacy. But it must be hard purging. There is a great tendency 
to obstinate constipation in most cases ; and this must be overcome, and free and 
frequent evacuations from the bowels obtained ; five grains of calomel and fifteen 
of jalap should be followed in three or four hours by a strong black dose ; and 
after that I should give, in such cases, three or four grains of calomel every four 
hours, and repeat the black dose at least every morning, until the symptoms gave 
way. If the mercury thus exhibited affect the gums, so much the better; but 
we must not, in this disease, combine it with opium, to prevent its passing off by the 
bowels. 

Dr. Abercrombie uses this strong language in reference to the value of purga- 
tive medicines in acute inflammation of the brain: — "In all the forms of the dis- 
ease, active purging appears to be the remedy from which we find the most 
satisfactory results ; and although blood-letting is never to be neglected in the earlier 
stages of the disease, my own experience is that more recoveries from head affec- 
tions of the most alarming aspect take place under the use of very strong purging 
than under any other mode of treatment. In most of these cases, indeed, full and 
repeated bleeding had been previously employed, but without any apparent effect in 
arresting the symptoms." He has found the croton oil the most convenient medi- 
cine for this purpose. 

Dr. Abercrombie is disposed to regard mercury as being useful in affections of 
the brain, chiefly in virtue of its purgative operation : and the opinions of a phy- 
sician of his large experience, and observing mind, must and ought to have great 
weight. But 1 must not conceal from you my own persuasion that, in the early 
periods of acute inflammation of the encephalon (and it is of the early periods 
that I have hitherto been speaking), if the mercury comes in a short time to produce 
its specific influence upon the gums, a great change for the better will often be per- 
ceived. Such is the result of my own observation. Recollect, however, that you 
are not to give calomel with the direct object of affecting the gums, but as part of 
the purgative plan, and you take the chance of its specific effect. You must not 
combine opium with it, for two reasons ; first, you would thereby shut up the 
bowels, and deprive yourself of the use of one of your best weapons ; and, secondly, 
you would incur the risk of augmenting and perplexing your patient's head symp- 
toms, and of puzzling yourself ; since you would not be able to determine how much 
of the coma that ensued was owing to the progress of the disease, how much to your 
remedy. 

When the second order of symptoms have arrived, those which are included 
under the general phrase of collapse, and which commonly result, I fancy, rather 
from the products of the inflammation than from the inflammation itself; from 
softening, that is, and from pressure exerted by effused serum, or lymph ; when this 
order of symptoms make their appearance, I believe the time for doing much good 
by active bleeding has gone by. If, however, blood-letting has not yet been em- 
ployed, and especially if the pulse continue hard, whether blood has been already 
abstracted or not, it will be right to give the patient the chance of that remedy. Of 
the propriety of doing so, take the following illustration : — " A girl, aged eleven, had 



244 



DISEASES OF THE BRAIN. 



violent headache and vomiting, with great obstinacy of the bowels ; and these symp- 
toms were followed by dilated pupils, and a degree of stupor bordering upon perfect 
coma ; pulse 130. She had been ill five or six days ; purgatives, ^hstering, and 
mercury to salivation, had been employed without benefit. One bleeding from the 
arm gave an immediate turn to this case, the headache was reheved, the pulse came 
down, the vomiting ceased, the bowels were freely acted upon by the medicines 
which they had formerly resisted, and in a few days she was quite well." (Aber- 
CROMBiE.) I must recite one other case — from among many which go to the same 
effect — to show the occasional influence of hard purging. " A young man who 
had had cough and dyspnoea, and been bled for those symptoms, appeared conva- 
lescent. One evening he became affected with headache, and some vomiting. 
About midnight, having got out of bed to go to stool, he fell down in a state of vio- 
lent and general convulsion. The convulsion returned during the night six or seven 
times with such violence that one of the paroxysms continued without intermission 
for an hour. The pulse during the night, varied from 60 to 120." (I should have 
mentioned before this great and rapid fluctuation of the pulse in respect to its fre- 
quency, as being a very common circumstance and sign, in inflammatory affections of 
the brain.) " At first it was found impossible to bleed him, on account of the vio- 
lence of the convulsions ; but about seven in the morning a full bleeding was ob- 
tained, after which the convulsions ceased, except some slighter attacks during the day, 
which appeared to be arrested by pouring cold water over his head. The next day he 
was oppressed ; with occasional tremors of the Hmbs, and some vomiting, and he had 
one or two threatenings of convulsion. He took repeated doses of active purga- 
tives with little effect ; and on the following morning he appeared to be sinking into 
a state of perfect coma, with a pulse at 50. Croton oil was now given, which 
operated powerfully seven or eight times. He passed a good night; and the day 
afterwards was free from complaint." 

Having this evidence of the separate efficacy of the three remedies — blood-letting, 
strong purgatives, and the local appKcation of cold to the head — we have much en- 
couragement to put them into combined operation in these very serious cases, espe- 
cially when we have the opportunity of using them at an early period. Should the 
disorder happily yield to these measures, great care will long be required on your 
part, and great prudence on the part of the patient and his friends, lest the recent 
mischief should rekindle. A relapse is even more perilous than the first assault of 
the disease. Such prudence and care will consist chiefly in the avoidance and 
denial of all that might excite and disturb the brain; whether it be a premature 
return to animal food ; or indiscreet and fatiguing interviews and conversations ; or 
the too early resumption of the cares and concerns of business. 

Are we to employ blisters in this disease 1 Not in the outset, during the period 
of excitement. They only add to the irritation, and make matters worse. And 
especially you should avoid putting them, as many are apt to do, upon the head 
itself, at that stage of the disease. We should not suppose, a priori, that they could 
then, and in that place, have any beneficial effect. They cannot divert the blood 
from the inflamed part ; but they may attract it towards the encephalon. If they 
could be expected to do any good at all, it would be when they are placed upon the 
feet or legs. But this kind of revulsion is better accomplished by means of mustard 
poultices, or fomentations with hot water, which are often of much apparent service, 
in addition to the measures already spoken of. Experience confirms what reason 
teaches us to look for in this matter. 

When, however, the patient had sunk into a state of coma, he has sometimes, in 
my experience, emerged from that condition after a cap of bhstering plaster has 
been put upon his head. It is only when the violent symptoms of excitement have 
abated that I can venture to advise you to employ blisters: they may then be applied 
to the nape of the neck, or behind the ears, or to the head itself. 

The symptoms which I enumerated as marking the period of coUapse or sinking, 
are fearful symptoms ; but the conditions on which they depend are not, necessarily, 
hopeless conditions. These symptoms do not always proceed from fatal disorganiza- 
tion of the brain, but sometimes (there is resison to beheve) from simple exhaustion 



Ex\CEPHALITIS. 



245 



of the nervous power. And this is a point of critical importance. Patients appa- 
rently moribund are occasionally saved by the judicious administration of stimu- 
lants and restoratives ; of ammonia, Hoffman's anodyne, beef-tea, wine, and, it may 
be, of well-timed opiates. This plan of treatment you must therefore cautiously try, 
when an extreme degree of collapse occurs. If the structure of the brain be already 
seriously injured, and the disease irretrievably mortal, no harm can be done ; while 
in doubtful cases, and when the symptoms result from mere depression of the vital 
powers, the patient may be rescued ; and this chance in his disease must not be 
thrown away. 

Do you ask whether there be any mode of discriminating these opposite condi- 
tions, one of which is within, and the other beyond, the range of possible recovery ? 
I believe there is. If the tendency to death by coma be strong, the prospect is very 
discouraging : if, on the other hand, the symptoms that mark the mode of dying by 
asthenia predominate, you may hope to push the patient through. But to succeed, 
you must watch him hour by hour. Pallor, a feeble and flying pulse, extreme de- 
bility and tremors, coldness of the extremities, a want of power to respond to exter- 
nal impressions; these are alarming, but not absolutely desperate symptoms, espe- 
cially if the menial faculties remain. Whereas profound stupor, partial palsy, 
profuse sweats, are of the worst omen ; yet even these do not preclude the trial, 
together with blistering the head, of internal stimuli ; and no other plan affords even 
a gleam of hope. 

There is just one caution that 1 wish to mention before t leave the subject of acute 
encephalitis ; and it applies to all cases of coma and insensibihty, and especially when 
there is any paralysis mixed with the coma : it is, that you should daily ascertain 
that the bladder is emptied. Always make the attendants show you the urine that 
has been passed ; and lay your hand upon the hypogastric region, and try whether 
there is any undue hardness or prominence there, produced by the distended blad- 
der. I shall revert to this matter more particularly at some future time ; and I con- 
tent myself with merely suggesting its importance to you now, in all cases of head 
affection. If the patient does not or cannot empty his bladder, of course it must be 
emptied for him, by means of a catheter. 

It would seem perhaps the most natural arrangement if I next proceeded to speak 
of cerebral inflammations which are chronic, or partial. These forms of disease are 
more common, in adults, than acute and general encephalitis. I shall be obliged also 
to treat, separately, of inflammation of the brain as it is modified by its occurrence 
in young children, — of what is called acute hydrocephalus. But before I touch upon 
any of these, I am desirous to bring under your notice at once a very singular and 
extremely interesting complaint, which is not, I am persuaded, in its essential nature, 
inflammatory, but which may easily be mistaken, and has over and over again been 
mistaken, for acute inflammation of the brain and its membranes, with the consider- 
ation of which we have just been occupied. The mistake is the more serious, 
because the remedies I have been recommending for encephalitis, and especially 
blood-letting, not only are not required, but are in most cases positively injurious, in 
the disorder of which I am now about to speak : and which is best known under the 
appellation of delirium trem.ens. Nay, this affection of the nervous system may 
actually be brought on, in a predisposed subject, by the abstraction of blood. I go 
apparently out of my way in taking notice of this complaint now, but 1 do so that 
I may have the opportunity of contrasting it with encephalitis, while the phenomena 
of the latter disease are fresh in your memory. It certainly resembles it also in 
many respects: and it has been regarded as an inflammatory disorder by some 
excellent pathologists. 

The symptoms which mark a decided attack of delirium tremens, and which 
have sometimes been found so equivocal, are very striking. You wiU be sum- 
moned to a man who is supposed to be mad, or to have brain fever. You find him 
with a red face, perhaps, and injected eyes, talking wildly and incessantly, fidgeting 
with his hands, affected often with tremors of the limbs, having a rapid pulse, and 
Dathed in sweat. Now it is very natural that a person not on his guard should look 

v3 



246 



DISEASES OF THE BRAIN. 



upon these symptoms as indicating inflammation within the head. But if you look 
closely into the matter, you will find in the state of the patient, and in his history, 
some things very pecuhar. The delirium you will generally find to be, not a fierce 
or mischievous dehrium, but a busy dehrium : he does whatever you desire him to 
do, but he does it in a hurried manner, with a sort of anxiety to perform it properly. 
During the approach of the malady, while he is yet able to go about, he manifests 
great impatience of any interference, or advice, or assistance, in his ordinary duties, 
which he sets about in a bustling and blundering manner. His loquacity is extreme, 
and he refers to matters that are not present before him : he is not altogether inattentive 
to the objects and proceedings that are going on around him, but his mind wanders 
away to other subjects. There is an odd mixture of the real and the ideal in his 
thoughts and language. Sometimes he is very suspicious that those who are about 
him intend him some injury ; or that he is surrounded by enemies. You will find 
also that he does not sleep ; that he has not slept perhaps for several nights, but 
been restless and rambhng ; and you will generally learn that he has been habitually 
intemperate, or subject to some great source of care, or anxiety, or excitement : and 
in many cases he has recently been somehow or other debarred from his customary 
stimulus. In addition to these points in his history, you will frequently be told that 
having been unwell, first he has been kept upon low diet, and then, as the delirium 
came on, he has been freely bled ; and that he has been none the better, but com- 
monly the worse for the bleeding. When you gather such particulars as these 
from his friends (for upon his own statements you cannot place any rehance), and 
when you find the delirium to have the characters I have been attempting to de- 
scribe, and especially when there has been obstinate watchfulness, and the tongue 
is moist, and the skin is sweating, you may be pretty certain that your patient is 
affected, not with inflammation of the brain, but with delirium tremens ; and that if 
you bleed him further, you will make him worse. 

But what are you to do under such a fearful state of things ? Why the great indi- 
cation is to procure sleep ; and the remedy which, in nine instances out of ten, you 
will find successful, is opium. The beneficial effects of this drug, in tolerably 
favourable cases of delirium tremens, are really surprising. I will give you an 
exam.ple or two, which will be more instructive than any abstract description. 

Tn the year 1831 I was requested, by a most respectable practitioner in this town, 
to visit a patient of his whom he reported to have had phrenitis, for which he had 
been freely bled, cupped from the back of the neck and purged ; and who, he 
beheved, was now rapidly sinking, and not likely to survive many hours. I found 
the. patient, a middle-aged man, with a red face, ferrety eyes, a frequent pulse, 
bathed in perspiration, busy with his hands, which trembled a httle, and talking 
much and incoherently. He was particularly anxious that his legs should not be 
scarified, told me he was wiUing to do any thing I pleased, if I would not scarify his 
legs, nor let any one else scarify them. There was nothing the matter with his legs, 
nor had it entered any body's head but his own, that they wanted scarifying. He 
had not slept for several nights. He had been intemperate, especially of late, drink-* 
ing a good deal ; and somewhat anxious about his affairs : he was a builder. 

His former history was not very promising. He had brought up a good deal of 
blood a few months before, and some years previously he had had jaundice ; latterly 
he had been troubled with indigestion. 

I saw him in the afternoon, and prescribed one-third of a grain of morphia : in the 
evening he was just in the same state. I then directed half a drachm of laudanum 
to be given immediately, and twenty drops every two hours afterwards, till he slept, 
1 said to the gentleman who had called me to the case, that I thought it very likely 
our patient might be well the next day ; he smiled and shook his head. I was 
obliged to leave London, early the next morning, for two or three days ; on my 
return, I learned from the medical man that the patient took five doses of the laud- 
anum, after which he fell asleep, and slept soundly, and for a long time, and then 
awoke (to his attendant's extreme surprise and satisfaction) sane, and well. 

I was asked by the apothecary of the Middlesex Hospital to see a publican in 
that neighbourhood. I found a large strong man between 30 and 40 years of age. 



DELIRIUM TREMENS. 



247 



He had been without sleep for several nights, somewhat incoherent, and (what is 
not usual in such cases) violent, threatening and striking those about him because 
they refused him access to strong drink. He was joint proprietor with another in a 
gin-shop, and for some time previously he had been a sot, and daily muddled with 
drink. He told me he was quite well ; there was not much tremor. I found that 
the object of his partner and relations in sending for me was that I might sanction 
his removal to St. Luke's, for his strength made him altogether unmanageable, and 
his insane and extraordinary conduct was hurting the business of the house. I 
declined to take any part in consigning him to a mad-house, and recommended 
morphia. After one full dose he soon slept ; and the next day he was quite rational, 
and comparatively well. 

These are the broad outhnes of delirium tremens ; there are many other features 
wanted to complete the portrait of the disease, which I shall endeavour to paint at 
our next meeting. 



LECTURE XXIV. 

Delirium Tremens, concluded. Chronic Inflammation of the Brain. Softening, 
Suppuration, Abscess, Induration, Tumours in the Brain. 

I DREW a rude outline, yesterday, of that singular and interesting malady usually 
denominated delirimn tremens. The disease is very common in this country ; for 
its causes are in common and powerful operation. You will meet with it in every 
walk of life : and you will be almost sure to witness several examples of it during 
the course of every year, in any of our metropolitan hospitals. It is not a chronic 
or vague complaint, likely to be treated with placebos, or by waiting upon nature. 
Active measures are pretty certain to be adopted ; and, in many cases, one plan of 
treatment, vigorously pursued, will hurry the patient to his grave ; another plan 
will restore him to health with an almost magical celerity. It certainly bears a 
strong resemblance to that most formidable disease, inflammation of the brain and its 
membranes ; but the great remedy for encephalitis acts hke a poison in pure deli- 
rium tremens ; and the drug, by the timely and careful administration of which we 
can often promise a speedy cure in delirium tremens, is one which we must care- 
fully avoid, in the earlier treatment, at least, of encephalitis. Accuracy of diagnosis, 
therefore, between these different disorders, with similar outward signals, becomes 
of the very highest importance. 

Delirium — tremens. — There is delirium always ; and there is generally, but not 
always, tremor. The name is a good enough name, in my humble opinion ; yet it 
has been found fauk with, because the trembling is not in all cases present; and 
some have, therefore, christened it delirium e potu, or delirium ebriositatis : but 
these terms are open to just the same objection as the other ; for though the disorder 
is most commonly connected with intemperate habits, that is not always the case. 
One very curious fault has been discovered in the name : it is said that the delirium 
cannot tremble; and, therefore, that it is better to say, delirium cum fremore, or 
tremefaciens : and you would hardly suppose it, but there has been a sort of conten- 
tion for the honour of thus mending the nomenclature of this disease. But they who 
do object to delirium tremens appear to see no harm in delirium ferox ; whereas it 
is just as incorrect to say delirium is fierce, as to say that it trembles: it is the 
patient who is furious, even as it is the patient who trembles ; and all this dispute 
about a name is mere trifling. It matters not what we call a disease, so that the 
name conveys no erroneous theory as to its nature or treatment. No such source 
of error attaches itself to the term delirium tremens : and, therefore, if it be only to 
avoid the inconvenience of change, we will adhere to that term. 

Recollect that the strong features of the complaint are sleeplessness ; a busy, but 
not angry or violent delirium ; constant chattering ; IrembUng of the hands, and aa 



248 



DELIRIUM TREMENS. 



eager and fidgety employment of them. To these are added other symptoms which, 
though they are not so calculated to strike a looker-on, are of not less importance, 
inasmuch as they help to estabhsh the diagnosis. The tongue is moist and creamy ; 
the pulse, though frequent, is soft; the skin is perspiring, and most commonly the 
patient is drenched in sweat. The sweat is usually described as having an offensive 
or a peculiar smell : I cannot say that I have observed it to be so. The face also is 
said to be pale ; but that, I know, is not always the case, and therefore this point 
cannot be rehed upon as a distinguishing circumstance. In one of the instances 
which I related in the last lecture, the face was flushed, and the eyes red and ferrety. 

Let me remind you, in a few words, of the peculiar characters of the dehrium. 
If you question the patient about his disease, he answers quite to the purpose ; de- 
scribes, in an agitated manner, his feelings, puts out his tongue, and does whatever 
you bid him: but immediately afterwards he is wandering from the scene around 
him to some other that exists only in his imagination. Generally his thoughts appear 
to be distressful and anxious ; he is giving orders that relate to his business to per- 
sons who are absent ; or he is devising plans to escape from some imaginary enemy : 
he fancies that rats, mice, or other reptiles, are running over his bed, or that strangers 
are in his room. He looks suspiciously behind the curtain, or under his pillow, and 
he is perpetually wanting to get out of bed ; but he is readily induced to lie down 
again. It is very seldom that he meditates harm, either to himself or to others ; there 
is rather a mixture of cowardice and dread with the dehrium. 

All the points that I have been mentioning require to be investigated in every case 
of this nature : and an inquiry into the previous history of the patient, into what the 
French call the commemorative symptoms, is equally important. In a large majority 
of instances you will find that he has been an habitual drunkard ; and very frequently 
that from some reason or other this habitual stimulus has been diminished or taken 
away. Some accidental illness has befallen him, and he has been restricted to low- 
diet, and, as a sailor would say, "his grog has been stopped." When, with symp- 
toms such as I described just now, you hear a history of this kind, you may be 
satisfied that the disease is not inflammation of the brain, but delirium tremens. I 
beheve that habitual intoxication of any sort may lead to this disorder ; but distilled 
spirits more surely than wine ; Avine more than beer. I make no doubt either, that 
what is alleged of the habitual use of opium, in preparing a person to suffer in the 
same way upon its being withheld, is quite true, although I have had but few oppor- 
tunities of noticing such cases. 

But the disease is not confined to drunkards, akhough it is so commonly connected 
with that pitiable vice, as to have been called mania e potu. You meet with it occa- 
sionally in men who have overstained their nervous system by other modes of strong 
excitement. Long-continued mental anxiety, that state of mind in which gamblers 
and great speculators (who are indeed gamblers) are accustomed to hve, may cause 
it ; any thing by which the mind is over-wrought. A well-informed medical man, 
of temperate habits, told me a few days ago that he was on the brink of delirium 
tremens in the year 1825. He had foolishly entangled himself in some of the specu- 
lations which prevailed here like an epidemic at that period, and his mind was on 
the tenter-hooks of suspense and apprehension for some time. He could not sleep, 
and he found himself everlastingly chattering. It comes on in the course of certain 
diseases ; as sometimes, for example, in apoplexy : and it is a very common result 
of bodily injuries and accidents, and of surgical operations ; or, I should rather say, 
that it often follows such diseases and casualties ; for it is, even then, the conse- 
quence of the treatment and regimen to which the patients are subjected, rather than 
of the surgical or medical complaint. And it is certainly more apt to occur, under 
these circumstances, in old people ; and in those who, being younger, are known to 
have been intemperate. So frequently does the delirium manifest itself upon the 
cessation of the accustomed spur, that the continually recurring stimulus has been 
regarded as the predisposing, and the privation of that stimulus the exciting cause 
of the affection. Sometimes, however, it comes on in men who are perpetually 
fuddled, even akhough they have not intermitted their usual indulgence in drink. 
We had a porter (an old soldier he had been) at the Middlesex. Hospiialj who was of 



DELIRIUM TREMENS. 



249 



great use to us as a subject to practice upon, and to show to the pupils. I never saw 
him so drunk as to be unable to perform his duty : but I cannot conscientiously say 
that I ever saw him sober. Every three or four months we were sure to have 
him in the wards with delirium tremens. Sometimes he fell into the hands of one 
physician, and sometimes of another; but in one of his attacks he slipped through 
our fingers. I am not certain that he was not nominally my patient on the last and 
fatal occasion : but assuredly he was never an example of the disease coming on 
from the adoption of more temperate habits. We often find that the malady shows 
itself immediately after an unusually severe debauch, which has disturbed the 
stomach and bowels, and left behind it a proportional degree of exhaustion and 
languor. 

Without knowing why it should be so, my own experience would lead me to the 
belief that delirium tremens is very uncommon among women. The number of beds 
for females in the physicians' wards of the Middlesex Hospital is somewhat greater 
than for males. On the men's side of the house cases of dehrium tremens are very 
frequent: whereas I scarcely remember any on the women's. Yet each sex is 
obnoxious to its main causes. The gin-shops of this town are said to draw a fearful 
crowd of votaresses. And we might expect that the more sensitive character of the 
female constitution would render them especially liable to this peculiar consequence 
of the abuse of alcohol. My experience, however, is such as I tell yon. On the 
other hand, Dr. Roots thinks that he has seen quite as many instances of delirium 
tremens attacking females as males. The result of M. Rayer's observations is more 
in accordance with my own. Of 176 patients seen by him, seven only (not one in 
twenty-five) were women. A still smaller ratio is recorded by Bang, ten in 456 : 
less than one in forty-five. The disorder appears to be more common in the summer 
than in the winter months. 

The peculiar nature of the complaint, and the proper method of treating it, were 
first brought into general notice in 1813 by a httle M^ork of Dr. Sutton's, of Green- 
wich. He saw a gOod deal of the diseases of the smugglers, and of the customers 
of the smugglers, who frequent the coast of Kent ; and he was struck by the difl^erent 
event of this disorder in the hands of different practitioners, according as bleeding or 
narcotics were adopted. It is the same disease which Dr. Abercrombie speaks of as 
" a dangerous modification of m.eningitis, which shows only increased vasciilarity." 
Dr. Bright also includes it among his cases of " Arachnitis." Both these eminent 
physicians had learned, however, that the complaint requires a particular method of 
treatment. Of late years many essays and papers on the same malady have ap- 
peared in this country, in France, and in the United States, where the disorder is 
common. But even now it is not so weh understood, throughout the profession, as 
it ought to be. 

You may ask me, what is the essential nature of the disease : and I can only 
state in reply that it consists in yiervoiis irritation. Some persons hold that this is 
tantamount to no answer at all ; but I do not agree with them. They seem to think 
that if you assign a state of the brain or nervous system which is not visible or tangi- 
ble, you lose yourself in mere hypothesis. But we see a number of striking phe- 
nomena in this and in many other forms of disease, for which phenomena we can 
trace by our senses, in the organ affected, no physical cause ; yet we are sure that 
they have a cause ; and we call that cause irritation : if we had given it some Chi- 
nese name, it would have been all the same. From certain symptoms we infer irri- 
tation ; just as from certain phenomena we infer gravitation. I do not mean to put 
the two upon an equal footing ; or to pretend to say that the laws of irritation are 
established with any thing like the certainty which belongs to the ascertained laws 
of gravity: but we pursue the investigation of these laws in the same w^ay in the 
one case as in the other: and it is quite idle to object to an arbitrary term, like irri- 
tation, because it is meant to represent something which makes itself known to us 
only by its effects. 

Now I apprehend that we are borne out, by authentic facts, in believing that cer- 
tain changes in the blood-vessels will lead to irritation, and at length to inflammation, 
of a part. But there are other sources of irritation ; and irritation in its turn will 



250 



DELIRIUM TREMENS 



lead to changes in the blood-vessels. In the one case we bring oaCiC the blood-vessels 
to their healthy condition, and the symptoms of irritation cease. In the other we 
calm the irritation, and the previous effect of it upon the blood-vessels stops. In 
other words, deviations from the natural and healthy state of the nervous system are 
sometimes the cause, and sometimes the consequence, of disturbances in the sangui- 
ferous system. Whether this be good philosophy, or whether it seem to you rational 
and intelligible, I do not know ; but it is the best explanation that I can offer you 
upon this subject. 

I apprized you, in the last lecture, that the great remedy in delirium tremens is 
sleep ; and that our most powerful means of inducing sleep are to be found in opium. 
The opium must be given in full doses ; and it must be fearlessly repeated if its 
desired effect does not follow. If the patients pass many nights without sleep, they 
will die. I have tried various forms of opium; and I am quite satisfied witli 
morphia. Some persons, however, have not found it so successful as solid opium, 
or as the common tincture, laudanum. You may try the one or the other, or the 
one after the other, if you please. No particular rules can be laid down that will 
suit all cases. After clearing out the bowels by a moderate purgative, you may 
give three grains of soHd opium ; and if the patient show no inclination to sleep 
after two or three hours have elapsed, you may begin to give one grain every hour 
till he does sleep. Or you may prescribe corresponding quantities of the acetate or 
muriate of morphia : or of laudanum : or of the black drop : or of Battley's sedative , 
liquor. His room, meanwhile, should be kept dark and quiet. If he sleeps for some 
time he will awake calmer and more sensible ; perhaps perfectly so: and you must 
withhold the remedy, or continue it in smaller or less frequent doses, according to 
the circumstances of the case. 

Dupuytren found opiate enemata of great efficacy in the cases of traumatic deli- 
rium which came under his care. That mode of administering the narcotic may 
properly be adopted, if there be any impediment to its reception or retention by the 
stomach. | 

Now sometimes this opiate treatment alone is quite enough : sometimes it is not. | 
You will meet with patients who resist very large doses of the drug; but who pre- | 
sently sleep, or become composed, if you give some of their accustomed stimulus 
with it : "a hair (as the vulgar saying goes) of the dog that bit them :" if you put | 
their opiate dose into a glass of gin, or a pint of porter. Nervous exhaustion goes j 
along with and augments the nervous irritability. This I have continually expe- * j 
rienced with hospital patients. And I rather think that you may get some clue to , \ 
the particular cases which require this treatment, by examining into the state of the { 
digestive functions. If you learn that, notwithstanding the intemperate habits of | 
the patient, his appetite for food has continued unimpaired, and his digestion sound, 
you will, I believe, generally find that good nourishing diet, strong broths for | 
example, and the opium, will suffice for the cure. But if the powers and natural i 
sensations of the stomach have been injured and perverted, as is too often the fact, ! 
then a temporary recurrence to the habitual stimulus will frequently be necessary : ' 
and it is well to ascertain, in such cases, what the stimulus has been, whether spirits, 
or beer, or wine, and to order it accordingly. Of course this is not to be continued , 
after the patient has recovered from his delirium ; but the stimulus under these cir- j 
cumstances must be cautiously withdrawn. When the stomach retains its power 
of digestion, the bad habit of drinking ought to be broken off at once : and if, after ' 
sleep, you can get the patient to eat heartily of a beef-steak, or mutton-chop, I should 
always advise it. i 

There are some things which I find it necessary to mention, for the sake of dis- 
commending them. I know 'persons who in treating these cases combine calomel 
with the opium. And they say that they cure their patients so ; and I make no i 
doubt that they do ; neither can I doubt that the same success would have followed '\ 
the same quantity of opium without the calomel. In pure cases of delirium tremens 
I advise you not to give calomel. I know no possible good it can answer : it is j! 
itself a source of great irritation to the nervous system in many persons : and if it ji 
comes to affect the mouth, you inflict upon your patient a superfluous discomfort ; j 



f 



DELIRIUM TREMENS. 



251 



and, I believe, in many cases, a downright injury. You will be told also of digitalis, 
as a specific remedy for the disease ; or you may read of it : but do not be led away 
from the standard remedies which reason recommends, and large experience has 
sanctioned. Knowing what we do of the power of opium generally, and of its 
efficacy in this complaint in particular, I should consider myself guilty of a criminal 
trifling with human hfe if I made experiments with digitalis, upon the loose reports 
of some one or two persons, qf whose credit or information I knew nothing ; and 
whose dicta had been transferred perhaps from some foreign journal to fill a vacant 
corner in one of our own. Of the combination of opium and antimony, which has 
been much praised by good and competent judges, I am unable to tell you any thing 
from my own experience. 

In hospital practice it sometimes becomes necessary to confine the patient to his 
bed by straps, or to muffle his hmbs in a strait waist-coat : but this is a most unfor- 
tunate necessity. Physical coercion, whether manual or mechanical, should never 
be resorted to in delirium tremens, when by any means it can be avoided. The 
angry feeling and mental fret which it produces, and the exhausting bodily struggles 
to escape or resist the thraldom, are ahvays highly injurious and full of danger to the 
patient. A couple of strong and good-tempered attendants will not have much diffi- 
culty in persuading and managing the sick man, who is seldom either boisterous or 
obstinate : and if he be intractable by soft words, he will yield more patiently to 
their gentle restraint than to the force of manacles ; while the appearance of coercion 
need not be continued a moment'after his acquiescence. 

I have drawn the line between encephalitis and delirium tremens with sufficient 
clearness, because I have taken well-marked forms of each. But I am sorry to add 
that there are mixed cases, which are very puzzling when they occur, and exceed- 
ingly difficult to treat ; and which require opiates on the one hand, and moderate 
depletion on the other. When the indications are uncertain, or equivocal, we must 
carefully w^eigh the difTerent symptoms, and we must cautiously try the remedies. 
The circumstances that most distinguish the one form of the disease from the other 
are to be found in the pulse ; which is hard and resisting in the earlier stages of in- 
flammation of the encephalon, soft and compressible in delirium tremens : in the 
tongue; which is mostly parched and rough in the former, moist and creamy in the 
latter : in the skin; which is hot and dry in the one case, covered with sweat in the 
other : in the countenance ; which is flushed in inflammation, and mostly (though 
not always) pale in delirium tremens : in the tremors ; which are not common in 
the primary periods of inflammation of the brain : in the usual absence of headache 
in delirium tremens : and in the peculiar characters, which I need not recount, of 
the delirium in the two cases. If these symptoms contradict each other, as they 
sometimes will, you had better act on the worst supposition, and presume that there 
is inflammation, and employ antiphlogistic remedies : but you must not do so with 
a strong hand ; you must use them cautiously, and watch their effects, and guide 
thereby your subsequent treatment. Take a moderate quantity of blood from the 
arm : observe whether it has the bufTy coat : and note the condition of the patient 
afterwards. In mixed or ambiguous cases it will be proper to combine calomel with 
the opium. You wiU sometimes find a state resembling dehrium tremens left after 
the subsidence of acute inflammation of the parts within the cranium, and requiring 
the treatment of dehrium tremens. 

I do not know that there is much good to be expected from counter-irritation in this 
disease. But after the more decided symptoms were gone by, I have sometimes 
thought that the recovery has been accelerated by the application of a blister to the 
nape of the neck. 

Inflammation of the brain, and delirium tremens, are distinct diseases. Hence, in 
the mixed cases, of which I just now spoke, we may expect after death to find, and 
we often do find, unquestionable traces of inflammatory action within the skull. But 
pure delirium tremens frequently leaves behind it no morbid appearance whatever 
in the brain or its membranes. In other cases there is serous liquid collected in the 
interstices of the pia mater, or in the cerebral ventricles ; and I have on several 
occasions seen the arachnoid thicker and less transparent than is natural, and 



252 



DELIRIUM TREMENS. 



sprinkled over with little spots or streaks of a milk-white colour. Changes of this 
kind we believe to be owing to chronic inflammation of the membrane. But, even 
in these cases, I see no reason for thinking that the fatal disorder had any connection 
with the morbid state of the arachnoid. We meet continually with like appearances 
when there has been no delirium tremens ; and we have delirium tremens without 
any such appearances. The habitual abuse of ardent spirits leads to chronic inflam- 
mation in various parts and tissues of the body : in the blood-vessels, in the liver, in 
the kidneys, and in the arachnoid. We need not be surprised at finding that mem- 
brane thickened and partiallj^ opaque in the victims of delirium tremens ; since they 
are chiefly men who have run a long course of intemperance. I believe that disease 
to bear the same relation, and no other, to the chronic arachnitis in such persons, as 
to the chronic hepatitis to which they are equally subject. There is but one morbid 
condition which, since my attention was first directed to it, I have found constant ia 
persons dead of delirium tremens, and that is, a remarkably soft, pale, and flabby 
state of the muscular tissue of the heart. 

The chemist may be more hkely to detect altered conditions in the brain, in these 
cases, than the anatomist. Very lately Dr. Percy has obtained alcohol from the 
brain of a person who died from excessive drinking ; and from those of various ani- 
mals which had been killed by that poison. These facts are interesting, but they do 
not help us much in our attempts to explain the phenomena of the disorder. 

Cases, such as I related in the last lecture, where violent symptoms are calmed at 
once, and the patient is rescued in a few hours from great apparent peril, make a 
strong impression upon those who witness them ; and the practitioner gains amazing 
credit, and is spoken of to all their acquaintances as a wonderfully clever man. It 
is unfortunate that we are obliged to set off, against this advantage, a corresponding 
danger, when the disease ends ill, of being blamed without our deserving it. When 
these patients die (and they usually persist in their evil habits and die at last in one 
of the attacks of the disease), when they so die, they are apt to die much in the 
same way as patients who are poisoned by opium ; and if their friends are aware 
that we have been giving large and repeated doses of that drug, they sometimes 
have the charity to lay the death at our door: and you ought to be prepared for 
this ; and I will conclude what I have to say upon the subject of dehrium tremens 
by relating a case, in which I have no doubt that I suffered (though quite unjustly) 
under that kind of imputation. 

Several years ago I was asked, one morning, by a general practitioner at the west 
end of the town, to see a patient with him : of whom he gave me this account. The 
man was about forty years old. He had been attacked some days before with sore 
throat, common cynanche tonsillaris. The tonsils and fauces were so much swelled 
that his deglutition was greatly impeded, and for four or five days he had not been 
able to swallow any thing. The night before I saw him he had become dehrious, 
and then had been largely bled, and he was worse in the morning. His bowels had 
also been very much purged. 

I found him propped up in his bed, with a coronet of leeches round his head. He 
was pale ; there was no headache, nor affection of his breathing ; his pulse was not 
very frequent, and it was quite soft and compressible. He was sweating profusely. 
He answered the feAv questions I put to him readily and pertinently, and then went 
talking on in a rambling way about his business. He \vas a hackney-man or stable- 
keeper, in a large way. He said (I remember) that the boj-s were all ready to 
start, that there were two pair of horses going down the road, and that he must go 
and see after them ; and much more on the same subject. His mind was busy 
about the execution of imaginary orders. He had not slept at all for some nights. 

Upon my inquiring into his previous condition, his wife told me that without any 
furn for dissipation he had for some time been an habitual hard drinker; that he had 
frequent dealings with the coachmen to the various families which he furnished with 
horses ; and that he was obliged to drink something with each of them ; so that every 
day he had many glasses of spirits, and a good deal of porter. She told me, also, 
that his mind had been anxious and uneasy ; that the business was a large and 



DELIRIUM TREMENS - 



253 



harassing one ; that he had embarked a considerable sum of money in it ; and that 
it had not turned out so prosperously as he had expected. 

Putting all these things together, there could be no doubt, either as to the charac- 
ter of the complaint, or as to the treatment proper to be adopted. Here was a man 
who had been hving a ]ife of continued mental and physical excitement. Suddenly 
the stimulus to which he had been accustomed, was taken away ; he could not swal- 
low even such nourishment as his case required or admitted : then came on delirium 
— a symptom not belonging to the disease in his throat — and protracted watchful- 
ness. He is largely bled, and profusely purged, and he gets worse instead of better 
under these remedies. At the same time his skin is moist and perspiring, and there 
is no hardness in his pulse. 

I recommended that the leeches should be removed from his head; that he should 
take immediately (for he could swallow now) two grains of opium, and afterwards 
twenty drops of laudanum every two or three hours till he fell asleep. 

Somewhat unluckily, his wife's brother — a very young man — was the apprentice 
or assistant of a surgeon in the neighbourhood of town, and he came in to see his 
relative. After hearing what I had said, he went home, and probably consulted his 
books, and then came back again with doubts whether the complaint really was 
delirium tremens after all. Whether in consequence of these doubts I cannot tell, 
but for some reason or other only one or two doses of the medicine were taken. I 
had offered to see the patient again in the evening, but his friends said they would 
send for me if he did not get better. They did not send. The patient did not sleep. 
At night, therefore, at ten o'clock, three grains of opium were administered. The 
result of this was, that he passed a quiet but a sleepless night. Perhaps (but I can- 
not be sure of that) if the opium had been persisted with, the case might have termi- 
nated otherwise. About eight o'clock the next morning I was summoned to him in 
a great hurry ; when I got there he was dying, perfectly comatose, breathing sterto- 
rously, with blue lips and contracted pupils. He had appeared so much better at 
seven, that he was, for the first time, left alone for a quarter of an hour ; and when 
they went back to him, he was changed in the manner I have described. 

The general practitioner with whom I had first seen the patient — a very sensible 
man — was much concerned at this issue of the case, and observed to me that doubt- 
less our patient had been poisoned by the three grains of opium. I was able, how- 
ever, to relieve his mind from this notion : and I have mentioned the case chiefly 
for the sake of guarding you against similar misgivings, under similar circumstances. 
The manner of dying was just such as opium will produce; but, then, death by 
coma is also frequently the termination of delirium tremens. Effusion at length is 
apt to take place into the ventricles, or into the meshes of the pia mater, and stupor 
comes on, and the patient sinks. But in this instance I was certain that his death 
had nothing to do with the opium he had taken, for this reason : that so long a space 
of time had elapsed — nine hours — between his taking the opium and the coming on 
of the comatose symptoms. Dr. Christison, in his elaborate and valuable work on 
Toxicology, states it as the resuk of extensive inquiry into this subject, that when 
opium has been swallowed in a poisonous dose, it almost always begins to act as a 
poison within an hour; that very rarely indeed has its specific operation been post- 
poned much beyond the hour, except, occasionally, when the person taking it was 
intoxicated at the time. In one remarkable instance a drunken man took two ounces 
of laudanum, and no material stupor followed for five hours. I guess that I incurred 
the reproach of recommending a fatal plan of treatment in the particular case I have 
now related ; but I am quite satisfied that the opium was innocent of the patient's 
death, and I even think that his chance might have been much mended if the opi- 
ate, in smaller doses perhaps, had been steadily continued. 

We may be content to bear occasionally, these unfounded imputations when we 
consider the other side of the account, and call to mind the far greater number of 
instances in which spontaneous recoveries are credited to us as cures ; and the Doc- 
tor, like Belinda's Betty, is "praised for labours not his own." 

[The account given by the author, of the character, phenomena, causes, and treatment 
of delirium tremens, is, upon the whole, so very judicious, that it would scarcely appear to 



254 



DISEASES OF THE BRAIN. 



demand any other comment, than one of general approval. But as there exists a very decided 
difference of opinion among American practioners in regard to the proper management of 
tlie disease, a few words upon this point may not be improper. 

Four different plans of treatment have been recommended, and the results of their exten- 
sive employment for a series of years, have been adduced, by their respective advocates, in 
evidence of the superior efficacy of each. One practioner cures all or nearly all his cases by 
repeated emetics, another, by the free exhibition of alcoholic drinks, and a third, by opiates' 
in free doses, continued at short intervals, until sleep is procur&d — while a fourth considers 
that neither excitants proper nor opiates are necessary, but simply a state of tranquillity in a 
quiet and darkened chamber — with perhaps an emetic to unload the stomach in the com- 
mencement of the attack, and some gentle cathartic to keep the bowels open — and vi^hen the 
stomach will retain it, a light, nutritious, and easily digested diet. 

The opiate practice is the one, in favour of the superior efficacy of v^hich we have the 
most imposing weight of evidence — and it is unquestionably the one that will, in the majo- 
rity of cases, when judiciously and cautiously man aged, the most promptly and effectually remove, 
the symptoms of the disease. That the opiate practice has been abused, we are perfectly 
aware. Under the supposition that opium to any extent that may be requisite to induce' 
speedy sleep can be administered in delirium tremens with perfect safety, we have cause 
to fear that a state of coma has in more than one instance been induced from which the 
patient has never awoke. We have never been in the habit of administering large doses of 
opium, and have usually combined each dose with an equal quantity of camphor, and about 
half a grain of ipecacuanha. In young, robust, and plethoric subjects, we believe that the 
application of cups to the temples and nape of the neck, or even a moderate bleeding from 
the arm, is an important measure in the commencement of the attack, which should not be 
lost sight of 

That there are many cases of delirium tremens in which a perfect recovery may be effected 
without the administration of opium or of any stimulant is very certain — but our experience 
has taught us, that when the disease occurs in confirmed inebriates, with a broken down 
constitution, and in whom there is almost complete destruction of the proper functions of the 
digestive organs, almost the only means by which it can be certainly and promptly arrested 
is opium administered in moderate doses at short intervals. 

The treatment of delirium tremens by alcoholic drinks, while we can have no doubt of its 
very general efficacy, — is attended with an evil of too serious a character, to permit us to. 
give to it, under any circumstances, our sanction. It cannot fail, we are persuaded, to con-' 
firrh the patient in his intemperate habits — and thus render him liable to a renewal of the 
disease after a short interval. That it is not the only successful treatment we are convinced 
from ample experience. In the practice of our preceptor as well as in our own, which has 
extended now beyond a quarter of a century, we have had sufficient opportunities for testing 
the value of the opiate practice in this disease, and have seldom been disappointed in its 
effects. We do not say that the patient will invariably recover under it. There are cases, 
in which, from the condition of the patient's system — the complication of the temulent deli- 
rium with serious disease of the brain or other important organs, death is inevitable under 
any plan of treatment : we believe, however, that in the general run of cases, the success of 
a properly conducted opiate treatment will equal that of any other ; while in the old, broken 
down drunkard, it, or the stimulant practice, is the only one upon which any dependence 
can be placed. Of the emetic treatment, as recommended by Dr. Klapp, we cannot, it is 
true, speak from experience ; in the very few cases in which we have tried it, we were dis- 
appointed in its effects. 

On the subject of the proper treatment of delirium tremens, the reader may consult with 
profit Dunglison's Practice of Medicine, 2d edition, vol. ii., page 274, and the able note by 
Dr. Gerhard in Tweedie's Library, American Edition, vol. ii., page 237. — C] 

I should next wish to put you in possession of what has been ascertained in 
respect to partial and to chronic inflammation of the brain, as these are met with in 
adults ; for I must speak of the head affections of children separately. But I really 
do not know how to bring this part of the subject before you in a practical manner. 
If I were first to describe symptoms, and then to state what organic changes had 
been discovered after death preceded by them, I should have to tell you of different 
symptoms with the same morbid conditions, and of the same symptoms with different 
morbid conditions, in various individuals. I believe the best method, upon the whole, 
will be to describe the several morbid appearances which the brain is found to pre- 
sent ; and then to mention the symptoms that have most commonly been observed 
to occur in association with such morbid conditions. I must premise, however, that 
the whole subject is full of uncertainty and apparent irregularity. Doubtless there 
is some constant and uniform connection of cause and eflfect between the altered 



RAMOLLISSEMENT. 



255 



phj'sical states of the brain and the altered manifestation of its functions: but we 
have not yet been successful in our search after those settled relations ; or we have 
but partial and imperfect glimpses of them. 

One very remarkable condition of the brain has been several times mentioned in 
these lectures ; viz., softening — ramoUissement. A great deal of attention has been 
paid to this condition of late years, both in France and in this country : and some 
points in its pathology have been fairly made out. I will bring them together as 
concisely as 1 can. In the first place, the softening varies greaily in degree, from 
the consistence which naturally belongs to the cerebral substance, to that of thin 
cream. In its minor degrees it may be easily overlooked ; and is more perceptible 
by the touch than by the eye. The cerebral matter is less coherent, but it is not yet 
discontinuous or broken down. It may be washed away, however, by letting a 
slender stream of water fall upon it ; and the softened parts are thus easily distin- 
guishable from those which retain their natural consistence. In the next stage of 
softening we recognize the complaint at once, for the softened parts undergo a change 
of form by their own weight : parts that are prominent in the healthy state, as the 
optic ihalami, corpora striata, and convolutions, sink down, as it were, and are more 
or less flattened. If you m.ake a horizontal section through a part thus diseased, a 
portion of the softened brain adheres to the knife, and is removed by it, and a de- 
pression is left. In a still more advanced degree, the natural texture of the organ in 
the softened part is entirely destroyed and confused by the change, diffluent : you 
may pour the softened matter out. 

The colour of the softened portions varies also considerably. Sometimes they are 
unchanged in colour : sometimes they are quite white, and present a strong contrast 
with the tint of the neighbouring parts : sometimes they are marked with various 
shades of redness, from a rosy pink to an orange, or deep red, or even a mahogany 
brown. Often there are red spots mixed irregularly with the softened cerebral pulp, 
and giving it very much the appearance of a mixture of raspberries and cream. 
In other cases we find the softened mass of a pale yellow, or straw colour, infiltered, 
as it were, with purulent matter : and sometimes it is mixed with serous fluid. 

Softening of the brain is usually partial. It may occupy any part ; but it is said 
to be more frequently met with in the gray than in the white matter ; and more often 
in the gray matter of the convolutions than of the more central parts of the brain. 

You will find softening of the septum lucidum, and of the fornix, occurring 
very frequently in connection with an accumulation of serous fluid in the lateral 
ventricles. 

Now it is well established that softening of the brain is a common result of two 
very different morbid conditions. It is often caused by inflammation of the softened 
part : it is often caused, also, if I may say so, by its starvation ; by the diminished 
supply of arterial blood, in consequence of diseased blood-vessels. 

Can we distinguish these two forms of softening from each other by their phy- 
sical characters ? Why, sometimes, we can : and sometimes, it must be confessed, 
we cannot. 

The same parts that are most liable to have their consistence diminished through 
an inflammatory process, are also most hable to be softened from defect of nutrition. 
The most vascular parts of the brain, in short : the gray matter of the convolutions, 
and the gray matter of the thalami, and corpora striata. 

It is stated, however, that softening of the corpus callosum, septum lucidum, and 
fornix, from obliteration of the arteries, is extremely rare. 

If there be pus mixed with the softened brain, we know that there has been pre- 
ceding inflammation. Again, if we find the arteries impervious, we conclude that 
the softening has not been inflammatory. Dr. Carswell states that the obhterated 
arteries may occupy the softened cerebral substance, and often be seen ramifying 
through it ; and that when this substance is removed by pouring water upon it, the 
sohdified vessels retain their situation, and feel sometimes as hard as fine wires. But 
we come to the same conclusion if we find the larger vessels, the carotid or vertebral 
arteries, obstructed by ossification ; and a large portion of the brain unnaturally soft. 

We have no certain test of the nature of the softening in its being red. The red 



256 



DISEASES OF THE BRAIN. 



ness may be the result of inflammatory congestion ; but cerebral hemorrhage may 
occasion softening ; and, on the other hand, softening may give rise to cerebral 
hemorrhage, lliis may be said, however ; that the redness is seldom considerable 
when the softening proceeds from obliteration of the arteries. When the softening 
extends much beyond the redness, or the effused blood ; or when the redness occu- 
pies several small portions only of the softened pulp ; we may presume that the 
blood was extravasated subsequently to, and in consequence of, the softening. On 
the other hand, when redness and vascularity can be traced into the brain, some 
way beyond the softened part, we may regard the softening as the consequence of 
inflammation. And we adopt the same belief, with still greater confidence, when 
around the softened and disorganized pulp we find the cerebral substance hardened, 
and of a uniform reddish colour. 

In attempting to make the diagnosis between these two forms of softening, we get 
some assistance by noticing the age of the patient. The ossification, which gives 
rise to the obliteration of the arteries, is almost peculiar to the advanced periods of 
life ; whereas inflammatory softening may occur at any age ; in children, in adults, 
or in old persons. 

Some of the French pathologists have laid down this rule, as the result of their 
experience in regard to softening of the brain — that it is attended, during the earlier 
part of its progress, with a permanently contracted state of the flexor muscles of one 
or more of the limbs. " In some cases the contraction of these muscles amounts 
only to a slight degree of stiffness; in others it reaches such an extent, that if the 
arm be the part affected, the hand is clenched, and remains pressed against the 
shoulder ; or, if the leg, the heel is carried up to the hip." Sometimes this tonic 
spasm is so strong that you cannot extend the limb ; and the attempt to do so gives 
the patient pain. After a certain time the rigidity is succeeded by complete relaxa- 
tion ; the contracted limb has become utterly palsied. 

I believe that this is a valuable diagnostic symptom of softening, and especially of 
inflammatory softening — when it occurs. But it is often wanting. I wish I could 
tell you something more certain and constant in respect to the symptoms of this 
interesting change ; but the facts which I have myself observed, and which have 
been recorded by others, will not permit me to do so. Dr. Abercrombie even goes 
so far as to say, that judging from the cases that have fallen under his own notice, 
there is no foundation for the statement that ramollissement is distinguished by tonic 
contraction of one or more limbs : that the same thing is met with in connection 
with affections of the membranes, without any disease of the cerebral substance; 
and with the encysted abscess of the brain ; and that it is frequently observed in 
cases of typhus fever where there is much cerebral disturbance, but which terminate 
favourabl)^ I will give you the general resuh of his experience in this matter as 
being untinctured with any wish to reduce his facts into conformity with a precon- 
ceived opinion, or hasty generalization. He states that " the cases which terminate 
by ramollissement seem in general to be characterized by convulsion, more or less 
extensive, followed by paralysis and coma ; the convulsion ceasing for some time 
before death, and being succeeded by the coma." But he saw one case in which 
"the convulsion continued with the utmost violence till the very time of death." In 
another instance "there was no convulsion at all, but a sudden attack of palsy, 
exactly resembling the ordinary attack of hemiplegia from other causes." In two 
cases he found " ramollissement of very hmited extent, in connection with symptoms 
of long standing, both cases being at last rapidly fatal by a sudden attack of convul- 
sion." In other cases " there was extensive destruction of the cerebral substance, 
without either paralysis or convulsion, and even without coma." 

When you find the softened substance in filtered with purulent matter, you may call 
the case one of suppuration of the brain. But suppuration also occurs in another form; 
viz., in the form of abscess. The pus is contained in a regular well-defined cavity, 
surrounded by cerebral matter in a healthy or in a hardened state. Now in suppura- 
tion occurring in the brain, there is the same puzzhng diversity of symptoms as in cases 
of simple softening. Still, in the main, there seems an approach to the same order of 
symptoms ; convulsions in the earlier period constituting the most prominent feature 



RAMOLLISSEMENT. 



257 



of the disease ; paralysis in the latter. I will take one of Dr. Abercrombie's cases 
in illustration of the formation of encysted abscess in the brain. 

A girl, aged eleven, thin and delicate, after having complained for some days of 
headache, was seized on the 11th of January, with convulsions, which continued 
about half an hour : paralysis of the right arm followed the attack of convulsion. 
She was bled from the arm, and purged, and cold was applied to her head ; and she 
was much benefited by this treatment. On the 13th the headache was much abated, 
and she had recovered a considerable degree of motion of the arm. On the 15th the 
headache increased again, and the arm became more paralytic, and she was again 
bled: and on the 16th and 17th the power of moving the arm was greatly improved. 
On the 18th, after being affected with increase of headache, and some vomiting, she 
became convulsed, the convulsion being confined entirely to the head, and to the 
right arm ; the head was drawn towards the right side, with a rolling movement of 
the eyes ; the arm was in constant and violent motion. She was sensible, and com- 
plained of headache. Being bled to eight ounces, the convulsion ceased instantly, 
and the headache was relieved; but the right arm remained in a state of complete 
paralysis. Her pulse, during the five following days, fell from 100 to 60 ; some 
headache continued; she had occasional vomiting: and the convulsive attacks 
returned several times ; they were entirely confined to the right arm, which after 
the 23d, was left in a state of permanent palsy. Hitherto no other parts of the body 
had been affected by the convulsion ; but on the 24th it attacked the right thigh and 
leg, and left them powerless. The former remedies were repeated without any 
effect. The thigh and leg went through a course precisely similar to that described 
in regard to the arm, and on the 29th were permanently incapable of motion. 

She was now, therefore, paralytic of the whole right side ; she had no return of 
convulsion, was perfectly sensible, and made little complaint. Gradually she became 
dull and oppressed, and at length fell into a state of perfect coma, and died on the' 
14th of February, a little more than a month after the commencement of her illness. 

In the upper part of the left hemisphere of the brain there were two distinctly 
defined abscesses, containing together from six to eight ounces of very fcEtid pus. 
They were lined by a firm white membrane ; and a thin septum of firm white matter 
separated them from each other. The one was in the anterior part of the hemi- 
sphere, very near the surface ; and the other immediately behind it. In the poste- 
rior part of the right hemisphere there was a small abscess containing about half an 
ounce of pus. There was no serous effusion in any part of the brain, and no other 
morbid appearance. 

In this very interesting case it is worth remarking how the convulsion preceded, 
the paralysis, and how the palsy was more than once diminished by antiphlogistic 
measures. 

It is remarkable to conclude — it can hardly be called a conjecture — that in such 
cases of partial disease of the brain as T have hitherto mentioned, the occurrence of 
convulsion, or of rigidity, marks the inflammatory stage ; and the supervention of 
permanent paralysis denotes the period of softening or suppuration, of complete dis- 
organization, that is, of the texture of the brain in that part. 

Partial inflammation of the brain, especially when it is chronic, sometimes pro- 
duces a totally different change from any that have yet been described. Instead of 
becoming softer, or being converted into pus, the inflamed part is indurated ; comes 
to resemble in consistence portions of brain that have been for a short time immersed 
in weak nitric acid. In this state it is often unusually vascular and injected. When 
the induration is greater in degree, the hardened part assumes the appearance of 
wax, or of boiled white of egg, or (as Andral says) of Gruyere cheese, and contains 
but little blood, but is, on the contrary, distinguished by its pearly whiteness. That 
these changes are the result of slow inflammatory action is the more probable, be- 
cause they are sometimes found to exist around an old apoplectic clot or cell ; the 
blood effused having acted as a cause of inflammation of the neighbouring part, just 
as any foreign substance might do. In the progress of cases in which partial indu- 
ration is effected, convulsive movements are common, but paralysis does not appear 
to be so frequently present. The symptoms may go on for months, and often remit, 
17 w2 



258 



DISEASES OF THE BRAIN. 



and are again aggravated by paroxysms. These cases are the more interesting, 
because they offer a greater probability of cure than those that are attended with 
an opposite condition of the cerebral mass. 

Besides these varieties of inflammation, and their consequences, the brain is often 
infested with tumours, which also give rise to a great diversity of symptoms. There 
are fibrous tumours which grow rather around the nervous matter than within it, 
and are connected with the dura mater. They have been found at almost all parts 
of the surface of the brain ; at its base, at its sides, and towards its summit. Scro- 
fulous tubercles are also not uncommon : these are embedded in the nervous sub- 
stance, and assume a round, form, for the reason I formerly mentioned, viz., because 
the tubercular matter that is separated from the blood is not cast into any particular 
mould (as it is when it is effused into the small bronchial tubes), but poured forth 
into the homogeneous pulp, which exerts an equal degree of pressure upon it- on all 
sides. These scrofulous tubercles of the brain are infinitely more frequent in chil- 
dren than in adults ; and they are more commonly met with in the cerebral hemi- 
spheres than in any other part of the brain, occupying the cortical and medullary 
substance indifferently. They sometimes appear to originate in the pia mater« 
They differ from pulmonary tubercles in this respect, that they are seldom numerous 
in the same brain. Sometimes one only is found. They vary in magnitude from 
the size of a large pin's head to that of a hen's egg ; and they are sometimes even 
bigger than that. The substance of the brain immediately surrounding these tuber- 
cles may be unchanged, in which case it is probable that the tubercles themselves 
give rise to no particular symptoms, the cerebral matter of the spots they occupy 
having been gradually absorbed to make room for them ; but at length important 
alterations take place in the neighbouring texture ; congestions of blood, or soften- 
ing, or suppuration ; and then the ordinary consequences of these changes declare 
themselves outwardly. 

Cancerous tumours occur also in the substance of the brain. They usually 
occupy a large portion of it before they extinguish hfe. Hydatids are sometimes 
found there. 

Now of the occurrence of these various local maladies of the brain it is necessary 
that you should be aware, for you may expect to meet with them frequently in prac- 
tice. And it is right also that you should be aware that they do not disclose their 
precise nature by any peculiar symptoms, or succession of symptoms. They all, 
sooner or later, disturb the functions of the organ in v/hich they are situated ; and. 
they may all disturb them exactly after the same fashion. We may judge, some- 
times,/rom other circumstances, that the disease is of this or of that character. If 
we see scrofulous or cancerous disease in other parts of the body, we infer that the 
symptoms which denote disease of the brain are caused by scrofulous or cancerous 
tumours there situated ; but from the symptoms themselves, we can only learn that 
there is some morbid condition of the brain. 

I attended, recently, with Dr. Latham, a youth, whose symptoms led us to believe 
that he had tubercular disease of the peritoneum ; a very formidable complaint, 
which I shall more particularly describe hereafter. We thought it probable, also, 
although there were no physical signs of pulmonary disease, that his lungs con- 
tained crude tubercles. After some time, he went down to the coast; and was 
there attacked with a fit of general convulsions. Up to that period he had shown 
no symptoms whatever indicative of organic disease within the head. On being 
apprized of this seizure, we expressed "in a letter to the physician then attending 
him, our opinion that it had resulted from the presence of scrofulous tumours in the 
patient's brain. The convulsions returned a few days afterwards with great violence, 
and he died. It was as we had conjectured. The peritoneum was found studded 
with innumerable miliary tubercles : there were a few crude tubercles, of some size, 
around the roots of the lungs ; and two large masses of the same sort in the brain. 
Here, you see, we were directed to a correct special diagnosis of the cerebral dis- 
ease, simply by the evidence which had satisfied us that scrofulous tubercles existed 
in other parts of the body. 

[For a more full account of the present state of our knowledge in regard to tubercles of 
the brain, see the Editor's Treatise on Diseases of Children, page 572. — C] 



HYPERTROPHY. 



259 



In tlie case of specific tumours there is really nothing to be done by way of cure. 
We must then treat the symptoms, and seek to alleviate them as they arise. When 
it appears likely, or not unlikely, that the cerebral symptoms may be the result of 
cerebral inflammation, we must give the patient the chance of being benefited by 
some of the remedies of inflammation : we must treat the case in this instance upon 
the 7nost favourable supposition. The class of remedies from which most may be 
hoped in equivocal cases, are local bleeding, counter-irritation, and especially the 
cautious and regulated employment of mercury. I have stated to you before, that 
I have known several obscure but threatening symptoms of brain disease clear 
entirely away, when the gums were made sore by mercury, and kept slightly tender 
for some httle time. It is possible that we may sometimes do our patients harm by 
this mercurial treatment. W e may, now and then, accelerate the arrival of death 
in persons whom nothing could save ; but we must not be deterred from giving them 
this chance of being rescued from a disorder which may be susceptible of cure, but 
which, if unchecked, will be inevitably fatal. 



LECTUEE XXV. 

Hypertrophy of the Brain : Atrophy. Jlcute Hydrocephalus ; Premonitory 
Signs ; Different Modes of Attack ; Stages of the Disease ; Anatomical Cha- 
racters ; Causes, 

There is a very curious morbid condition of the brain, to which I shall advert 
before I take up the consideration of certain cerebral diseases as they occur in chil- 
dren. The condition of which I am about to speak I was totally ignorant of till I 
had been for some years in practice. In the spring of 1833 I admitted a young 
woman, 19 years old, into the Middlesex Hospital. Her countenance was sallow, 
and her lips pale. She complained of pain in her chest and limbs ; of great and 
increasing debility, and wasting ; and of nightly perspirations. She had some 
cough, and a frequent pulse ; and although no morbid sounds were audible in her 
lungs, I suspected that they might contain small or scattered tubercles. She had 
been in the hospital scarcely a week, when she had a violent fit of epilepsy ; and 
when she was somewhat recovered, she told us, for the first time, that she was sub- 
ject to such attacks. The convulsions recurred on the same day, and she became 
insensible, and remained so during the whole of the next day, and till the evening 
of the day after, when she died. During this period of insensibility she had many 
convulsive fits ; the pupils were dilated, the pulse 100, small and feeble. Leeches 
were apphed to the temples, a blister to the neck, and afterwards to the shaven head, 
and other measures were used, but in vain. 

When the surface of the brain was exposed by the removal of the skull-cap, and 
of the dura mater, it was observed that the convolutions were remarkably flattened, 
so that the little furrows between them were nearly eflaced ; and the surface of the 
arachnoid membrane was perfectly dry. These are not very unusual, though they 
are unnatural appearances. I had often seen such before : and I ventured to say 
that we should find some cause of strong pressure in the central part of the brain ; 
effusion of serum into the ventricles, or a large extravasation of blood. But to my 
great surprise, and much to the discredit of my prophecy, we found nothing of the 
kind. The ventricles were even smaller than natural, and contained scarcely any 
moisture. The skull-cap was afterwards examined, and the bone was found to be 
uncommonly thick, dense, and heavy ; and its inner surface, without being rough, 
was very irregular. I regret that, in this examination, the state of the blood-vessels 
of the brain, and the consistence of the cerebral matter itself, were not particularly 
noticed. In the record made at the time by my clinical assistant, it is merely stated 
that the brain was otherwise healthy. There was no disease in the lungs. 
, This dissection interested me much, for I had never seen nor heard of any thing 



260 



DISEASES OF THE BRAIN. 



like it before. But upon looking into some modern authors, I discovered that the 
same phenomena had been noticed by two or three observers, who had very properly 
(as it seems to me) considered them as the result of hypertrophy of the brain. There 
is a very good memoir upon the snbject, by M. Dance, pubhshed in the fifth volume 
of Breschet's Repertoire S.natomie : and Andral gives an account of the disease 
in his Pathology. It appears that Morgagni had not overlooked it, for he speaks of 
instances in which the brain seemed too big for its bony enclosure. When, in these 
cases, the skull is sawn through, the upper loose portion of bone starts up, as if 
moved by a spring, and the edges of the bone remain widely apart. Laennec, also, 
in Corvisart's Journal states that upon opening the bodies of persons whom he had 
thought affected with hydrocephalus, he had been surprised at finding a very small 
quantity only of fluid in the ventricles, while the convolutions on the surface of the 
brain were strangely flattened ; proving that the cerebral mass had undergone strong 
compression, which could only have arisen from its preternatural volume, and undue 
nutrition. 

Besides the characters I have mentioned, the hypertrophied and compressed brain 
is firmer and tougher than natural ; it contains but httJe red blood ; and sections of 
it are seen to be unusually dry and pale. 

In several of the cases of hypertrophy of the brain recorded by authors, the pa- 
tients had suffered epileptic fits, or rather paroxysms of convulsion ; and in some of 
them the convulsions terminated in paralysis. Andral states that the intellectual 
faculties have been observed, in some instances, to become dull and obtuse. Many 
of the patients were subject to severe headaches. All these symptoms are common 
to various cerebral complaints. The diagnosis of this rare disorder can be no better 
than conjectural ; and its treatment we have still to seek. 

Andral remarks, what is very true, that hypertrophy of the brain, i. e., an undue 
and disproportionate development of that organ, may, and does happen, without 
giving rise to any morbid phenomena at all. But, in such instances, the brain-case 
is equally enlarged in capacity ; so that no pressure upon the cerebral mass results 
from its own preternatural growth. It is only when the brain increases faster than 
the bony sphere which contains it, that the hypertrophy becomes a disease. In my 
patient there was also, in one sense, hypertrophy of the skull; the bone was consi- 
derably thicker, and more compact and heavy, than is usual ; but the capacity of 
the cavity had not undergone a proportional augmentation ; nay it might, for any 
thing I know, be diminished in consequence of the increased thickness of the bone ; 
the case may have been one of concentric hypertrophy of the bone, without any 
fauk of the brain itself; but what makes this the less probable is, that in other cases, 
the skull has been found of the ordinary thickness and density ; but too small for its 
contents. 

It is of some importance for you to be aware that the brain, and its case, may be 
extravagantly developed without there being any disease, or any symptoms of dis- 
ease. M. Scoutetten gives an instance of this which he observed in a child five 
years old. Its head was as large as that of a well-grown adult person. The skull 
was from a fine and a half to two lines in thickness. The dura mater adhered firmly 
to the bone, and the cerebral mass exactly filled up the cranial cavity. The superior 
and posterior part of the brain w^as developed beyond measure, so that to reach the 
ventricles it was necessary to make an incision nearly three inches in depth. There 
was nothing unusual to be remarked in any of the cerebral functions of this child ; 
it was just hke other children of the same age in respect of intellect. It died of 
acute inflammation of the bowels. 

The late Dr. Sweatman met with just such another child a few years ago : and I 
refer to his description of it the rather, because cases that occur near home are 
always more interesting, and satisfactory, than those which we merely read of in 
foreign authors. Dr. Sweatman had never read of any thing of the kind : but in 
August, 1834, a little boy, two years old, was brought to him on account of the size 
of his head. It had been gradually increasing from the age of six months, till it had 
become so large as by its weight to prevent the child from continuing long in the 
upright posture. The boy was active and lively, though thin. He never had any 



HYPERTROPHY. 



261 



fit or convulsion; but occasionally seemed uneasy, and then would relieve himself 
by laying his head upon a chair. He had never squinted nor was he subject to 
drowsiness, or startings during sleep; and his pupils contracted naturally. His 
appetite was good, and all the animal functions were properly performed. Dr. 
Sweatman got Mr. Mayo to see the child with him : they both set it down as a case 
of hydrocephalus, but agreed in thinking that in the absence of symptoms it would 
be wrong to risk disturbing his digestive organs by active medicines. In the early 
part of 1835 the child died of inflammation of the chest, and Dr. Sweatman and Mr. 
Mayo examined the head. I here show you a cast of it. It measured from ear to 
ear, over the vertex, twelve inches ; from the superciliary ridges to the occipital, 
thirteen inches ; and in circumference twenty-one inches. The anterior fontanelle, 
which was quite flat, measured across its opposite angles two inches and a quarter 
by one and a half ; the posterior fontanelle was completely closed, as was the frontal 
suture. There was no absorption of bone at any part ; on the contrary it was 
becoming thicker. The dura mater adhered with great firmness to the skull ; and 
a layer of false membrane, as big as a crown-piece, was found upon its upper and 
anterior part. Beneath the arachnoid at that part there was shght jelly-like effusion. 
In all other respects the organ was sound. The convolutions were perfectly distinct, 
and retained their proper rounded shape. All the ventricles were found empty, 
and not dilated. The surfaces, however, of the medullary matter, exposed by differ- 
ent sections, presented very unusual vascularity. 

The lesson we learn from cases of this kind is, that we are not to regard every 
child that has a very large head as a hydrocephahc child ; and especially that we 
are not to inflict upon such a child a course of mercury, or other active remedies, 
unless some morbid symptoms appear. The nimia cum medici may in these, as in 
many other cases, destroy health ; produce disease where none existed before. 

[The subject of Hypertrophy of the Brain would appear to demand a more extended notice 
than has been given in the text. There is reason to believe that the disease is of more fre- 
quent occurrence than is generally suspected, and that to it are to be ascribed many cases of 
convulsions, epileptic attacks, inflammation and softening of the brain, and even of idiocy, in 
which the connection has heretofore been entirely overlooked ; we know that hypertrophy 
of the brain has, in more than one instance, been mistaken for chronic hydrocephalus, and 
that even the operation of tapping the brain has under such circumstances been proposed, 
jnay, probably performed. 

Hypertrophy of the brain, or at least a condition of that organ predisposing it to undue 
and more or less rapid augmentation in bulk, is often congenital. Thus children are not 
unfrequently born with heads of dimensions far exceeding the usual standard — • while, in 
other instances, the head soon after birth is found to augment rapidly in bulk, disproportion- 
ately to the growth of the rest of the body, and within a short period to attain an enormous 
magnitude. 

When the cranium is developed in the same ratio with the brain, at first no morbid symp- 
toms are produced, or only slight ones. In almost every case, however, we have observed 
more or less apathy, dullness, and drowsiness, to accompany these cases of undue develop- 
ment of the brain, from a very early period. 

After, however, the disease has existed for some time, and particularly when there is a 
disproportion between the morbid development of the brain, and the expansion of the 
cranium, the patient becomes affected with apathy to external objects, a disposition to som- 
nolency — great irritability of temper, giddiness, habitual headache, attended with severe 
exacerbations at irregular intervals, and inordinate appetite. The intellect becomes more 
and more obtuse, verging occasionally upoTi complete idiocy. There i^, usually, a debility of 
the muscles of the extremities, particularly of the inferior, which constantly increases, until, 
finally, complete paralysis results. 

The bowels are usually torpid, and the pulse remarkably slow. In many cases, the 
muscles are affected with convulsive twitchings, at first slight, and occurring at long irre- 
gular intervals, but gradually becoming more severe and frequent, until regular convul- 
sive parox3'"sms ensue. The convulsions, not unfrequently, assume all the characteristics of 
epilepsy. 

In some cases there suddenly ensues a considerable reduction, and, occasionally, an entire 
abolition of sensibility. In other instances, the patient is suddenly attacked with acute deli- 
rium, quickly followed by complete coma and death. Mania was observed by Andral in one 
case. In the majority of cases that have fallen under our notice, the patients have been 
inclined to fat. 



262 



DISEASES OF THE BRAIN. 



The disease is divided by Andral into two stages : — 1st. The chronic, marked by few 
symptoms, or simply by slight obtuseness of intellect — more or less headache, either perma- 
nent or intermittent — vertigo, apathy, drowsiness, broken at irregular intervals by convulsive 
paroxysms. All of the foregoing symptoms may occur, simultaneously or successively, in 
the same case^ or only one or a part of them may be present. 2d. The acute stage, marked 
by sudden attacks of violent convulsions, idiocy, epileptic paroxysms, deep coma, or the 
ordinary symptoms of acute hydrocephalus. 

The prognosis in cases of hypertrophy of the brain is not necessarily unfavourable. As Dr. 
Lees correctly remarks, the affection of the brain is rather an error of development than an 
actual disease, and the excess of nutrition will often cease, and the brain may even return to 
its normal state. Many patients who have laboured under cerebral hypertrophy have entirely 
recovered, others will arrive at puberty, or even a more advanced age, with but little suffer- 
ing or inconvenience, while others again die at an early age from the accidental occurrence 
of hyperasmia of the brain, convulsions, or meningeal inflammation. In some instances death 
occurs suddenly during an attack of convulsions — or, the patient becoming more and more 
comatose, death finally ensues without a struggle. The chief danger arises from the very 
great susceptibility of the hypertrophied brain to disease, especially upon the occurrence of 
any accidental affection of one of the other organs, or of either of the affections incident to 
childhood. 

Upon dissection, the brain is found to be enlarged in size, the convolutions being flattened — 
the blood-vessels containing a diminished amount of blood, the cortical substance exhibiting 
in consequence a morbid paleness, with but little or no serum within the ventricles or be- 
neath the membranes. The substance of the brain is in many cases increased in density. 
Sometimes, according to Sims, the hypertrophy is confined to one lobe, or to the corpora striata 
or thalami; in all cases, the hypertrophy is chiefly confined to the cerebrum, the cerebellum 
being seldom much, if at all affected. Instances occasionally occur in which the vessels of 
the brain are injected with blood ; others where a slight amount of reddish serum is found 
at the base of the brain, — and others again with a clot of blood within the substance of the 
brain, and rupture of the fibres of its medullary portion ; in all these cases, it will be found, 
tipon an inquiry into their history, that death was preceded by symptoms of cerebral disease, 
in addition to those which properly belong to simple hypertrophy of the brain. 

It is important to distinguish the hypertrophied state of the brain from chronic hydroce- 
phalus, to which, particularly in its advanced stages, its phenomena bear a strong resem- 
blance, so much so as to have caused the two to be not unfrequently confounded. Drs. Lees 
and Muncmeyer point to a particular and very striking projection of the parietal protube- 
rances, in hypertrophy of the brain, as a valuable guide in our diagnosis, while Dr. Hennis 
Green suggests the difference in the sensation communicated to the fingers when pressed upon 
the fontanelles in children affected with the two diseases, as a diagnostic sign. The sensation 
being that of a tense membrane filled with water in cases of hydrocephalus, and of a firm 
solid substance in cases of hypertrophy. Dr. Mauthner, in his work on Diseases of the Brain 
(^Vienna, 1844), lays down the following diagnosis between these two affections: — In hyper- 
trophy, it is the posterior part of the skull which is first observed to become abnormally 
prominent, the projection of the forehead occurring subsequently; whereas, in chronic hydro- 
cephalus, the enlargement of the forehead is one of its first results. The latter affection is 
usually associated with a general emaciated condition of the body ; the former with a leuco- 
phlegmatic habit, and an increased deposition of fat. The constitutional symptoms likewise 
differ in the two afiections — restlessness, convulsions, and sopor, mark the early stages of 
chronic hydrocephalus, while spasmodic affections of the respiratory organs are among the 
earliest indications of hypertrophy of the brain, but seldom occur until the advanced stage 
of hydrocephalus. (See Condie on Diseases of Children, 2d edition.) — C] 

Having told you what I know of hypertrophy of the brain, it is proper that I 
should say a word or two respecting the opposite condition ; of atrophy of the cere- 
bral mass. There are two forms of this affection : one is congenital, and results from 
imperfect development, or an arrest of development, of the brain in its fcetal state. In 
the other the change appears to take place in consequence of disease, either in the 
membranes of the brain, or perhaps in its arteries ; though the effect of disease in 
the arteries is usually softening, which is a species of atrophy. But in the atrophy 
to which I am now alluding, the volume of the atrophied part is diminished, not its 
consistence. And the diminution of size may extend only to a few convolutions: or 
it may be most manifest in the interior of the organ ; in the optic thalami and corpora 
striata for example. There is still another alteration to which some have applied the 
term atrophy, though improperly, I think : I allude to those cases, which I shall 
speak of more particularly soon, in which the form and disposition of the cerebral 
substance is altered, the convolutions being unfolded, and the nervous matter spread 



ACUTE HYDROCEPHALUS. 



263 



out by a large collection of fluid in the interior cavities of the brain, constituting the 
disease called chronic hydrocephalus. I have not much to say upon what may be 
styled atrophy proper of the brain : that it will give rise to symptoms we cannot 
doubt, but that it shows itself by any peculiar or characteristic symptoms is what I 
have not discovered. 

I shall content myself, on this subject, with showing you Cruveilhier's representa- 
tion of a strongly pronounced example of atrophy of the entire cerebrum on one 
side. The drawing from which this engraving was made, was painted from the 
body of a patient who died in the Hotel-Dieu, dropsical, in consequence of disease 
of the heart. He was forty-two years old. When you look at the engraving you 
will perceive that the left side of the cerebrum is diminutive compared with the 
right. It filled up, however, a larger space than it appears to do in the plate ; for 
the lateral ventricle on that side was distended by a quantity of serous fluid, which 
ran out when the ventricle was punctured ; and then the surface of that side of the 
brain sank down, and collapsed. Still the convolutions on that side, and all the 
dimensions, are remarkably less than on the other. The anterior lobe projected half 
an inch further on the right than on the left side. The frontal bone, you will observe, 
is much thicker ; twice as thick on the atrophied as on the natural side ; and the 
frontal sinus very wide and open. The internal parts of the brain are all diminished 
in proportion. There was a large quantity of serous liquid filhng and distending 
the subarachnoid areolar tissue. The nervous matter was whiter and harder on the 
atrophied side. One very curious thing is, that the left lobe of the cerebellum was 
the bigger of the two; but there was no such marked difference between them as 
between the two sides of the cerebrum. 

Now, the patient, in whom this singular disproportion between the two sides of his 
brain was met with, had been incompletely hemiplegic, as long as he could recollect, 
on the right side ; and the imperfectly palsied limbs were shrunk and withered, and 
the fingers of the hand contracted. Yet he had managed-to walk about with the 
help of a stick ; and there was nothing remarkable, one way or the other, in the state 
of his intellectual faculties. 

The same condition has been seen on both sides of the brain : the organ itself 
existing in miniature, as it were, and lying at the lower part of the vaulted cavity 
of the cranium: the intermediate space being filled up with water. In long-standing 
cases of this description you must not suppose that the nervous matter has been 
compressed into a smaller compass by the effused fluid ; but that the fluid has been 
poured out to fill that part of the skull which is empty of brain, and which must 
be filled with something. This condition of the cerebrum is accompanied by idiotcy. 

I proceed in the next place to the consideration of that disease to which the name 
of acute hydrocephalus has been given. By that term I desire to signify inflamma- 
tion of the brain, as it frequently occurs in children, and especially in scrofulous 
children. The inflammatory character of the disorder, though not always very 
clearly expressed in its symptoms, is sufficiently attested, in many of the fatal cases, 
by the changes discovered within the cranium. 

I made some observations, in the last lecture, respecting the nomenclature of 
diseases, and said something in defence of the name dehrium tremens. Now it must 
be confessed that the complaint we are about to consider was unfortunately named, 
when it was called hydrocephalus. I repeat that it matters not at all how we deno- 
minate a disease, provided that its title does not involve any erroneous notion of its 
nature. I think hydrocephalus a bad name, because it reminds us of one circumstance 
only of the malady, viz., the serous effusion, which so far from being the cause, or 
the essence, is only a frequent effect of the disease ; nay, it is no uncommon effect 
of other morbid conditions also, besides inflammation. But hydrocephalus, or water 
in the head, is an appellation so established, both among ourselves and with the 
public, that I cannot venture to propose any change. 

After v/hat I have already stated in respect to inflammation of the brain in adults, 
you will be prepared to hear that acute hydrocephalus (remember, I restrict that 
term to the same inflammatory malady as it occurs in strumous children) — I say you 



264 



DISEASES OF THE BRAIN. 



will not be surprised to learn that acute hydrocephalus furnished a great variety of 
symptoms ; and many variations in the mode of their coming on, and in their combi- 
nation, and succession. 

It is of the greatest importance to recognize acute hydrocephalus in its earliest 
stages ; and even to look out for indications of its approach. I shall, therefore, de- 
scribe those changes in the state of the young patient, which have been found to be, 
in many cases, premonitory that the disease was impending. But such symptoms 
are by no means always followed by acute hydrocephalus ; nor is acute hydroce- 
phalus always preceded by such symptoms. Still, when they do occur, they should 
put us upon our guard. 

The precursory symptoms to which I allude consist chiefly in a morbid state of 
the nutritive functions. The child loses his appetite ; or his appetite becomes capri- 
cious : he sometimes appears to dislike his food, and sometimes devours it voraciously: 
his tongue is foul, his breath offensive, his belly enlarges, and sometimes is tender ; 
his boweis are torpid, and the evacuations from them unnatural ; the stools are pale 
and contain but httle bile ; or they are dark, with vitiated bile, foetid, sour-smeUing, 
slimy, or scybalous ; and the child loses his former healthy aspect, becomes paler, 
and thinner. Even already there are obscurer indications of derangement in the 
cerebral functions ; the child is heavy, languid, and dejected ; his customary spirit 
and activity are gone ; he gets fretful and irritable, and is manifestly uneasy ; and 
sometimes he shovv^s a little unsteadiness and tottering in his gait. 

In very young children, when the disorder is at hand or incipient, an unnatural 
wakefulness is often observable. A frequent sudden cry or scream, a clenching of 
the httle fists, and a turning in of the thumb towards the palm of the hand, give 
warning also of the approaching malady. 

Now when this sort of alteration is observed in a child who has any hereditary 
title to scrofula, or bears the marks of the strumous diathesis, or is even a precocious 
and particularly clever child, and still more if he present any other indications of 
strumous disease, there will be much reason to apprehend that mischief is brewing 
within his head. I advert to these tokens of scrofula, because the inflammation, 'm 
a. majority of cases, if not in all, is of a scrofulous character. But there is this 
peculiarity in it, which distinguishes it from scrofulous inflammation in most other 
parts, viz., that it occurs in an organ of a very delicate structure, and one which is 
essential to life, its progress is jnore rapid, and it is more necessary to treat the 
disease promptly. 

It has been made a question whether the derangement of the digestive organs that 
has just been described is or is not the cause of the aflection of the brain ; or whether 
both the abdominal and cerebral disorder are not common and concurrent efiects of 
the same cause. It is said that the stomach and bowels are more in the way of being 
acted upon by injurious influences than the brain, and that, therefore, the complaint 
may be supposed often to originate in their derangement ; and great good, it is alleged, 
is done, the disease of the brain is often prevefited, by remedying the disordered 
condition of the stomach and bowels. On the other hand, it may be stated that a 
similar derangement of the digestive organs often comes on and lasts long in children, 
without leading to hydrocephalus ; and hydrocephalus often attacks a c£ild in whom 
no such symptoms of abdominal disease have appeared. We can never be certain, 
therefore, that hydrocephalus has been prevented, in any given case, by remedies 
addressed to the digestive organs. I cannot think the question is one of much prac- 
tical importance. Whether the disturbances of the nutritive functions cause the 
brain disease, or merely indicate it, they are equally valuable in directing our atten- 
tion to the head. 

In these little patients any source of irritation seems to act as an exciting cause : 
surgical operations, which are sometimes necessary at that tender age — falls or in- 
juries of any kind — painful dentition. 

There are, at least, three several ways in which this disease may make its attacks ; 
and with these it is proper that you should be acquainted. 

In the first place, it may come on gradually ; after such symptoms as have already 
been spoken of as being premonitory. Probably this is the way in which it most 



ACUTE HYDROCEPHALUS. 



265 



frequently commences. After a period, of uncertain duration, in which the child has 
complained of occasional pains in the belly and head, and signs of derangement of 
the stomach and bowels have been present, the pain in the head begins to be more 
severe and to recur more frequently. It is not mere headache, but generally a sharp 
shooting pain, recurring at intervals ; sometimes it affects one side of the head more 
than the other; the httle patients wake and shriek out with the pain, and this in 
children is a very characteristic symptom. As coma comes on, this shrieking gives 
place to an habitual moaning, which is scarcely less characteristic. Very often in 
the beginning of the disease there are pain and stiffness at the back of the neck ; 
sometimes there is much pain of the limbs in the early periods, and in some chil- 
dren extreme tenderness of the scalp, so that they cannot endure to have the head 
shaved. The pain of the head becomes complicated with vomiting, and both these 
symptoms are aggravated by motion. Very often nausea is excited by the erect pos- 
ture, and the patient begs to lie down. The child sighs frequently, and looks grave 
or sad ; his eyes are pained by a strong light, so that he knits his brows. The pulse 
becomes rapid, and the disturbance and irregularity in the abdominal functions 
increase. This stage of the complaint may last ten days or a fortnight, the child 
becoming daily more weak, and more peevish, and looking more and more ill. 

In the second form of attack there are no premonitory symptoms ; or they occur 
for a very short while only before the disease sets in suddenly and violently, with 
acute pain in the head and high fever; or with convulsion : the face is flushed, the 
eyes are brilliant ; there is intolerance of hght and of sound, and there are pain and 
tenderness of the abdomen. In short, the disease, when it commences in this man- 
ner, is very like an attack of continued fever. You may find these varieties described 
in Dr. Cheyne's excellent treatise on this disorder. "We are led to suspect," he 
says, " some deeply-seated evil from the frantic screams and complaints of the head 
and belly, alternating with stupor, or rather lowness, and unwillingness to be roused ; 
and we are struck with the great irritability of the stomach, which exists in a degree 
beyond what we generally find it in the fevers of this country ; retching and vomit- 
ing being brought on by a change of posture, and certainly by every attempt to sit 
up in bed ; and the disordered state of the bowels, which attends this irritability of 
the stomach, is also remarkable : and when at any time the child has a little respite 
from the violence of these symptoms, we find our suspicions confirmed by his looks ; 
for when the features do not express pain or terror, there is not unfrequently a vacancy 
of look, the eyes being set, with an expression of dejection which is peculiar to cer- 
tain diseases of the brain." The mode of attack which has now been described, 
although the most regular in its progress, is not so common as the first, nor as the 
third, which I have yet to mention. The third way in which the disease makes its 
advances is very insidious : the head symptoms supervene upon the subsidence of 
some other malady : presently after the disappearance of an eruption from the scalp ; 
during the decline of scarlet fever, small-pox, hooping-cough, or any inflammatory 
or febrile complaint ; and even after painful dentition. In these cases the early 
symptoms are often but slightly marked, or do not take place at all ; the sudden 
occurrence of convulsions or paralysis affording the first evidence that the brain is 
implicated. This is the most dangerous form of hydrocephalus. It has received, the 
expressive title of water-stroke. 

In whatever way the disease makes its invasion, it is apt to be attended with many 
and variable symptoms ; and different observers, with a view of facilitating their 
description of the disease, and of making it more intelligible and more easily remem- 
bered, have divided the symptoms into groups, and considered each group as charac- 
teristic of a particular stage of the malady. But they have not all done this in the 
same way. It may be of use, however, to inform you of the different classifications 
which have thus been proposed. Dr. Whytt, who was almost the first person in 
this country who wrote upon this disease (I believe Dr. Paisley of Glasgow was the 
first : you may see his paper in the third volume of the Edinburgh Medical Es- 
says), Dr. Whytt, I sd^j, whose description is an extremely good one, took the pulse — 
which undergoes very remarkable variations in the course of the disease — as the 
ground of his division. He makes three stages of it therefore ; the first, in whicU 

X 



266 



DISEASES OF THE BRAIN. 



the pulse is frequent ; the second, in which it is slow and irregular ; and the third, 
in which it again becomes frequent and feeble. These successive fluctuations in 
the pulse are to be noticed in very many cases. Dr. Goiis, again, an eminent Ger- 
man writer on hydrocephalus, whose httle work was translated by the late Dr. 
Gooch, as being the best book on the subject that he was acquainted with, makes 
four stages, according to what he believes to be the condition of the brain in each. 
First, he has the period of turgescence, which corresponds with that period in which 
the premonitory symptoms occur; secondly, the period of injiainmation ; thirdly, 
the period of effusion^ fourthly, the period palsy. The two last would appear 
to be almost identically the same. Dr. Cheyne makes three stages ; which he finds 
marked, not like Dr. Whytt, by the state of the circulation, but by the state of the 
nervous system. Thus he calls the first the period of increased sensibility, when 
every stimulus produces an impression more than proportioned to its common efl^ects. 
In the second stage, that of diminished sensibility, the child is not easily roused, his 
pupil is dilated, and his pulse slow ; he is lethargic, with obstinately costive bowels. 
The third stage with him is that of palsy and convulsions, in which there is squint- 
ing, rolling of the head, stupor, convulsions, with a rapid thready pulse. 

Cases often occur, however, that baffle all these attempts at classification. Con- 
vulsions, instead of being among the last, are not seldom among the very first symp- 
toms. The pulse is sometimes remarkably slow at the outset ; sometimes frequent 
through the whole disease ; and sometimes perfectly natural. 

I do not make these statements to magnify the difficulty of distinguishing the dis- 
ease ; for the diagnosis is really not so difficult as it has sometimes been represented ; 
but to show you that you must not trust to any succession of symptoms, still less to 
any one symptom, as being pathognomonic. 

The symptoms that occur during the first stage are very variable, as you may 
suppose from what I have said of the different modes in which the disease is apt to 
set in. Those that are most constant are, pain of the head, severe shooting pain, I 
say, it seems to be, for the child puts its hand there, and cries out frequently, " Oh ! 
my head ;" restlessness ; inabihty to sit up ; very disturbed sleep, with grinding of 
the teeth, and from this sleep the child often starts apparently in terror, and with a 
scream. The head is hot externally ; the little patient is annoyed by light and by 
noise ; the pupils are contracted most commonly during this stage ; the child is un- 
willing to be disturbed, and, therefore, does not reply readily to questions ; but the 
replies, when made, are correct and rational. This stage is marked, also, by vomit- 
ing, a total loss of appetite, a white tongue, offensive breath, costive bowels, unna- 
tural stools, green often, or black, like tar, scanty and high-coloured urine. Dr. 
GoHs says that the abdomen, which has been tumid and tender, perhaps, sinks down 
and becomes flat, without any increased excretion by stool ; and that this is a very 
characteristic symptom. The pulse in this stage is frequent and sharp. In short, 
the symptoms are such (in general) as indicate very plainly that inflammatory action 
is going on within the head. Now the symptoms that characterize this first stage of 
the complaint sometimes rapidly pass into those which belong to the second. They 
may not be present for more than a few hours ; or they may last a day or two, or 
several days ; it is very seldom, I believe, that they continue longer than a week. 
The period answers, in the general character of the symptoms, to the period of 
excitement in encephalitis, which I repeat is very much the same disease, modified 
by its occurrence in the aduk and otherwise heakhy subject. 

So, also, the second stage of acute hydrocephalus corresponds, in its general 
features, with the period of collapse in encephalitis. The pulse becomes irregular, 
extremely variable and fluctuating, and often slow : it is easily accelerated, however, 
by the smallest exertion — by taking the child out of bed, or even raising him into a 
sitting posture. With this slowness of the pulse come on a diminution of sensibihty, 
and general heaviness and stupor ; the pupils dilate, the light is no longer trouble- 
some, the vision is imperfect, often it is doubtful whether the child sees at all. If 
the eye be closely examined and watched, the degree of light remaining the same, 
the size of the pupil will frequently be seen to fluctuate or oscillate, till at last it is 
wide open and immovable. Wjiile this goes on squinting takes place, and double 



ACUTE HYDROCEPHALUS. 267 

vision when the child can yet see any thing. One or both eyes are turned in, or 
more rarely outwards. Noises do not now disturb or irritate the child — who hes on 
his back, with the eyes half closed, in a state of drowsiness or stupor, which is oc- 
casionally interrupted by some cry or exclamation expressive of pain. Convulsions 
frequently occur, but not uniformly; sKght and partial spasmodic twitchings ; or 
general and long-continued convulsions ; paralysis ; sometimes hemiplegia. The 
urine and stools are passed unconsciously. Sometimes the shild, with feeble and 
tremulous hands, is incessantly picking his lips, or boring his fingers into his ears 
or nostrils. 

This stage may last a week or two. And what is remarkable, it is often attended 
with remissions, sometimes sudden and sometimes gradual — deceitful appearances 
of amendment, and even of convalescence. The child regains the use of its senses ; 
recognizes those about him again ; appears to its anxious parents to be recovering; 
but in a day or two it relapses into a state of deeper coma than before. And these 
fallacious symptoms of improvement may occur more than once. 

The third stage does not diifer materially in the character of the symptoms that 
accompany it, from the second, except that the pulse again becomes frequent, nay, 
uncommonly rapid : beating sometimes 200 strokes in the minute, so that you can 
scarcely count it. Dr. Whytt, in one instance, reckoned more than 210 pulsations. 
The child rolls its head perpetually from side to side ; moans continually ; waves its 
hands in the air, or one hand, the other frequently being palsied ; sometimes there is 
paralysis of one side, and convulsive twitchings of the other. The circulation is 
very unequal; one part of the body will be found hot and dr}', and another covered 
with a cold sweat : the cheeks are alternately pale and flushed ; the child is raving, 
or insensible ; the rapid pulse gets more and more weak ; and at length the patient 
expires. In many instances death takes place in the midst of a strong convulsion. 
This last period is of very uncertain duration ; it may be over in a few hours, or it 
may last a fortnight. 

For my own part, I conceive that for all practical purposes it would be quite 
enough to make two stages only of this disease. In the first the symptoms are those 
of inflammation of the parts within the cranium, or of some of those parts ; in the 
second, we have the symptoms that resuU from the consequences and products of the 
inflammation, from softening, and from the effusion of serum. And frequently these 
sets of symptoms are, in some respects, common to both these causes ; and more 
frequently still they are mixed up together, effusion taking place, yet the inflamma- 
tion going on. And we may understand how the whole collection of symptoms may 
vary and fluctuate, and assume an uncertain character, according as the inflamma- 
tory process has ceased, or is still in progress ; according as it exists alone, or is 
mingled with the further source of cerebral disturbance that is furnished by its own 
events ; and according as the inflammation may have come to an end, while its 
events remain behind, and declare their presence by appropriate signs in proportion 
to their place and extent, and their various kinds and combinations. 

What are these events? In other words, what are the morbid appearances pre- 
sented after death in acute hydrocephalus ? 

In some cases we find traces of inflammation of the membranes of the brain ; a 
firm attachment of the skull-cap to the dura mater: occasionally some adhesion of 
the opposite surfaces of the arachnoid membrane to each other. Very commonly 
there is an effusion of serous fluid beneath the arachnoid in the meshes of the pia 
mater, and especially in the depressions between the convolutions. You would 
suppose, upon looking at this collected fluid through the arachnoid, that it had the 
consistence of jelly, but it is not so ; if you divide the arachnoid by means of a sharp 
scalpel, a perfectly limpid fluid makes its escape. Not unfrequently there are layers 
of coagulable lymph interposed between the arachnoid and pia mater ; this is a most 
unequivocal evidence of foregone inflammation ; and it is more frequently met with 
in the strongly marked cases. When portions of the cerebral mass are removed by 
slicing it, a great number of red points are often observed, speckling its cut surface ; 
I mention this appearance just to say, that, to the best of my belief, it does not war- 
rant any conclusion in repect to the state of the brain before death. We find these 



268 



DISEASES OF THE BRAIN. 



red spots numerous in many cases, where there had been no cerebral affection mani- 
fested during Hfe ; and they are not always to be seen when we are certain that there 
was inflammation. 

[The gray substance of the convolutions, in cases in which the sub-arachnoid tissue is 
strongly injected, is usually of a pale rose, or bright red colour. The lining membrane of 
the ventricles is occasionally injected, opaque, or coverec^with a pseudo-membranous exuda- 
tion, or with numerous white flocculi, which become very apparent when the membrane is 
immersed in water. It is often easily separated from the cerebral substance. The plexus 
choroides is very often injected, and thickened ; sometimes, however, it is pale and dis- 
coloured, and lined with small hydatiform cysts .; this latter appearance has, also, been found 
in the cellular texture of the pituitary gland. — C] 

With respect to the nervous matter itself it is said to be sometimes softer than 
natural, and occasionally it has been found infiltered, as it were, with serous fluid ; 
wet, and so rendered soft. Golis describes an instance of this kind, in which, 
he says, the fluid could be expressed from the cerebral substance as from a 
sponge. 

[In some cases the substance of the brain has been found of a firmer consistence than 
natural, and to a certain extent hypertrophied. A case is related by Golis, in which, upon 
opening the skull, the whole brain expanded, so that it could not again be replaced within the 
cranium. The convolutions are sometimes flattened, apparently from pressure against the 
skull.— C] 

But the most common and characteristic change is softening of the central parts 
of the brain, with an effusion of serous fluid into the ventricles. Generally the 
effused fluid is thin and watery ; serosity rather than serum. It contains less animal 
matter, perhaps, than any other animal production. Dr. Bostock found that of 103 
parts, 98.6 consisted of water, 1 part of sak, and .4 only of animal matter. It is not, 
therefore, in common, coagulable by heat. The quantity effused is uncertain ; , 
speaking generally, it varies from two to six ounces. j' 

[In many cases the amount of effused fluid is very trifling ; in some scarcely a trace is to | 
be discovered. The effusion may take place in the arachnoid or sub-arachnoid tissues, or in 
the ventricles, or in all these parts at the same time. The greatest amount is generally met 
with in the lateral ventricle — occasionally the quantity is so great as to enlarge the posterior 
cornea, elevate the fornix, rupture the septum lucidum, and thus establish a free communi- 
cation between all the ventricles. The cellular tissue of the choroid plexus may also be 
distended with serum. When the serous effusion in the brain is considerable, it is often 
found also in the spinal canal. — C] 

But the effused fluid is not always clear and Hmpid ; sometimes it is turbid, like 
whey, or even puriform, with flocculent shreds floating in it. These have been con- 
sidered as flakes of coagulable lymph ; but I question whether, in many cases, they 
are not merely fragments of the softened and broken-down materials in the neigh- ' 
bourhood ; for the septum lucidum, the fornix, and other parts forming the walls of , 
the ventricles, are very commonly found soft, and pulpy, or entirely disorganized.* i 
The septum lucidum is perforated perhaps by a ragged irregular opening, the 
softened portion having fallen out ; the fornix has lost its consistence, and often its ' 
figure, or fails asunder when the most gentle attempt is made to raise it. Dr. Aber- 
crombie holds not only that this softness is the result of inflammation, which I think 
cannot reasonably be doubted, but that the inflammation of these central white pans | 
constitutes the essence of the disease, in very many cases of acute hydrocephalus ; ; 
and what bears him out in this opinion is the interesting fact, thai this softened con- 
dition of the septum lucidum, fornix, and corpus callosum, may be fatal without any | 
effusion of serum, and without any other morbid appearance, although with all the | 
symptoms which are usually considered to indicate acute hydrocephalus. He \ 
relates two striking examples of this kind ; one of them was as follows. — A woman 
became affected with violent pain in her head, shooting from temple to temple. i 
She was extremely restless, tossing from one side of the bed to the other ; her eyes 
were slightly suffused, and impatient of the light; pupils contracted; the pulse 60, 
soft and rather weak. She was repeatedly bled, both generally and topically, and 

[* This is the opinion of Barthez and Rilliet.] 



ACUTE HYDROCEPHALUS. 



269 



used purgatives, cold applications to the head, bhstering, (fee. For three days she 
was much reheved by these measures ; the violent pain was removed, and she com- 
plained of pain only when she moved her head. She was quite sensible, but 
oppressed, and inclined to he without being disturbed. At the end of four days her 
speech became affected, of which she was aware, for she said she felt a difficulty in 
getting out her words. Then came stupor, and at times incoherence, and double 
vision, and at last coma, and dilated pupil. She died on the eighth or ninth d-ay of 
the disease. 

The fornix and septum lucidum were found broken down into a soft white pulpy 
mass ; there was no effusion in the ventricles, and no other disease in any part of 
the brain. 

[In the cells of the arachnoid membrane there is often deposited a concrete yellowish 
matter, either soft and inelastic, or somewhat firm, elastic, and of a shining appearance. It is 
deposited either in patches, or in lines borderinjj the blood-vessels; and, as is the case with 
all the indications of inflammation in this disease, it is more commonly met with at the base 
than at the summit of the brain. Granulations and miliary tubercles are often interspersed 
in its midst. The whole base of the brain is often covered with a continuous layer of the 
yellowish gelatinous deposit alluded to. This deposit differs from the matter effused in in- 
flammation occurring in persons unaffected with tuberculous disease ; the difference is thus 
traced by Barthez and Riliiet (Malad. des Enfants, torn. iii). The former is almost always 
solid, the latter almost always fluid ; the former occurs more especially at the base of the 
brain, the latter upon its convex surface ; the former is of limited extent, particularly when 
upon the surface of the hemispheres, the latter may spread over the greater portion of the 
surface of the brain ; finally, the former is almost invariably found in the cells of the pia 
mater, while the latter occurs habitually in the great cavity of the arachnoid. — C] 

Not unfrequently scrofulous tubercles are discovered in the substance of the brain ; 
and it is probable that these would have been more frequently met with if they had 
always been carefully looked for. They consist almost universally of a cheesy kind 
of matter, like that of large tubercles in the lungs. 

[Tubercles, varying in size from that of a pin's head to that of a pea, are very generally 
found scattered irregularly over the surface of the pia mater, following it between the con- 
volutions ; occasionally, however, they occur in distinct patches of an inch or more in extent. 
They are commonly hard, and semi-transparent, sometimes opaque and of a whitish, grayish or 
yellowish colour. They are found upon all parts of the surface, the convex and lateral portions 
as well as tlie base, in the infractuosities of the convolutions, and in the fissures. According to 
Riliiet and Barthez, they are more frequent iipon the convex surface of the hemispheres than 
at the base. Dr. Hamernjh (Schmidt's Jahrbucher, 1845) found them more frequently at or 
near the base of the brain. They are much more abundant upon the brain than the cere- 
bellum. They are met with, also, imbedded in the gray matter of the brain, and are here 
often surrounded by a halo of redness, usually connected with an enlarged vessel, ramifying 
from the pia mater. More rarely, tubercles are detected in the medullary portion of the 
brain, where they are often overlooked in consequence of their pale, semi-transparent, yellow- 
ish tint. The plexus choroides, is, also, often covered with tubercles. They are very com- 
monly met with, likewise, on the serous membranes of the thorax and abdomen, in the lungs, 
and occasionally in the substance of the liver. In twenty-seven out of thirty-three cases of 
hydrocephalus, Barthez and Riliiet found tubercles or granulations, associated with inflam- 
mation of the pia mater; in four cases the meningitis was unattended by any trace of tuber- 
cular deposition in the encephalon ; and in two cases, the granulations or meningeal tubercles 
were unattended with any traces of inflamm.ation. In all the thirty-three cases the symptoms 
were nearly identical.— C] 

You will find a good deal said by writers on this disease, of morbid appearances 
found in other parts besides the brain, and especially in the abdominal organs, — 
enlargement of the liver, inflammation of its peritoneal covering, a preternatural 
development of Peyer's glands, tuberculous matter in the glands of the mesentery. 
One remarkable change is very often seen, viz., intussusception of the small intes- 
tines. This probably takes place a short time only before death, and appears to be 
the result of spasmodic or irregular movements of the bowels, analogous to those 
which are observed in the voluntary muscles. The intussuscepted portions are 
easily pulled out, and show no marks of inflammation. 

There have been endless discussions respecting the true pathology of acute hydro- 
cephalus, and it may be proper that I should offer you a few remarks upon this 
point, before I proceed to the treatment of the disease. 

x3 



270 



DISEASES OF THE BRAIN. 



I need not, I conceive, take any further pains to convince you that the disease is 
essentially inflammatory. We are inevitably led to that conclusion by the symptoms, 
which nearly resemble those that occur when undoubted inflammation has arisen 
from injuries of the head : by the appearances on dissection, which are always such 
as inflammation may have produced, as softening and effusion of serum; and 
frequently such as nothing but inflammation could have produced, as suppuration, 
and the formation of adventitious membranes : and lastly, by the unequivocal relief 
given by blood-letting, and other evacuations, the blood drawn being sometimes also 
sizy. 

Many persons, as I have already hinted, lay great stress, when discussing the 
pathology of acute hydrocephalus, upon the previous unhealthy state of the nutri- 
tive apparatus. They hold that the primary disease — the /oris et origo mail — lies 
in the stomach, or bowels, or hver ; and that the brain affection is secondary, and 
caused by sympathy with these distant parts : and this opinion they fortify by refer- 
ring to the frequency of organic disease, met with after death, in the abdominal 
viscera. In accordance with these views of its origin, they propose to cure, or to 
prevent, hydrocephalus, by redressing the faulty condition of the digestive organs. 

Now this, in my judgment, is not only an erroneous, but an unsafe doctrine : for 
it tends to divert our attention from the head, and to suggest a feeble and inadequate 
plan of treatment. The grand predisposing cause of acute hydrocephalus is cer- 
tainly the scrofulous diathesis, and this is why w^e see the complaint run so often in 
families : so that one child having died of that disorder affords much ground for 
apprehending that others, belonging to the same family, will become victims to it. 
The constitutional tendency is hereditary, and children born with it are liable and 
likely to have strumous disease set up in various organs at once, or perhaps in suc- 
cession ; not, however, a succession of cause and effect, but of common relation to 
one pervading disposition. We need not be surprised that scrofulous inflammation 
should affect the brain and abdomen at the same time. When we find obvious 
organic disease of the brain, scrofulous tubercles for instance, which must have been 
antecedent to the hydrocephalus, it would be just as absurd to look to the abdomen 
for the cause of the hydrocephalus, as it would be to seek in the brain for an expla- 
nation of the cause of jaundice or of dysentery, when the liver or the colon was 
known to be diseased. 

I do not mean to assert that the morbid conditions of the brain and of the abdomen 
are perfectly independent each of the other. The vomiting that is so constant a 
feature of acute hydrocephalus, the constipation that is so common a consequence of 
head affections, affords familiar evidence of the influence which cerebral disorders 
may exercise upon the abdominal functions. Conversely, any disease in other parts 
of the body may react injuriously upon the brain, and may sometimes be regarded 
as an exciting cause of disease in that organ. 

The period of life is also a strong predisposing circumstance ; acute hydrocephalus 
being very much more frequent during infancy and childhood than at any subsequent 
time. It is said that fifty children are attacked by it in the first five months of life, 
for one child that has it afterwards. But it may occur at any age up to the twelfth 
or fourteenth year. After that period it is comparatively rare. 

Whatever tends to deepen and aggravate the scrofulous diathesis — improper or 
insufficient nutriment, exposure to cold, inadequate clothing, impure air — may be 
regarded as a predisposing cause of acute hydrocephalus. And whatever tends to 
call scrofulous disease into action, may be reckoned among the possible exciting 
causes of acute hydrocephalus. Any general irritation may bring it on. It some- 
times supervenes upon the drying up or repression of eruptions, as tinea capitis, or 
sores behind the ears. Such eruptions, therefore, occurring in strumous children, 
we must not attempt to cure suddenly ; and free purging should be employed when 
.they begin to disappear. The irritation produced by difficult and painful dentition 
is a very frequent exciting cause ; and this is a source of danger which, in many- 
cases, may be obviated by timely and judicious management. Violent heating 
exercise has sometimes, apparently, kindled the cerebral inflammation. Among the 
exciting causes we may place all physical injuries which jar and stun the brain ; 



I 



ACUTE HYDROCEPHALUS. 



271 



blows on the head, falls from a height, although the head may not be the part struck ; 
and all moral ao-encies which shock or strongly disturb the nervous system ; severe 
bodily pain, violent fits of anger, sudden fright. Gohs goes even so far as to say 
that great terror and distress of mind in the mother during the latter months of preg- 
nancy may lead to the occurrence of acute hydrocephalus in the child ; and he brings 
forward this curious fact in support of his opinion : — -A large proportion of the chil- 
dren that were born in Vienna soon after the bombardment of that place by the 
French, in 1809, were seized with convulsions within a month after their birth, and 
died of inflammation within the cranium ; effusion of coagulable lymph between the 
membranes, and of serum in the ventricles, being discovered on dissection. 



LECTURE XXYI. 

Acute Hydrocephalus, continued. Prognosis and Mortality of the Disease. 
Treatment; Blood-letting; Purgatives ; Cold; Mercury; Blisters. Pro- 
phylaxis. Spurious Hydrocephalus. Chronic Hydrocephalus, or Dropsy of 
the Brain. Shape of the Head and Face. Anatomical Conditions. Symp- 
toms. 

The disease, of which I described the symptoms in the last lecture, acute hydro- 
cephalus, is a very dangerous disease : and, when once it is fairly established, many- 
more die of it than recover. Our chance of saving the patient's hfe, by appropriate 
treatment, is always greater in proportion as the complaint, or the tendency to the 
complaint, is detected early; and for that reason the precursory symptoms possess 
so high an importance. 

When our treatment commences while the symptoms are as yet rather those of 
the precursory state, than of the confirmed disease, it is impossible to say hov/ many 
of those cases Avhich, under such treatment, terminate favourably, would otherwise 
have ripened into well-marked hydrocephalus; and we must be content to have it 
said, without its being possible for us to refute the assertion, that not all of the dis- 
orders which we treat as acute hydrocephalus are really instances of that complaint. 
We must act upon the worst supposition, and not wr.it until the nature of the symp- 
toms demonstrates that the malady is present, while it demonstrates also, at the same 
time, that it is Ave 11 nigh hopeless. These are cases which peculiarly demand de- 
cision on the part of the medical man ; and we are bound to act, in some instances, 
upon very slight indications ; as when, for example, we perceive what we think 
threatenings of acute hydrocephalus in a scrofulous child, or in a child belonging 
to a family in which others have already been cut off by that disorder. 

It has been supposed, by some, that the case is hopeless after effusion has taken 
place, but we cannot be sure of that ; nay more, there are no symptoms by which 
we can ever tell for certain that effusion has taken place. 

I remember to have heard it gravely maintained, in the debating societies which 
I sometimes attended when a student, that there are no such things as absorbents, 
and no absorption, in the brain ; and therefore that perfect recovery from serous 
effusion in that organ is impossible. [There is no evidence that the effusion within 
the cranium is the cause of danger, or even of the symptoms which mark the latter 
stage of the disease. — C] But this notion is refuted by plain and well-knowm facts. 
We shall see hereafter, that blood poured forth within the nervous pulp is capable 
of being removed by absorption. How an opinion so palpably erroneous could 
ever have found credit, except with that class of men who can or will believe nothing 
which they cannot see, I am at a loss to guess. 

The prognosis, always doubtful or bad, is a little better when the disease is vio- 
lent, and occurs in tolerably healthy subjects, than when it creeps on slowly and 
insidiously, and in weakly, scrofulous patients. In the former case there is more 
room for the adoption of active measures ; and the disease is more likely to be arne- 



272 



DISEASES OF THE BRAIN. 



nable to remedies, and less likely to be obstinate ; it is also less likely to depend 
upon a permanent cause, such as the existence of a scrofulous tumour in the brain. 

The probable issue of the disease is often judged of by the state of the pulse. 
The quick pulse belonging to the early stages of the disease will become slow ; but 
it may become slow in two very different ways : it may diminish in frequency in a 
gradual and moderate manner, and then we may hope that the alteration proceeds 
from the progressive declension of the fever ; or it may drop suddenly, which would 
be a reason for our fearing that the second stage of the disease was about to estab- 
lish itself. We must take care, under the former circumstances, not prematurely to 
assert that the disorder is on the dechne, and the patient safe. On the other hand, 
if the pulse has been morbidly slow, a gradual and shght increase in its frequency 
must be considered as a favourable omen ; while its rapid and great acceleration 
would show that the disease was passing into its worst and final stage. 

I have already cautioned you against being misled by that deceitful truce, and ap- 
parent improvement, which is apt to take place in the course of the disease. If the 
signs of amendment continue, or make progress, during two or three entire days, we 
may venture to admit a little more hope. But the patient can never be considered 
secure while any approach to what are thought symptoms of effusion remains ; 
while the pupil continues dilated, for example ; or even so long as it does not con- 
tract briskly under a strong light. 

The prognosis is especially bad when acute hydrocephalus supervenes upon other 
disease ; or when it is engrafted (as it sometimes is) upon the chronic form of the 
disorder. It is very seldom that the acute form subsides into the chronic. 

To show you that we are warranted in the expectation of sometimes carrying our 
patient through this most perilous malady, I will mention a few statistical facts that 
have been recorded in respect to its mortality. Dr. Odier, of Geneva, states that, 
upon an average, eighteen cases of acute hydrocephalus occur every year in that 
place ; and of these six get well; i.e., the recoveries are to the deaths as one to two. 
Dr. Golis, to whose work I referred in the last lecture, and who had the charge of a 
large institution for children in Vienna, gives an account of thirty-seven cases, out 
of w^hich five recovered. He had seen, upon the whole, forty-one instances of reco- 
very from acute hydrocephalus. Dr. Mills, who has also written on the disease, has 
narrated twenty-eight cases, all of which died but seven ; and Mr. Brichetau lost 
four out of eleven. Adding these together, and taking the average, we have seventy- 
six instances of the disease, and nineteen recoveries ; exactly one in four. The 
cases in which recovery took place were mostly those in which antiphlogistic mea- 
sures were adopted early. 

The treatment of acute hydrocephalus is difficult to conduct ; and scarcely less 
difficult to describe and teach. The disease being essentially an inflammation, 
requires, in its earlier periods at least, the remedies of inflammation. But we must 
ever bear in mind that our patients are children ; and, for the most part, weakly and 
scrofulous children. Their time of fife, and the presence of the strumous diathesis, both 
forbid that strenuous appliance of antiphlogistic remedies which might be proper and 
necessary in aduks of strong and healthy frame. We take our w^eapons, however, in 
either case, from the same armoury. 

The only event of the inflammatory process compatible with the safety of the 
patient is resolution. To this end, therefore, must our efforts be earnestly directed. 
If the child be feverish, the pulse sharp, the head hot, the cheek flushed, the pain 
severe, and if, moreover, the case be seen early, there need be no doubt about the 
propriety of abstracting blood. It is a matter of obvious importance to ascertain how 
far we may safely and beneficially carry this measure, in the diseases of infants. 
Dr. John Clarke, a ph)rsician of large experience (the elder brother of the present 
Sir Charles Clarke), found that very young children would very well bear the lo^s 
of blood, even to fainting, once or twice : but that their vital powers were apt to 
sink if the bleeding, to that extent, was oftener repeated. It is better, in my opinion, 
to apply leeches to the temples, or to the mastoid processes, of these little patients, 
than to cut one of their veins. Recollect that, upon very young children, leeches 
produce an effect tantamount to that of venesection. Their bites bleed more freely 



ACUTE HYDROCEPHALUS. 



273 



than in grown persons, on account of the greater activity of the capillary circulation 
in children. No general rule can be prescribed in respect to the number of leeches 
to be used ; three will take as much blood in one case as half a dozen in another ; 
but assuming that one leech will, on an average, cause the discharge of one ounce 
of blood, we may apply three of them to a strong infant of six months, when the 
symptoms are violent. Of course the further efflux of blood must be stopped if syn- 
cope occurs. In older children the quantity of blood requisite to be taken will be 
somewhat larger: six ounces drawn from a vein is a full bleeding, I should say, for 
a child five or six years old. I mention these quantities as mere approximations, as 
guides to what you may expect to find practically needful : the true measure and 
test of salutary blood-letting being in this, as well as in other inflammations, the 
effect it has at the time. The first bleeding, in what manner soever the blood is 
taken, should be a sufficient one ; should produce some decided and manifest im- 
pression. By attending to this rule you will break the force of the early disease 
more surely, and more safely too, than by drawing blood in frequent driblets ; a mode 
of using the remedy calculated to subdue the patient rather than to overcome his 
.nalady. You must afterwards go on with the leeches to the head, or you must with- 
:iold them, according to the exigency of the particular case ; according to the state 
of the pulse, the continuance or the cessation of the pain, the increase or diminu- 
tion of the fever, the previous strength and condition of the child, and so forth. And 
let me once more admonish you that, as you have to deal, in general, with scrofulous 
children, any superfluous removal of blood, the abstraction of more than is required 
for extinguishing the inflammation within the head, will be hkely to prove injurious 
to the general system ; and even dangerously to depress the vital power. After the 
full formation of the comatose state, a further prosecution of the bleeding has some- 
times been rapidly followed by death. 

The next in rank and importance to bleeding come purgatives. They are to be 
exhibited with the threefold view of correcting depraved secretions, of clearing the 
alimentary canal of its irritating contents, and above all, of deriving, as the phrase 
is, from the head ; producing a discharge of the watery parts of the blood, and 
taking off the stress from the cerebral arteries. The best forms of purgative medi- 
cine to be used for these purposes with children, consist of calomel and jalap, or 
calomel and scammony ; and if these do not act freely, senna and salts must be 
given in aid of them. I have already made you acquainted with Dr. Abercrombie's 
high estimate of the efficacy of purgatives in inflammation of the brain, whether in 
the child or in the adult. Dr. Whylt, again, states that he never saw even tempo- 
rary relief of the symptoms produced by any other means than those which increased 
the evacuations. Purgatives are to be administered, therefore, at an early period. 
But sometimes the stomach is so irritable that it rejects them. A previous bleeding 
wdll often correct this ; and it is no small part of the benefit derived from the ab- 
straction of blood, that it prepares the way for the more effectual operation of aperi- 
ents and of mercury. A large clyster will often be of service, both in setthng the 
stomach, and in procuring stools, when there is much vomiting, and a continual 
rejection of medicine given by the mouth. Dr. Cheyne mentions a form of medi- 
cine by which he sometimes succeeded in quieting the irritable stomach, and pro- 
curing evacuations ; he would give a drachm or two of magnesia, saturated with 
lemon juice, every two or three hours. You may sometimes get calomel and scam- 
mony, however, to remain on the stomach, when almost every other medicine is 
rejected. The purgative plan should be steadily persisted in for several days. 

To show you how torpid the bowels are apt to be in this disease, and how diffi- 
cult it sometimes is to procure evacuations from them, I may mention the following 
circumstances which I heard Dr. Alison relate as having occurred in the practice of 
his uncle, the late Dr. Gregory, of Edinburgh. He had one patient who took 140 
grains of calomel in the course of five days ; yet his bowels were not relieved till he 
had also taken two doses of jalap, the first of 30, and the second of 35 grains. In 
another case, a child of twenty-eight months took in nine days 350 grains of calo- 
mel (nearly 40 grains a day) ; ^d in six of these days 136 grains of jalap (more 
than 20 grains a day) : the effects were a gentle purging from the jalap, none from 



274 



DISEASES OF THE BRAIN. 



the previous calomel, and but slight salivation. The child recovered after having- 
been nearly in a comatose state. Of course large doses of this kind are never to be 
given, until the inefficiency of smaller ones has been ascertained. :' 

Cold applied to the head : — I have before given you examples of its power. It 
is especially useful in the early periods of the disease, when there is much heat, 
and when evacuations have been obtained. I am doubtful about the propriety of j 
•keeping ice in contact with the surface of tiie head in very young children. It will 
in many cases be sufficient to lay a linen rag wet wdth cold water (or spirit and 
water, to promote evaporation), upon the child's head, taking care to renew it fre- 
quently, not merely as often as it gets dry, but as often as it gets hot ; or water may [ 
be poured from a pitcher upon the head, a basin being held under the chin. Dr. i 
Darwall states that he has known cases, which seemed utterly hopeless, retrieved I 
by letting water fall in a small succession of drops upon the scalp, and continuing | 
it until the head no longer recovered its high temperature upon intermitting the j 
dropping. I need scarcely say that under all circumstances it is expedient to keep | 
the head somewhat elevated. The influence of this mode of applying cold to the | 
head is increased, and perhaps rendered safer, by immersing the lower extremities i 
of the patient at the same time in warm water. ' 

Different opinions have been held in respect to the value of mercury in this dis- | 
ease. Knowing how powerful an influence it has in controlling inflammatory action, 
and that the inflammation in acute hydrocephalus often leaves behind it traces show- i 
ing that it was of the adhesive kind, I should not omit giving mercury ; but (as I 
stated when upon the subject of encephahtis) I should not give it with the direct ' 
object of affecting the gums, of producing ptyahsm. I believe the evidence respect- 
ing the efficacy of mercury carried to sahvation in acute hydrocephalus is this : — > 
that some few very desperate cases have got well, the improvement commencing at 
the time when the mercurial influence on the system was becoming apparent ; and 
that in other cases, the occurrence of salivation has been followed by no alleviation 
of the symptoms, but the disease has run on, unchecked, to its fatal termination. In 
truth it is a very difficult matter to sahvate a child ; there is a great reluctance in 
the system, at the earlier periods of hfe, to take on the specific mercurial action ; and 
the disincUnation seems peculiarl)'' strong during the presence of this disease ; and 
the younger the child, the more difficult is it to affect the gums. Perhaps this may 
be considered fortunate ; for when salivation does take place in these little patients, 
it sometimes proceeds to an alarming extent. Dr. John Clarke, who employed 
calomel largely in a variety of diseases, never saw more than three instances ia 
which sahvation was produced in children under three years of age. I 

If you are desirous of taking the chance of the specific influence of mercury ! 
doing good, you had better give calomel as a part of the purgative plan, and rub in ' 
some of the mercurial ointment ; you had better do this than lock up the child's 
bowels by combining opium with the calomel; not to mention the injurious effects 
of opium upon young children in general, and in the early period of head affections 
in particular. The calomel should be given steadily, in equal doses, at equal in- 
tervals. Green evacuations from the bowels, resembling wet tea-leaves or chopped 
spinach, usually follow its continued administration ; and this appearance (like 
the rising of the gums in adults) is generally regarded as a proof that the influ- i 
ence of the mineral is felt by the system, and that it is doing all the good of which 
it is capable. 

Upon the whole, I believe it will be found that they who have had the most ample 
experience of this perilous disease, have ended with the conviction, that moderate 
local depletion, and the regulated exhibition of mercury in small quantities, afford, 
generally, a better chance of success than the large bleedings, and the full and fre- 
quent doses of calomel, which have sometimes been recommended. ; 

Of blisters I may repeat the substance of what I stated when we were considering , 
encephalitis. I should abstain from them at the commencement of the disease. 
Even when applied at a distance from the head, they are apt to prove a source of 
hurlful irritation in these young and susceptible suliyects. But in the second stage ' 
pf the malady, I believe blisters are often of good service. They may be applie(i 



ACUTE HYDROCEPHALUS. 



275 



to the nape of the neck, or to the head : and several may be applied in succession ; 
or the ulcerated surface may be kept open by the ^Ip of irritating ointment, such 
as the unguentum cantharidis, or the ceratum sabinse. 

These are the main remedies to which we trust in the treatment of acute hydro- 
j cephalus : bleeding, purgatives, cold, in the outset ; mercury and bhsters, of more 
I equivocal efficacy than the former, in the more advanced stages of the disease. 
When there is much irritability towards the decline of the disorder, or in its latest 
period, opiates may cautiously be tried ; they sometimes have appeared to be ex- 
tremely beneficial : two or three grains of Dover's powder furnish a very eligible 
j form of opiate in such cases. 

[Dr. Wood {Prac. of Med. vol. 2, page 636) remarks : " One additional remedy should be 
employed in this form of meningitis, from its supposed influence over the scrofulous habit 
of body, and in the hope, that if it do not promote the absorption of the tuberculous matter, 
it may possibly prevent its deposition. I allude to iodine. I would commence with it in 
such doses as the stomach of the child could bear, and continue it throughout the treatment. 
The iodide of potassium, or the compound solution of iodine (U. S. Ph.) should be employed. 
The iodide of mercury might with great propriety, be substituted for the calomel at the stage 
at which it is desirable to aim at the mercurial impression 5 and, in this case, the other 
preparations of iodine should be abandoned." — C] 

I do not feel called upon to say any thing, in addition to what I stated in a former 
lecture, about other remedies ihat have been proposed in acute hydrocephalus ; 
digitalis, colchicum, squills, antimony. These may be useful, when they act as 
diuretics : but they have no specific virtue. 1 have told you the remedies which I 
believe to be the best ; and which will save the patient, when judiciously used, if 
the case be within the compass of our cure : and you will do w^ell to learn how to 
manage these powerful means. I am confident you will find that more to your pur- 
pose than trying now this and now the other remedy, because it is new, or because 
some persons tell you they have been wonderfully successful with it. 

[When the disease has reached the paralytic stage, its fatal termination is usually supposed 
to be inevitable; but Dr. Christie, of Scotland, and Dr. Woniger, of Hamburg, have each re- 
cently reported a case, in which a cure was effected after paralysis had occurred, by the 
administration of iodine. Dr. Christie employed a solution, containing sixteen grains of iodide 
of potassium, and four grains of iodine to one ounce of water, given in the dose of a tea- 
spoonful every four hours, at the same time that a weak ointment of the biniodide of mer- 
cury was rubbed upon the child's scalp. Dr. Woniger gave a solution of one drachm of 
iodide of potassium, dissolved in half an ounce of water, in the dose, at first, of forty, and 
subsequently of fifty drops every two hours. In the case of Dr. Christie, the first indication 
of improvement occurred in thirty-six hours after the employment of the iodine was com- 
menced with, but in Dr. Woniger's case, not until after the end of seventy-two hours. In 
both the recovery is said to have been complete and permanent. — C] 

Let me say a word in reference to the prevention of this disease : concerning 
which your advice will be sure to be asked again and again. In families, in which 
acute hydrocephalus has occurred, or which show decided marks of the scrofulous 
diathesis, the earliest attention should be paid to any deviation from the healthy con- 
dition of any of the functions. Weaned children in such families should be kept 
upon a nourishing but Hght and unstimulating diet ; consisting of well-dressed vege- 
tables, farinaceous substances, and a moderate proportion of animal food. Particular 
care should be taken to keep the bowels regular ; not that weakening purges should 
be given, but the bowels should be fairly reheved at least once every day. Any 
disturbance of the digestive organs should be immediately corrected ; by antacids, 
laxatives, change of diet, and sometimes by mercurials, as the hydrargyrum cum 
creta. Such children should also, if possible, be brought up in the country, and be 
freely exposed to mild and dry air ; and in winter great care should be taken to have 
them sufficiently clothed. During the hazardous period of dentition, the state 
of the teeth and gums must be sedulously attended to. There is good reason for 
believing that a seton or an issue in the neck or arm has been very serviceable in 
warding off and preventing attacks of the disease. Dr. Cheyne mentions some 
striking instances of the good effect of establishing an artificial irritation at some 
distance from the brain, when there has been a disposition to disease in that organ. ^ 



276 



DISEASES OF THE BRAIN. 



There is another caution, too, which you will often find reason for suggesting :• 
and that is, not to press or entourage the development of the mental faculties in 
children who are quick and intelligent beyond their years. Parents are apt to be 
proud of the early acquirements of their little ones : they are not aware that such 
precocity of the mind implies danger to the health of the body ; and they provide 
^hem with instructors, and to a certain extent abridge their hours of exercise and 
amusement, that they may do justice to their cleverness. But it is our duty to 
admonish them of the risks they are thus running : to advise them to think only, 
for the present, of corroborating the corporeal strength of the child ; and to avoid 
ovfer-cultivation of his intellect until this dangerous period of his existence is got 
over. 

There is still one point remaining, and one of the utmost importance, in relation 
to the acute hydrocephalus of children. I told you in the last lecture that, in general, 
the diagnosis was not very difficult. But there is a form of disorder very apt to be 
mistaken and treated for acute hydrocephalus, by those who are not forewarned ; and 
one which may be rendered fatal, if the remedies of acute hydrocephalus be di- 
rected against it. Encephahtis, whether it occur in the child or in the adult, has its 
spurious double. As, in morals, every virtue has its corresponding vice, which apes 
its actions and assumes its garb, so is it also with many opposite bodily disorders : 
and it is of great moment that we should be capable of discerning the essential dif- 
•ference of character that lurks beneath external similarity of feature. It is a most 
curious, but unquestionable fact, that ansemia of the brain, a diminution of its natural 
supply of red blood, and exhaustion of the nervous power, will produce symptoms 
very much resembling those which result from the diametrically opposite condition. 
To excess of pressure on the one hand, and to defect of pressure or support on the 
other, there are many phenomena in common. If you pay no regard to the state of 
the general circulation, as indicated by the temperature and by the pulse, you will 
find the actual symptoms of syncope, and of apoplectic fullness, to be identically the 
same. When a human being bleeds to death — -as many do from wounds, from ute- 
rine hemorrhage and so on — what do we see ? Why the patients may have nervous 
delirium, become convulsed, and then insensible, with a wide and fixed pupil. The 
outward visible signs of concussion and of compression of the brain are very much 
aUke. The vulgar always confound them, and are clamorous that a vein should be 
opened; a measure which would be proper and useful in the one case, but mur- 
derous in the other. It is the same with the functions of other parts : we have pal- 
pitation of the heart when that organ is insufficiently supplied with blood; 
palpitation when it is over-loaded ; dispncea, or hurried breathing, when the lungs 
are congested ; hurried breathing when blood does not arrive in them plentifully 
enough. You must see that the importance of distinguishing between the causes 
of these analogous phenomena is immense. Several authors in modern times have 
noticed the condition of the brain to which I now wish you to attend, and which 
may be called spurious hydrocephalus. Dr. Marshall Hall, Dr. Abercrombie, and 
the late Dr. Gooch — each of these three physicians appears to have discriminated 
for himself the spurious from the genuine disease; but their several accounts of it 
were made public in the order of time in which I have here mentioned their names. 
Dr. Gooch's Essay is entitled — " Of some Symptoms in Children erroneously attn- 
huted to Congestion of the Brain.^'' His description of the disorder in question is 
very graphic. It is chiefly indicated, he says, by heaviness of head and drowsiness. 
The age of the little patients whom he had seen so affected was from a few months 
to two or three years ; they Avere generally small of their age and of delicate health, 
or had been exposed to debilitating causes. The physician finds the child lying on 
its nurse's lap, unable or unwiUing to raise its head ; half asleep ; one moment open- 
ing its eyes, and the next closing them again, with a remarkable expression of 
languor. The tongue is shghtly white, the skin is not hot, at times the nurse re- 
marks that it is colder than natural ; in some instances there is now and then a slight 
and transient flush. In all the cases that Dr. Gooch saw, the bowels had been 
already disturbed by purgatives ; the symptoms had invariably been attributed to 
congestion of the brain ; and the remedies employed had been leeches and cold lotions 



SPURIOUS HYDROCEPHALUS. 



277 



to the head, and purgatives — especially calomel. Under this treatment the patients 
had gradually got worse, the languor had increased, the pulse become quicker and 
weaker, and at the end of a certain number of days the children had died. In two 
instances he had known coma to come on during the last few hours ; stertorous 
breathing, and dilated and motionless pupils. 

Dr. Hall describes a very similar set of symptoms : the face pale, the cheeks cool 
or cold, the eyelids half closed, the eyes unattracted by any object put before them, 
the pupils unmoved on the approach of light, the breathing irregular and suspirious, 
the voice husky. These symptoms are sometimes preceded by irritabihty, and a 
feeble attempt at reaction ; in which case the diagnosis requires extreme care and 
circumspection. He attributes the disorder, which he calls the " hydrocepha/oic? 
disease," principally to exhaustion. In early infancy the exhaustion has its origin 
chiefly in diarrhosa, or catharsis ; in the latter periods of infancy, in the loss of blood, 
with or without a relaxed condition of the bowels. The diarhoea is often produced 
by improper food, and frequently succeeds weaning; or it results from the ill-timed 
administration of purgative medicine. The exhaustion from loss of blood generally 
follows the apphcation of leeches, for some previous complaint — or for this very com- 
plaint itself, when incipient, and misunderstood. 

I will take one of Dr. Gooch's cases in illustration, and give it you in his own 
■words. "I was going out of town (he says) one afternoon, when a gentleman drove 
up to my door in a coach, and entreated me to go and see his child, which he said 
had something the matter with its head, and that the medical attendant of the family 
was in the house, and was just going to apply leeches. I went with him immedi- 
ately, and when I entered the nursery I found a child ten months old, lying in its 
nurse's lap, exactly in the state which I have already described ; the same unwilling- 
ness to hold its head up, the same drowsiness, languor, absence of heat and all 
symptoms of fever. The child was not small of its age, and had not been weak ; 
but it had been weaned about two months, since which it had never thriven. The 
leeches had not been put on. I took the medical gentleman into another room, related 
the foregoing case [i. e., a case in which a child had been leeched out of its life), 
and several similar to it, which had been treated in the same way, and had died in 
the same way. Then I related to him a similar case which I had seen in the neigh- 
bouring square, which had been treated with ammonia and decoction of bark, and 
good diet, and which had recovered ; not slowly, so as to make it doubtful whether 
the treatment was the cause of the recovery, but so speedily that at a third visit I 
took my leave. He consented to postpone the leeches, and to pursue the plan which 
I recommended. We directed the gruel diet to be left off, and no other to be given 
than ass's milk, of which the child was to take at least a pint and a half, and at 
most a quart, in the twenty-four hours. Its medicine was ten minims of the aro- 
matic spirit of ammonia in a small draught every four hours. When we met the 
next day the appearance of the child proved that our measures had been right; the 
nurse was walking about the nursery with it upright in her arms. It looked happy 
and laughing. The same plan was continued another day ; the next day it was so 
well that I took my leave, merely directing the ammonia to be given at longer inter- 
vals, and thus gradually withdrawn ; the ass's milk to be continued, which kept the 
bowels sufficiently open without aperient medicine." This case contains both a pic- 
ture of the morbid state and a summary account of the treatment it requires. Instead 
of the sal volatile, you may occasionally substitute with advantage from five to ten 
drops of brandy mixed with arrow-root. You are to restrain diarrhoea if it exists ; 
give the child plain nourishing diet — there is none so good for it as that furnished 
from a mother's breast ; caution the nurse or mother against raising it into the upright 
position ; keep its extremities warm with flannel ; and if the season permit, let a 
current of mild fresh air blow freely over it. 

Bear in mind, then, the distinctive characters of this spurious hydrocephalus — the 
pale, cool cheek ; the half-shut, regardless eye ; the insensible pupil ; the interrupted 
sighing respiration: and when the mere symptoms are more ambiguous, your judg- 
ment concerning the true nature of the case will be much aided by tracing the man- 
ner in which they came on, and the causes to which they seem to be attributable. 

* Y 



278 



DISEASES OF THE BRAIN. 



In very young children — in respect to whom the question is most likely to arise — 
you may often determine between congestion and exhaustion, between fullness and 
emptiness, between too much and too little pressure, by a very simple and easy test, 
which is not adverted to, so far as I remember, by any of the three writers whom I 
have mentioned. I mean, by taking notice of the state of the unclosed fontanelle. 
If the symptoms proceed from plethora, or inflammation, or an approach "to inflam- ' 
mation, you will find the surface of the fontanelle convex and prominent, and you | 
may safely employ, and expect benefit from, depletion. If, on the other hand, the i 
symptoms originate in emptiness and want of support, the surface of the fontanelle 
will be concave and depressed ; and in that case leeches, or other evacuants, will do ' 
harm, and you must prescribe better diet, ammonia, and so forth. i 

All that has hitherto been said has reference to acute hydrocephalus, which is an i 
inflaramation. I have next to speak of chronic hydrocephalus, which is a dropsy. 
From some cause, not well understood, a watery fluid collects within the skull, most 
commonly in the ventricles of the brain ; and this occurring at the earlier periods i 
of hfe, before the whole of the brain-case has become solid, the containing parts yield i 
to the increasing pressure, and the size of the head is augmented in various degrees; 
at the same time the cerebral functions are more or less deranged. This dropsy of j 
the cranial cavity often commences before the period of intra-uterine life is com- 
pleted, and the head of the foetus becomes so large, that it cannot pass with safety 
into the world. Accordingly, many of these infants perish at the moment when 
their separate existence commences ; — nascentes moriuntur. The pressure of the 
maternal pelvis is fatal to them ; or the diseased head bursts ; or it is crushed by the 
accoucheur, to preserve the hfe of the mother. The skull is emptied of its contents, 
and the shell, if I may so call it, collapsing, passes through the natural outlets. 

In many cases, however, the dropsical skull is expelled entire and unhurt, and the ' 
infant Hves for a shorter or longer period. Sometimes the fluid does not begin to 
accumulate till after birth : in a few days, however, or after some weeks, or some 
months even, the head is perceived to enlarge with a rapidity quite disproportionate i 
to the growth of the other parts of the body ; and enlarging, it becomes misshapen ! 
also. The intervention of the membranous partitions called fontanelles and open 
sutures, between the ununited bones, allows the centrifugal pressure of the gradually 
accumulating water to modify the shape of the head. These membranous inter- 
spaces are unnaturally wide, and more numerous than in healthy children. Never- 
theless the process of ossification goes on, but the bones are extremely thin. We 
see little islands of bone in seas (as it were) of membrane. By degrees, if the child I 
survives, the proportion of membrane to bone becomes less and less, and at length ! 
the whole brain-case is hard, and firmly closed up, its surface exhibiting an unusual j 
number of joinings ; there are many ossa triquetra. 

In the mean time the direction and relations of the loose and yielding bones are | 
altered. The os frontis is tilted forwards, so that the forehead, instead of slanting a ] 
little back, rises perpendicularly, or even juts out at its upper part, and overhangs i 
the brow. The parietal bones bulge above towards the sides; the occiput is pushed 
back ; and the head becomes long, broad and deep, but flattened on the top. This, 
at least, is the most ordinary result. In some instances, however, the skull rises up i 
in a conical form, like a sugar-loaf. Not unfrequently the whole head is irregularly 
deformed, the two sides being unsymmetrical. Some of these rarer varieties of form 
are fixed and connate ; others are owing, probably, to the kind of external pressure 
to which the head has been subjected. 

While the skull may be rapidly enlarging, the bones of the face grow no faster 
than usual, perhaps not even so fast ; and the disproportion that results gives an odd 
and peculiar physiognomy to the unhappy beings who are the subjects of this j 
calamity. They have not the usual round or oval face of childhood. The forehead j 
is broad, and the outline of the features tapers towards the chin. The visage is 
triangular. The great disproportion of size between the head and the face is diag- 
nostic of the disease, and would serve to distinguish the skull of a hydrocephalic ' 
child from that of a giant. Heartless parents sometimes make a wretched profit of ;' 



! 



CHRONIC HYDROCEPHALUS. 



279 



the deformity. A penny show of that kind existed very recently in the immediate 
vicinity of this college. 

When, after death, we explore the physical causes of these singular deviations 
from the natural figure and bulk of the cranium, we find that they proceed from the 
pressure of accumulaied water: the complaint is manifestly a dropsy. But the 
situation of the water, and the condition of the brain itself, are subject to some curious 
varieties. 

In a certain number of cases the brain is incompletely formed ; deficient in some 
of its parts, or even altogether wanting. That portion of the cranial cav^iiy which 
should contain the nervous pulp is filled up by a thin pellucid fluid. From some 
unknown cause, operating during the period of intra-uterine life, the progressive 
formation of the brain has been arrested. Marks of imperfect development are often 
visible in other parts of the same infants ; they have a hare-lip, a bifid spine, or a 
fissured palate. It is in cases of this kind generally that the skull, unnaturally small 
perhaps, is pinched up into a conical peak, and has considerable thickness. They 
are obviously hopeless cases. To the physiologist they are subjects of much inte- 
rest; for the practical physician they have none. 

But in the majority of instances, when the infants survive their birth, the liquid 
is contained in the central cavities or ventricles of the brain, which are expanded into 
one. The convolutions are unfolded, and the cerebral matter is spread out into a 
hollow sphere ; the irregularities of the surface have disappeared ; the whole of the 
brain is smoothly extended in a thin layer, immediately beneath the bones and the 
membranes that connect them, and surrounds the inclosed liquid like a bag. Less 
frequently a different stale of matters is seen. The liquid, instead of being included 
within the cerebral substance, lies in contact with the dura mater ; while the brain, 
perfect in all its essential parts, is at the bottom of the cavity. The difference, how- 
ever, is more apparent than real ; the two conditions are substantially the same, only 
that, in the one case, the solid parts that lie around the ventricles gradually expand 
as the fluid slowly collects, much as an air-balloon dilates in proportion as gas is in- 
troduced within it ; while in the other case the seams, or commissures (as they are 
technically called), that unite the hemispheres of the brain, give way, or are deficient, 
so that the ventricles, and the general sac of the arachnoid form together one huge 
cavity ; the hemispheres are turned aside, or folded back ; the surfaces that naturally 
have a central aspect look upwards, and seem to constitute the summit of the cere- 
brum. This was the state of the parts within the immense skull from which the 
largest of the casts before you was taken. It belonged to a man named Cardinal, 
who died in Guy's Hospital, in 1825, and of whom Dr. Bright has given a very 
interesting account. 

Now some of the consequences of this distension of the brain and skull with 
watery fluid are simply mechanical. The child is top-heavy. His large unwieldy 
head is too much for the muscles of his neck to sustain without fatigue ; or even, 
when they are unassisted, to sustain at all. He walks gently and carefully, like a 
person balancing a heavy load upon his head ; or he holds and partly carries his 
head with his hands, as a milkmaid steadies and supports her pail ; or he reclines the 
weight of his burden upon the chair, or table, as he sits. 

But far more important effects of the disease are those which relate to the three 
great functions of the brain. The child is soon found to be deaf or bhnd ; or palsied 
in one or more of its limbs ; or idiotic ; or all these. In other words, the special 
senses, the power of voluntary motion, and the mental facukies, are apt to be defec- 
tive or perverted. Instances, however, do occur, in which these functions are, for 
some time, but Httle deranged. The greater number of those who are afflicted with 
dropsy of the brain either recover or die during their infancy. Still, a few survive, 
bearing their complaint to the adult period, and even to old age ; and in some of 
these individuals who, with excessively large heads, have yet numbered many years 
of existence, the intellect and the senses, if not entire and perfect, have been suffi- 
ciently effective to answer the common wants and purposes of social hfe : the moral 
emotions strong, the feelings lively and correct, the memory tolerably retentive, the 
reasoning powers respectable. Dr. David Monro relates the case of a hydrocephahc 



280 DISEASES OF THE BRAIN. 

girl, six years old, whose head measured two feet four inches in circumference. She 
is described by him as being " as Hvely and sensible as most of her age," and as 
" having a strong memory." Dr. Bright's patient, Cardinal, was nearly thirty years 
of age when he died. He was born in 1795. At the time of his birth, his head 
was only a little larger than natural ; but it had a pulpy feel, as if it were almost 
destitute of bony matter. A fortnight afterwi^rds, it began to increase rapidly ; and 
when he was five years old, it was but little less, according to his mother's account, 
than when he died. He could not walk alone till he was nearly six, and then only 
on level ground. If he attempted to run, or to stoop, he fell down. He was sent to 
school when he was about six, and soon learned to read well and to write tolerably ; 
but writing he soon gave up, because, as he was near-sighted, it obliged him to stoop, 
which he could not conveniently do. When a candle was held behind his head, or 
when his head happened to be between a spectator and the sun, the cranium ap- 
peared semi-transparent ; and this was more or less the case till he was fourteen 
years old. About the age of twenty-three, epileptic fits began to occur ; and after 
that his health, which previously had been very good, failed somewhat. The ossifi- 
cation of the skull was not complete till two years before his death, the anterior 
fontanelle being the last part that closed. It has been mentioned that he was near- 
sighted ; but he was very quick of hearing, his taste was perfect, and his digestion 
good. Dr. Bright states that his mental faculties were very fair, and his memory 
tolerable ; but it was not retentive of dates. It was said that he was never known 
to dream. There was something childish and irritable in his manner, and he was 
easily provoked. He died, at last, of fever and diarrhcea. There were seven or 
eight pints of fluid within the cranium, in contact with the dura mater. On the base 
or floor of the skull lay the brain, with its hemispheres opened outwards, like the 
leaves of a book. 

How comes it that the cerebral functions are thus sometimes fulfilled, or go on so 
welJ, when the machinery through which the mental powers are manifested — the 
instrument whereon and whereby the immaterial principle mysteriously operates— 
is so palpably and greatly deranged ? -How comes it that life, and especially the life 
of the mind, subsists at all ? These questions open very interesting considerations. 
It would appear, from such cases as I have been referring to, that the curious 
arrangement and collocation of the several parts of the brain are rather a matter of 
convenient package than of necessary relation. The pulp which furnishes the 
medium of sense and thought, and volition, is there, but it is disposed in an unusual 
shape. In neither of the two varieties of the malady that have been described as 
being compatible with prolonged existence, is there any necessary diminution of the 
cerebral mass. The brain itself, which forms a bag in the one case, and is spht in 
halves in the other, has been found to weigh quite as much as a heakhy brain at the 
same period of hfe. There has been no loss, therefore, of substance ; the pressure 
has been gradual, and it has not been made to act injuriously by counter-pressure ; 
no effectual resistance has been afforded by the rigidity of the brain-case ; and thus 
the unopposed distending force neither causes absorption of the cerebral pulp on the 
one hand, nor, on the other, induces coma, or convulsions, or idiocy, by its com- 
pression. 

Most commonly, however, the mental and voluntary functions are maimed or per- 
verted ; and these serious calamities make parents look at a large head in a young 
child with anxious solicitude. But you are aware, after what I stated on this sub- 
ject in the last lecture, that the head may be extravagantly large without dropsy of 
the brain and without disease. 

We have just seen that, while the brain itself is gradually unfolded, or its hemi- 
spheres are parted and turned aside, by the liquid accumulating within the cranium, 
the functions of the organ may suffer but little, so long as the yielding brain-case 
permits the expansion or separation of the nervous substance, without inordinate 
pressure. But as soon as undue pressure begins to be exercised, then morbid symp- 
toms arise, or the defects that have previously shown themselves are aggravated. 
Hence that period of life becomes a perilous period, at which the skull, by the 
closure of its fontanelles and sutures,, loses its capability of further expansion^ In 



CHRONIC HYDROCEPHALUS. 



281 



some rare cases, the closed sutures re-open under the augmenting pressure, and a 
respite is thus obtained. Dr. Baillie has recorded an instance in which this hap- 
pened in a boy seven years old. A similar case is mentioned in Dr. Yeat's work 
on hydrocephalus. The patient was a boy nine years of age. The sutures of his 
skull separated again after having been united ; and it was remarked that the teeth 
in the jagged edges, whereby the bones interlock with each other, were much fewer 
than is usual. If this be always so when the sutures give way, it will serve to faci- 
litate our understanding how such a separation can take place. The skull may, 
however, go on expanding, although the sutures are permanently closed ; there still 
being left intervals between the several points of ossification, which, intervals are 
covered by membrane only. The beautiful preparation on the table, showing this 
remarkable state of the cranium, I have borrowed for your inspection from Dr. Sweat- 
man's museum. 

Indeed, although I have spoken of this complaint as being especially a disease of 
childhood, it does occasionally commence long after the skull has become a complete 
case of bone. Enlargement of the head, in these cases, is impossible ; but this cir- 
cumstance, and the symptoms it is apt mechanically to produce, form the only differ- 
ences between the disorder as it affects the child and the adult. In both cases dis- 
turbance of the cerebral functions arises, and at length convulsions or coma closes 
the scene. In both, a dropsical state of the ventricles of the brain constitutes, often, 
the only morbid change presented after death. A young and distinguished lawyer 
of my acquaintance had one or two attacks of rather sudden loss of consciousness 
while engaged in the Court of Chancery ; by degrees he became dull, stupid, for- 
getful, and, at length, insensible. In this condition he died. A large quantity of 
serous liquid was found distending the ventricles of his brain. No other alteration 
could be detected. 

Dr. Baillie describes a case of chronic hydrocephalus that occurred in a man fifty 
years old. Six ounces of fluid were contained in the lateral ventricles. He had 
been paralytic on the right side of the body ; and for eleven months before his death 
had lost the recollection of his own language, with the exception of four or five 
words, which he employed, with different intonations, to express his various wants. 

The celebrated Dean of St. Patrick's afforded another instance of the same dis- 
ease, attended with a similar interruption of the power of discoursing. The case, as 
related in Sir Walter Scott's Life of Dr. Swift, is curious, and contains an early 
suggestion of a piece of practice which, in our own time, has met with more favour. 
" A few days afterwards he sunk into a state of total insensibility, slept much, and 
could not, without great difficulty, be prevailed on to walk across the room. This 
was the effect of another bodily disease : his brain being loaded with water. Mr. 
Stevens, an ingenious clergyman of his chapter, pronounced this to be the case 
during his illness, and upon opening his head it appeared that he was not mistaken ; 
but though he often entreated the Dean's friends and physicians that his skull might 
be trepanned, and the water discharged, no regard was paid to his opinion or 
advice." « 

He remained from October 1742, to October 1745, in a state of silence, with few 
and slight exceptions ; and died in the 78th year of his age. 

Gohs also mentions three instances in which this disease began in advanced life ; 
two of the patients v/ere above seventy years old ; the third, who was a physician 
at Vienna, likewise died in the decline of life, having suffered under the disorder for 
ten years. 

Now, what can we do in these wretched cases ? Seldom much good, I am afraid. 
Yet something we must try, for parents will flatter themselves with hopes of a cure : 
and to say the truth, there have been, under judicious management, a sufficient num- 
ber of recoveries to forbid our despairing in any case, and to make it incumbent 
upon us to employ carefully afi those measures which have occasionally brought the 
disease to a favourable termination. Golis even affirms, that of the cases which 
began after birth, and which he saw and treated early, he was fortunate enough to 
save the majority. 

y2 



282 DISEASES OF THE BRAIN. 



LECTURE XXVII. 

Treatment of Chronic Hydrocephalus ; Internal Remedies: Mechanical Expedi- 
ents; Bandages, Tapping. Symptoms of Spinal Disease. Inflammatory con- 
ditions of the Spinal Marrow. 

The cure of chronic hydrocephalus may be attempted by internal remedies, or by 
external mechanical expedients, or by both. 

The internal remedies by which most good appears to have been affected, and 
from which, therefore, most is to be hoped, are diuretics, purgatives, and above all, 
mercury, which is beheved by many to have a special and powerful influence in 
promoting absorption. Conjointly with these, the abstraction of small quantities of 
blood from the head, by means of leeches, has been found beneficial. 

Golis advises that calomel should be given in half-grain doses, twice a day ; or 
if that quantity should purge too much, in doses containing only one-fourth of a 
grain. At the same time he would rub a scruple or two of mercurial ointment, 
mixed wnth ointment of juniper berries, upon the scalp, every night. He recom- 
mends that the head should be kept constantly covered also by a woollen cap, In- 
fants require, he says, no other nutriment than good breast milk ; while older patients 
should take a moderate quantity of meat. In mild weather they should be as much 
.as possible in the open air. Under this plan of treatment he afhrms that he has 
known the circumference of the head decrease by half an inch or an inch, in a period 
of six weeks or three months ; and that perseverance in this method has frequently, 
in his experience, been followed by perfect recovery, both of the mental and of the 
bodily powers. If no improvement should be perceptible in two months, he advises 
that diuretics should be given, with the former remedies: the acetate of potash, or' 
squills, or both : that an issue should be made in the neck, or in each arm, and 
be kept discharging for several months. And he thinks that when convalescence 
has once begun, it may often be much accelerated by minute doses of quina ; the 
fourth of a grain, for example, thrice daily. 

In a disease so unpromising as chronic hydrocephalus, we are warranted in tiding 
any plan that has been found, or supposed, to be useful. An apothecary of consi- 
derable experience — now dead — once took the pains to w^rite out and send me the 
particulars of two cases in which he had seen a pecuhar mode of administering 
mercuiy successful. I will give you them nearly in his own w^ords. 

In the year 1817, he had under his care a lad, named Scott, labouring under 
chronic hydrocephalus. He had been ill two or three years, was nearly blind, had 
very little use of his lower extremities, and could not walk across the room without 
support. He suffered violent pains in his head, and was unable to bear the least 
pressure on his scalp. His bowels were constipated, and his pulse " oppressed." 
Cupping and blistering, the blue pill, drastic purgatives, and ordinary diuretics, tried 
in combination and succession, gave him temporary rehef ; but no permanent benefit 
was obtained. Dr. Gower then suggested a plan which he had himself found suc- 
cessful in such cases, and which had first been used by Dr. Carmichael Smith, who 
had recorded ten cases of recovery^ under its adoption. Dr. Gower's plan was to 
rub dowm ten grains of crude mercur^^ with about a scruple of manna, and five 
grains oi fresh squills; this w^as to be one dose: and it was to be repeated every 
eight hours. 

My informant rubbed the quicksilver down with conserve of roses, and then added 
the fresh squills, making the whole into the consistence proper for pills with liquo- 
rice powder. The patient took this dose three times a day, for nearly three weeks, 
without any ptyalism being produced. Its effects were great prostration of strength, 
and loss of flesh, with gradual relief of all the boy's sufferings. It operated profusely 
by the kidneys. The medicine was continued twice a day, and at length once, for 
another fortnight ; when all the symptoms of the disease had disappeared. The boy 
was greatly emaciated. He was then ordered an ounce and a half of Griffith's 



CHRONIC HYDROCEPHALUS. 



283 



mixture thrice daily ; and soon regained his health and strength, and got quite well. 
He remained well eight years afterwards. 

The success obtained in this case led to the pursuance of a similar course in that 
of the son of a well-known fishmonger in Old Bond Street. He was about twelve 
years old, and afflicted in nearly the same manner as Scott, except that the pain in 
nis head was more acute, and caused violent screaming: relief had been repeatedly 
given for a time, by cupping. The physician in attendance was unwilling to try 
the plan, when it was proposed to him, but said that he would give what was equi- 
valent — small doses of blue pill, with squills in powder. The result was saHvation 
in a few days, without any amendment. In about three weeks, the local effects of 
the mercury having subsided, and the patient then suffering extreme pain in the 
head, loss of sight, and want of power over the lower extremities, my informant was 
desired to adopt any measures he thought fitting. The medicine was given as in 
the former case, and with the same happy consequence. It acted, as before, without 
producing ptyalism, but with a great reduction of strength and flesh. Health was 
restored by steel, after the symptoms of hydrocephalus had disappeared. This cure 
also was permanent. 

I think you will give me credit for not being over-fond of recommending what 
may be called conundrums, instead of well-tried and approved means of cure ; but I 
say that in such a complaint as chronic hydrocephalus, we have generally the oppor- 
tunity of testing the virtues of many reputed remedies, one after another ; and we 
are not to despise or neglect any measures that have been found beneficial, merely 
because they are out of the way, or because we cannot see in what manner they can 
excel the more common formulas. 

You wiU observe that these were cases in which the disease came on some time 
after the sutures of the skull had closed. 

[Dr. Hannay relates a case of chronic hydiUcephalus, in the Edinburgh Med, and Surg. 
Journal, in which he attributes the recovery of the patient mainly to tlie application to the 
scalp of a liniment, composed of powdered ipecacuanlia and olive oil, each two drachms, 
and half an ounce of suet. Dr. Hannay remarks, that the application of this liniment, three 
or four times a day, is followed in about thirty-six hours, by a papular and vesicular eruption ; 
and he is of the opinion, that as chronic hydrocephalus often succeeds to the suppression of 
eruptions on the scalp, the use of this counter-irritant will prove in many cases extremely 
useful — its effects are much more manageable than those of the tartar emetic ointment, 
whichj in this disease, has been found advantageous. — C] 

The mechanical remedies of chronic hydrocephalus are two : and they have a 
totally opposite mode of action. By the one, the brain is compressed ; by the other, 
it is lightened of its pressure : yet both of them have proved successful. What does 
this show 1 what, but a confirmation of the doctrine that there are different states of 
the encephalon, very dissimilar in their essential character, yet having some symp- 
toms in common ; and those the most likely of all to catch our attention. Such 
common symptoms resemble an algebraical symbol, which derives its value from the 
plus or minus sign prefixed. Surely it is of vital importance to study, and if we can, 
to settle, the differences whereby these inverse conditions, requiring contrary reme- 
dies, may be discriminated. 

Bandaging the head is one of these two expedients ; puncturing it the other. 
Neither of them is practically appHcable after the bones of the skull have united. 

Bandages appear to have been suggested by the notion that the increase of the 
fluid within the head, and probably some of the symptoms too, might depend, more 
or less, upon the want of firmness and proper resistance in the outer containing 
parts ; in the feeble and half solid skull. A certain amount of support and pressure 
is requisite for the due exercise of the cerebral functions. Beyond this amount all 
increase of pressure is hurtful. The middle point of safety it may be hard to hit. 
It is certain that the easy yielding of the bony walls of the head, by reason of the 
membranous interspaces that exist in the early periods of hfe, proves oftentimes the 
safety of these patients. If the skull did not expand as the water gathered, morbid 
symptoms would ensue. Great nicety must therefore be requisite in the use of this 
remedy. While the head is palpably enlarging, compression by means of plasters 



284 



DISEASES OF THE BRAIN. 



or bandages would probably be mischievous. When the disease is stationary, and 
the unconnected bones of the skull are loose and fluctuating, and the child is pale 
and languid, much benefit may be expected from moderate and well-regulated sup- 
port. The late Sir Gilbert Blane was the first, I believe, to suggest this mode of 
treatment ; but its safety and efficacy have been more recently demonstrated by Mr. 
Barnard, who has related several examples of complete success from the employment 
of bandages. In these cases the children were pale, bloated and feeble, with flabby 
muscles : the bones of their heads were movable and floating, and the functions of 
the brain more or less impaired. Mr. Barnard applied strips of adhesive plaster, 
about three-quarters of an inch wide, completely round the heads from before back- 
wards : covering the forehead from the eyebrows to the hair of the head, as low 
down on the sides as the ear will permit, and lapping over each other behind. Then, 
cross-strips are carried from one side of the head to the other over the crown ; and 
lastly, one long slip, reaching from the forehead, within half an inch of the root of 
the nose, over the vertex to the nape of the neck. In his first trial of this plan, but 
never afterwards, Mr. Barnard laid pieces of hnen, wetted with cold water, over the 
plasters. The only internal medicine given was castor oil, to regulate the bowels. 
The effects, in all this gendeman's cases, were these : a gradual diminution of the 
size of the head ; mitigation, and ultimate disappearance, of all head symptoms, such 
as strabismus, rolling of the eyes, starting of the muscles, and convulsions : and at 
the same time, increased tone of the muscular system, with an improved appearance 
of the skin and of the secretions from the bowels. These are striking results. They 
show that, in certain conditions of chronic hydrocephalus, a part of the danger arises 
from a lack of due support and confinement of the brain ; and they prove that com- 
pression alone may be equal to the cure. To such cases, Dr. Arnott's air-press 
would seem, from the facility with which its equable compressing force may be regu- 
lated, to be especially adapted. 

But in children who are not of this pafe and feeble habit, and in whom ossification 
of the skull goes on, the period when the walls cease to yield is the period of 
danger. The water continuing to accumulate, inordinate pressure begins to take 
place. Under these circumstances, the application of bandages or plasters must, if 
nothing else be done, be insufficient or unsafe. The brain-case being no longer 
capable of expansion, there remains to be attempted a reduction of the quantity of 
the liquid which it contains. 

Now, any considerable diminution of the accumulated fluid, through the agency . 
of mere absorption, is scarcely to be expected ; even although we endeavour to aid 
that process by applying leeches and cold to the head, and by purgatives, or diuretics, 
or diaphoretics. Some mode, more certain and efTectual, of emptying the distended 
cavity, has therefore been earnestly sought after ; and the second mechanical expe- 
dient of which I have spoken offers a very sure method of attaining this object. He 
must have been a bold physician who first proposed to decant the water from the 
brain, by means of a perforation, made with a trocar, through the membrane of the 
fontanelle, through the membranes of the brain, and through even the expanded 
cerebral substance itself. But the success of the project has amply vindicated his 
happy audacity. It is not a very new suggestion, but it has received particular 
attention in this country of late years : and though tapping the brain in chronic hy- 
drocephalus has been denounced as useless and cruel by some high continental autho- 
rities, by Gobs and Richter especially, it furnishes one of the best of the few chances 
of safety to the patient. Of course I mean ultimate safety, for the operation itself 
is attended with the present risk of accelerating the patient's death. Other means, 
however, faihng, we are justified in advising that hazard. We have to consider that 
by performing the operation we incur the danger of abbreviating the existence of a 
being, whose fife, without it, could scarcely be long continued, or capable of enjoy- 
ment : but then we afford some chance of a perfect cure. A speedy death, or an 
uncertain life of mental and bodily imbecility, or complete restoration : these are the 
three events to be looked at. Of the three, the second is, in my judgment, incom- 
parably the worst ; and if the case were my own, if I had to decide the painful 



CHRONIC HYDROCEPHALUS. 



28^' 



question in reference to one of my own children, I would accept the alternative of 
probable speedy death on the one hand ; possible complete recovery on the other. 

To say the truth, the immediate danger is not so very great as you might suppose; 
provided that the operation be skilfully and cautiously performed, and only a mode- 
rate quantity of water drawn off at a time. That even a very rough operation is 
not necessarily fatal we learn from a singular case related by Mr. Greatwood. A 
child, fifteen months old, afflicted with chronic hydrocephalus, fell down, and struck 
the back part of its head against a nail, which penetrated the skull. Above three 
pints of water gradually flowed out at the orifice thus made, and the child was 
cured. 

I will mention a few instances in which tapping the brain has been performed ; 
for I know no better mode of showing you the manner in which the operation 
should be done, the cautions to be attended to in doing it, and what kind of success 
it has had. 

There is an account of the performance of this operation by Lecat, in the Philo- 
sophical Transactions for the year 1751. This date is subsequent to the period 
when the Rev. Mr. Stevens suggested the propriety of trepanning Dean Swift's cra- 
nium. In 1778, Dr. Remmet, of Plymouth, punctured the head of a hydrocephahc 
child on five several occasions, with a lancet, and took away, in all, no less than 
eighty ounces of fluid ; five pints, as pints were measured in that day. The child 
died seventeen days after the last tapping. A very interesting case of the same kind 
is related by Dr. Vose, of Liverpool. His patient was an infant seven months old. 
Its head was more than twice the ordinary size. Three operations were performed ; 
the first with a couching needle. Upwards of three ounces were on that occasion 
evacuated ; and it was estimated that about the same quantity dribbled away after- 
wards. The child thereupon became very weak, but was presently revived by some 
cordial medicine. About six weeks afterwards, the liquid having collected again, an 
opening was made with a bistoury, and eight ounces were removed ; and nine days 
after that, twelve ounces more, without any bad consequences. The head dimin- 
ished in size, the patient got apparently well, and the case was published as a suc- 
cessful one. Unfortunately, however, the complaint afterwards returiied, and the 
child died of it. 

Mr. Lizars, of Edinburgh, operated upon a little patient of his twenty times in 
the course of three months; using a small trocar. Dilatation of the pupils, and 
squinting, which had previously existed, ceased immediately upon the escape of the 
water. The child recovered. Another very striking and instructive instance is 
recorded by Mr. Russell, of Edinburgh. The patient was an infant three months 
old, with an enormous head ; twenty -three inches in circumference, and fifteen 
inches and a half from one ear to the other. The child was affected with strabis- 
mus, and a perpetual rolling of the eyes. The usual routine measures, compression 
among the rest, had been employed without any success. By four operations per- 
formed at intervals of about ten days, the size of the head was considerably reduced: 
but, the fluid continuing to collect, calomel was given in small and frequent doses, 
and the gums became sore, and the child got well. At eight months old the dimen- 
sions of the head were less, by four inches in circumference, and by two inches and 
a half across the vertex, than they had been before the first tapping ; and the sutures 
had entirely closed. 

But Dr. Conquest, of Finsbury Square, has, more than any other person, given 
authority to these operations. In a paper published in the Medical Gazette in March, 
1838, he tells us that he had then tapped the heads of nineteen children for this com- 
plaint, and in ten of the nineteen cases the children survived. He introduces a small 
trocar through the coronal suture below the anterior fontanelle, and cautiously makes 
pressure upon the head afterwards by means of strips of adhesive plaster ; and he 
closes the wound in the integuments carefully after each time of puncturing. The 
greatest quantity of liquid withdrawn by him at any one time, has been twenty 
ounces and a half; and the greatest number of operations on any one child has been 
five, performed at intervals of from two to six weeks. The largest total quantity of 
water removed was fifty-seven or fifty-eight ounces by five successive tappings. 



286 



DISEASES OF THE BRAIN. 



This expedient, therefore, though doubtless hazardous, is really a valuable one. 
The rales relating to its performance may be briefly summed up. The operation 
should scarcely be had recourse to until other means have failed. The trocar should 
be small, and it should be introduced perpendicularly to the surface, at the edge of 
the anterior fontanelle ; so as to be as much as possible out of the way of the longi- 
tudinal sinus, and of the great veins that empty themselves therein. The fluid 
should be allowed to issue very slowly ; and a part of it only should be evacuated 
at once. The instant that the pulse becomes weak, or the dilated pupil contracts, or 
the expression of the child's countenance manifestly alters, the canula should be 
withdrawn, and the aperture in the skull closed. Gende compression should be 
carefully made to compensate, in some degree at least, the pressure that has been 
removed with the fluid. Should the infant become pale and faint, it must be placed 
in the horizontal posture; and a few drops of sal volatile, or of brandy, mixed with 
water, may be given. Sometimes slight inflammatory action comes on in the course 
of a day or two after the tapping. When this happens, we must apply cold lotions, 
and leeches, and use the other remedies which I mentioned before, as proper to sub- 
due such inflammation. 

I once got a surgeon to perform the operation upon the infant of a poor woman, 
after I had tried in vain all the other measures I have spoken of. To our horror, 
when the trocar was withdrawn from the canula, instead of clear serosity, a fine 
stream of purple blood spouted forth. The opening was at a considerable distance from 
th^longitudinal sinus ; but the trocar was not so dehcate as it might have been, and 
1 presume that one of the larger superficial veins had been pierced. I do not think, 
either, that the instrument was introduced in a sufficiendy perpendicular direction. 
Of course the risk of hitting a vein is increased when the trocar is carried obliquely 
inwards : and a larger portion of the cerebral mass is also wounded. We naturally 
thought it was all over with the child, which presently became deadly pale and faint. 
A verdict of infanticide hy misadventure stared us in the face. But under the use 
of stimulants the infant revived again; no hemorrhage went on internally, as we 
apprehended it would ; but the child, after a day or two, seemed very much the 
better for the loss of blood. This amendment, however, did not last; and the 
mother, who had been terrified by the immediate consequences of the operation, 
feared to come near me, lest I should wish to have it repeated ; and at length our 
patient died. I w^as very desirous to examine the interior of the head ; but this was 
not permitted. 

On one subsequent occasion I have witnessed the operation. The subject of it 
was an infant about eight months old. Four months after its birth, its head was 
observed to grow inordinately large. At the time of the operation the fontanelles 
were exceedingly tense ; the child screamed frequently, occasionally vomited, and 
was slightly convulsed ; the features were pinched, and the eyeballs distorted down- 
wards ; but the pupils were not dilated. Four ounces of transparent liquid were let 
out by puncturing the anterior fontanelle. A few hours afterwards the child was 
tranquil, and much improved in aspect; the distortion of the eyeballs had disap- 
peared. Three ounces more were taken away the next da3^ For two days there- 
after all the symptoms appeared to be mitigated ; but the skull was flaccid ; yield- 
ing, hke a broken egg, to the gentlest pressure. On the evening of the fourth day 
after the first tapping, the respiration became hurried, the child grew dull, and, before 
midnight, expired. In this case it appeared to me that the chance of success was 
baulked by the want of external support subsequently to the tapping. 

You will not expect me to draw any comparison between the merits of compres- 
sion and paracentesis, as substantive remedies. They are opposite measures, and 
adapted to different and opposite conditions of the brain. The one repairs defect of 
pressure ; the other relieves its excess. To hold the balance even requires much 
care, a steady an^ gentle hand, an accurate judgment, and incessant vigilance. 
Either expedient may suffice, alone. Both may be (and have been) profitably em- 
ployed in the same case, in succession, according to its varying circumstances. If 
the walls of the head be tight and firm, the trocar should precede the bandage ; if 



CHRONIC HYDROCEPHALUS. 



287 



lax and movable, compression should be cautiously tried, and followed, if need be, 
by the puncture. 

[Dr. Whitney relates, in the Edinburgh Med. and Surg. Journal, an instance of the success- 
ful puncture of the brain in a case of chronic hydrocephalus. By the iirst operation, nine 
ounces of fluid were drawn off, and in three weeks subsequently, by a second operation, five 
ounces more. Neither operation was succeeded by any bad symptom, and the recovery of 
the child appears to have been complete. Two cases are related by Professor Wutzer, and 
Dr. Butcher, in the Austrian Medical Journal, in which the puncture of the brain was unsuc- 
cessfully employed. In the first, a child seven months old, death occurred in six days after 
the first operation; in the second case, of a child sixteen months old. the operation was 
repeated, after an interval of four weeks, and seven weeks after the second puncture, the 
child died in convulsions. Dr. West {^Report for 1844-45) states that of sixty recorded cases 
in which puncture of the brain was performed, seventeen, or one in 85, had a favourable ter- 
mination ; or, in other words, the recoveries have been to the deaths in the proportion of 28 
per cent. — C] 

I have now done with the inflammatory affections of the brain : in conjunction 
with which I have also considered some other morbid conditions, that are either con- 
nected with inflammation of the contents of the cranium, or resemble it in some of 
their phenomena. Thus, I have spoken of delirium tremens, which is apt to be 
mistaken for inflammation of the brain : of softening from disease of the cerebral 
arteries, which is liable to be confounded with inflammatory softening : of tumours 
of different kinds, which tend to produce inflammation, or symptoms hke those 
belonging to inflammation : and of chronic hydrocephalus, which sometimes is the 
sequel, sometimes the precursor, of acute hydrocephalus ; and has other points of 
analogy with that disease, the encephalitis of children. 

[^Meningitis encephalica. — Under this name, Dr. Brockman has recently described a peculiar 
form of cerebral disease incidental to childhood, in which the membranes of the medulla 
oblongata and pons varolii are chiefly afiected. 

Dr. B. has met with fourteen cases of this afiection. It was, at first, observed by him as a 
sequel of scarlatina, but siibsequently, he has seen it to occur most l"equently as an idio- 
pathic afiection. 

It is sometimes associated with general disease of the brain ; at others, it is uncomplicated. 
Notwithstanding, in its earlier stages, it is unattended by any serious symptoms, it is an afiec- 
tion fully as dangerous as cerebral meningitis. The first stage, or that of simple hypersemia, 
generally continues for one or two days. The child is dull and heavy, and the occiput is 
often hot ; the bowels, however, are regular ; there is no vomiting, no intolerance of light, 
nor any disturbance of sleep. The general dullness of the patient, and vague complaints of 
some uneasy sensation in the head, increase as the inflammatory stage sets in ; the heat of 
the occiput is augmented ; the head becomes retracted, as in the ordinary cases of acute hy- 
drocephalus ; and convulsive twitchings of the limbs occur, similar to the effects of light elec- 
tric shocks, which recur every few minutes while the patient is awake, but cease during 
sleep. The general febrile symptoms continue during the third stage; the pulse, however, 
diminishes in frequency and fullness, but does not become either irregular or intermittent. 
The general disquietude of the child subsides, by degrees, into a comatose condition, in which 
the head becomes still more retracted, but unattended with strabismus, or any morbid con- 
dition of the pupil ; the peculiar air of stupidity that characterizes hydrocephalic patients is 
wanting. Two pathognomonic symptoms, however, indicate the occurrence of the stage of 
effusion. One of these is deafness ; the other difiicult articulation, and difficulty in moving 
the tongue — both of which occur at the same time, probably from paralysis of the motor 
nerves of the tongue. The deafness and affection of the tongue usually occur suddenly; 
sometimes they are first observed upon the child awaking from a quiet sleep. They are, 
according to Dr. Brockman, the earliest and most certain indications of the occurrence of 
effusion. This stage continues, sometimes, for three, and sometimes for fourteen, days. Its 
termination is in fatal paralysis, the occurrence of which is often preceded by various singu- 
lar nervous phenomena — as sudden pauses in the respiration, or equally sudden syncope. In 
some cases, however, the paralysis does not follow, but the anomalous symptoms subside, 
and the patients gradually recover ; until, indeed, the paralytic stage is fully established, tlie 
recovery of the patient is still possible. 

In the uncomplicated cases of the disease, upon examination after death, the cerebrum in 
general, presents an extremely pallid and aucemic condition, in striking contrast with the 
cerebellum, the vessels of which are turgid with blood, while its substance, also, is often in 
a state of marked hypersemia. The hyperoemia increases in intensity towards the central 
portions of the encephalon ; and the membranes covering the pons varolii and medulla ob- 
longata are found in a most decided state of inflammation j the portion of inflamed mem 



288 



DISEASES OF THE BRAIN 



brane is perfectly isolated, and not more, usually, than a square inch in extent — the mem- 
brane of the cerebellum being entirely free from any indications of inflammation. There is 
ordinarily an effusion of a serous fluid into the sub-arachnoidal tissue; sometimes to the 
extent of several ounces ; occasionally a gelatinous matter is effused, and, in some caseS; the 
effusion is of a purulent character. 

This form of the disease is most frequently observed in children from three to ten years 
of age, and who had previously enjoyed good health. 

The treatment recommended by Dr. Brockman, in its first two stages, is depletion, by 
leeches to the posterior part of the head, cold applications to the scalp, and the free adminis- 
tration of calomel, which latter may be continued during the stage of effusion. Here, how- 
ever, it becomes necessary to support the strength of the patient ; for this purpose ammonia 
is directed by Dr. B., but he remarks that, in some cases, the administration of wine may be 
required. According to his experience, powerful counter-irritants, as a large blister, or the 
actual cautery, prove, also, sometimes beneficial. — C] 

Before I take up the subject of apoplexy, and of cerebral hemorrhage, I wish to 
direct your attention to the inflammatory conditions of the spinal cord. 

The whole pathology of this portion of the nervous system is extremely interest- 
ing ; but it has not yet been so thoroughly made out as to enable any one to give a 
very systematic or satisfactory account of it. In addition to those numerous difficul- 
ties with which I showed you in a former lecture that the entire subject of the dis- 
eases of the nervous apparatus is beset, there is this further obstacle to our studying 
dihgently the structural changes of the spinal marrow — that much labour and ex- 
pense of time are required for exposing the interior of the vertebral canal ; which is, 
therefore, too often neglected in examining the dead body. 

There are certain points in the anatomy and physiology of the spinal cord which 
it is necessary that you should bear in mind, if you would have any clear notions 
even of what has been learned in respect to its pathology. 

1. In the first place the spinal cord (including the medulla oblongata) is the seat 
and centre of that remarkable property, the reflex function ; by which so many of 
the automatic movements of the body are regulated. 

2. In order that we may feel, or be conscious of, what occurs in any part of the 
trunk or hmbs, and in order that our will to move any such part should be obeyed, 
it is necessary that there should be a continuity of nervous matter between the part 
in question and the brain. If the cord be cut across at any point, or so crushed as . 
to be thoroughly disorganized at that point, a complete aboHtion of sensation and of 
voluntary motion ensues in all those parts of the body that receive their sentient and 
motor nerves from that portion of the cord which lies beyond the place of the injury, 
reckoning from the brain. What is true in this respect of the mechanical division 
of the cord, is equally true of such disease as pervades and spoils the nervous matter 
composing it. 

Now it follows from this, that the effects of disorganizing forms of disease — as 
well as the effects of injury — must vary greatly according to the part of the cord 
they occupy. 

Thus any injury or disease affecting the whole thickness of that portion of the 
spinal marrow which is contained within the upper cervical vertebrae, is inevitably 
fatal at once ; producing suffocation by paralyzing those muscles through the play 
of which the motions of respiration are performed. You know that the intercostal 
muscles and the diaphragm have at all times the main share in carrying on the me- 
chanical actions of respiration ; and probably they execute the whole action in every 
case of ordinary breathing. Now the intercostal muscles are furnished with motor 
nerves from the spinal cord, all along the dorsal vertebra ; and the diaphragm is 
principally supplied by the phrenic nerves, which are chiefly derived from the third 
and fourth cervical nerves. These muscles obey the will ; but they act also inde- 
pendently of the will. The pneumogastric and trifacial nerves, with respect to them, 
are excito-motory nerves, and call into play a reflex power which is transmitted from 
the medulla oblongata. Hence any profound injury of the spinal cord, above the 
origin of the phrenic nerves, stops both the voluntary and the involuntary movements 
of the respiratory muscles, and the individual perishes by apnoea, in as strict a sense 



.AND SPINAL CORD. 



289 



as though the access of air to the lungs had been suddenly prevented by a ligature 
drawn tightly round his windpipe. 

Again, when a segment of the cord, however small, is disorganized in its cervical 
part, between the origin of the phrenic and the origin of the upper intercostal nerves, 
the breathing is not instantly suspended ; but is performed entirely by means of the 
diaphragm, the intercostal muscles having no share in it. The ribs cease to rise and 
fall; and the abdomen is alternately protruded, and sinks back again. In each case 
I suppose the disease of the cord to be such as suffices to paralyze the parts supplied 
with nerves from it, beyond the seat of the disease. If disease of this kind occur 
below the giving out of the intercostal nerves, the breathing is not affected ; we have 
paraplegia only, palsy and loss of feehng in the lower extremities, and, perhaps, in 
the hips, or even higher. Now a person in this condition may live a long time. 
When the disease is situated between the origin of the intercostal nerves and the 
origin of the phrenic, he may hve a few days, but he seldom lives a week, and 
never survives a month : and when the disease is higher still, in the very upper part 
of the cord, above the origin of the cervical nerves, he perishes outright. The kind 
and degree of disease, therefore, being the same, the character of the symptoms, and 
the amount of danger, differ remarkably according to the seat of the disease. 

3. Although sense and voluntary motion cease upon the disruption of the commu- 
nication with the brain, the excito-molory functions of the separated portion of the 
cord are not necessarily suspended. On the contrary, they seem to acquire increased 
activity. The automatic power is apt to run riot, as it were, when the controlling 
influence of the sensorium is withdrawn. All of you have probably seen the hmbs 
of a recently decapitated frog thrown into violent action by the stimulus of galvanism. 
I have witnessed the same thing in the human body after death by hanging. What 
is still more curious, you may have unequivocal manifestations of similar phenomena 
in the living body. I have lately been informed, by Dr. William Budd, of a case 
in which a man was afflicted with paraplegia, in consequence of disease of the ver- 
tebral column. He was totally deprived of the power of moving his lower extremi- 
ties. Sensation in them was almost, yet not entirely extinct. A sharp pinch, or the 
prick of a pin, he could feel; but slight friction he was quite unconscious of: yet 
(as he himself said) his hmbs were not; for when the inner edge of the foot was 
brushed or tickled by the hand of another person, the corresponding leg, over which 
he had no voluntary control, would start up, and be briskly convulsed. The same 
thing took place, in both limbs, whenever he passed his urine or feces ; so that he 
was obliged to have an apparatus of straps and hgatures to keep the legs down on 
such occasions. I have seen something like this myself.* 

4. Distinct and different filaments of the spinal cord connect themselves with, or 
help to form, different nerves which emerge from the cranio-spinal axis. A know- 
ledge of this fact enables us to understand how it happens (as it sometimes does 
happen,) that the upper extremities are bereft of sensibility, or of voluntary motion, 
or of both, by disease of the cord, while the same functions remain perfect in the 
lower and more distant limbs. Here the disease must have spared those strands or 
filaments of the cords which pass down to connect themselves with the nerves given 
off at the lower part of the spine ; while it has affected those strands or filaments 
only which belong to certain nerves from the upper part. 

5. « Under the sagacious researches of Dr. Marshall Hall, the physiology, and witli 
it the whole pathology, of the spinal cord is undergoing, at this very time, a com- 
plete reformation. I know of no modern discovery so fruitful of important practical 
consequences, or so hkely to improve our remedial management of nervous disor- 
ders, as the singularly interesting truths which he is even now engaged in demon- 
strating and enforcing. I do not profess to teach you this new physiology. I touch 
only, as I pass along, upon some of its cardinal points, to which I may have occasion 
to refer in future. We are considering how the signs of spinal disease may vary 
according to the particular location of that disease ; and I would have you remark. 



* This very interesting case has since been published, in detail, with several others re 
serabling it, in the 22d volume of the Medico-Chirurgical Transactions. 
19 z 



290 



DISEASES OF THE 



here, that inasmuch as all the acts of ingestion and expulsion, all the inlets and out- 
lets of the body, are governed by the spinal marrow, with its corresponding apparatus 
of incident and motor nerves — it is to be expected that disease in the upper part of 
the true spinal system should affect the orifices which answer to. that part, and which 
are principally inlets — the larynx, the gullet, the cardia : while disease in its lower 
portion will be hkely to disturb the natural functions of the lower orifices — the 
rectum and anus, the bladder and urethra, the os uteri — which are chiefly outlets. 

6. You must bear in mind also the grand discovery of Sir Charles Bell, that the 
two roots by which each spinal nerve arises have distinct and difierent functions ; 
the anterior roots being composed of motor fibrils, the posterior of sensiferous. 

It is not so clear, although that opinion is, I beheve, a prevalent one, that the 
anterior columns of the spinal cord are subservient to the purposes of motion, and 
the posterior to the faculty of sensation. This has been inferred, too hastily perhaps, 
from the ascertained endowments of the anterior and posterior roots of the nerves : 
and cases are cited which appear to favour such a notion : but then other cases go 
completely to contradict it. Thus Mr. Stanley has recently published an account of 
a patient who died in St. Bartholomew's Flospital. For some time before his death 
he had been completely unable to move his lower limbs, throughout their entire ex- 
tent ; while there was no discoverable impairment of sensation in any part of either 
limb. The spinal cord was the only organ found diseased : and the disease was 
strictly limited to its posterior half or columns. This portion of the cord, in its 
whole length, from the pons to its lower end, was of a dark-brown colour, and ex- 
tremely soft and tenacious. The anterior half, in its entire length, exhibited its 
natural whiteness and firm consistence. The roots of the spinal nerves were un- 
akered. 

It was remarkable, and illustrative of the difficulty of these subjects, that with 
the change of structure which the cervical portion of the cord had undergone in 
this instance, there was no defect either of motion or of sensation in the upper 
hmbs. 

7. We must not forget that the brain, and the spinal cord, which are distinct from 
but yet continuous with each other, sympathize largely and mutually under disease. 
This circumstance throws an additional obscurity over the study of their morbid 
conditions. It is one, however, which we cannot avoid, but which we must estimate 
and allow for, in our observation of diseases, as we best may. 

8. There are a few remarks made by Dr. Abercrombie in relation to some of 
the anatomical dispositions of the cord and its investing membranes, which may 
help us to comprehend better some of their morbid contingencies. Thus, with 
respect to the dura mater of the cord, it is practically of importance to recollect 
" that it adheres very slightly to the canal of the vertebrae by a very loose cellular 

^ texture ; and that it adheres very intimately to the margin of the foramen magnum. 

In this manner a cavity is produced betwixt the membrane and the inner surface of 
the spinal canal (external, i. e., to the membrane), which cavity may be the seat of 
effusion, and which has no communication with the cavity of the cranium. On the 
other hand, the space between the dura mater and the pia mater (or membrane im- 
mediately covering the cord), communicates freely with the cavity of the cranium ; 
so that fluid may pass easily from one to the other, according to the position of the 
body." « 

I shall pursue the same order, in speaking of the inflammatory affections of the 
spinal cord, as I followed in respect to the analogous conditions of the encephalon. 
And, first, let us inquire what has been noticed of inflammation of the membranes 
of the cord. They may undergo inflammation, independently of the substance of 
the cord, and independently of the brain : but this is not very common. Usually, 
when we have meningitis of the cord, we have the same disease also within the cra- 
nium; usually, also, with meningitis of the cord, we have more or less inflam- 
mation of the nervous matter composing it. The commonest symptoms of hi- 
flammation of the meninges of the cord (for I do not pretend to speak of the several 
membranes separately), appear to be pains, often intense, extending along the spine, 



SPINAL CORD. 



291 



and stretching into the linfihs, and aggravated usually by motion, and simulating ' 
therefore rheumatic pains : rigidity or tetanic contraction, and sometimes violent 
spasms, of the muscles of the back and neck, amounting in some instances to 
perfect opisthotonos : a similar affection of other muscles, also, as those of the upper 
or lower extremities : a sense of constriction in various parts, in the neck, back, 
and abdomen, as if those parts were girt by a tight string: feelings of sufFoca 
lion : retention of urine : obstinate constipation : and with these symptoms, rigors 
often. 

You are not to expect all the symptoms which I have been enumerating in. 
every case ; they will vary according to the seat and extent of the inflammation. 
We need not wonder at the spasmodic symptoms, when we recollect that the 
nerves which issue from the body of the cord receive a covering from its pia 
mater. The pain felt jaiong the course of the spine itself is said to be aggravated 
by percussion of the spine, but not by simple pressure ; and this seems very 
likely. 

I know of no way in which I can so well hope to awaken an interest in you 
about these diseases, or to offer you instruction respecting them, as by instances. 
The following I take, abridging it somewhat, from Dr. Abercrombie. A man, 
twenty-six years old, had for several years been subject to suppuration of the left 
ear, suffering ocasional attacks of pain on that side of the head, which were fol- 
lowed by a more copious discharge from the ear. In the first week of April he 
became ill, with pain of the forehead and occiput, disturbed sleep, and loss of appe- 
tite, but no fever. At the end of the week he complained of pain extending along 
the neck. This pain gradually passed downwards in the course of the spine, and 
deserted the head; and, at last, after many days, it fixed itself with intense severity 
at the lower part of the spine, shooting thence around the body towards the crest of 
the ilia. He became affected, also with great uneasiness over the whole of the ab- 
domen, and had much pain and difficulty in passing his urine. About the end of 
the second week in April his sufferings had become extreme. He could not he in 
bed for five minutes at a time, but was generally walking about the house in a state 
of great agitation, grasping the lower part of his back with both his hands, and 
gnashing his teeth with the intensity of the pain. He had no interval of ease, and 
was sometimes incoherent and unmanageable. On the 16th, he went to take a warm 
bath, walking down three stairs, and into an adjoining street, with little assistance. 
His speech afterwards became somewhat affected : there were convulsive twitches 
of his face, and difficulty of swallowing. Some transient squinting also was ob- 
served. The pulse was now very frequent. On the 18th, while sitting in a chair, 
he suddenly threw his head backwards with great violence, fell immediate!}?' into a 
state of coma, in which he remained for two hours, and then died. During the 
whole disease there had been no paralysis, except the slight affection of his speech; 
no difficulty of breathing; no vomiting; and no convulsion except the twitching of 
his face the day before his death. The pulse was small and irregular. The bowels 
were easily kept open, but the pain in his back was much increased by going to 
stool. Two days before his death he had several attacks of shivering ; and much 
purulent matter was discharged from his left ear during his illness. 

Upon a very careful examination of his body, every part of the brain was found 
to be in a most healthy state. Some gelatinous deposit was found under the me- 
dulla oblongata; and purulent matter flowed, in considerable quantity, out of the 
spinal canal. The spine being entirely laid open, the cord was seen covered with 
a coating of purulent matter, which lay betwixt it and its membranes. The matter 
was most abundant at three places ; at the upper part, near the foramen magnum — • 
about the middle of the dorsal region — and at the top of the sacrum : but it was 
also distributed over the other parts with much uniformity. The substance of the 
cord was soft, and separated in some places into filaments. All the other viscera 
were healthy. 

You may find several interesting examples of this form of disease in Ollivier's 
Treatise on the Spinal Marrow. The prominent symptom was generally pain, 
referred to some part of the spine, and increased by motion; and what is curious, 



292 



DISEASES or THE 



sometimes little complained of except upon motion. In general, also, it extended 
along some of the limbs, and was accompanied by muscular rigidity or tetanic 
spasms. Palsy occurred in one case ; but this seemed to have been owing to soft- 
ening of the cord itseh^. Constantly there was increased sensibility; a circum- 
stance which Ollivier thinks calculated to distinguish inflammation of the membranes 
from inflamm.ation of the substance of the cord ; the latter being usually attended 
with diminished sensibility. In the case that I have quoted from Dr. Abercrom- 
bie, the intense pain underwent no remission or abatement. In one of Ollivier's 
examples, there was at the commencement of the disease, a striking intermittence of 
the pain ; it came on with intense severity at ten at night, and lasted till three in the 
morning. 

The causes of spinal meningitis are not always to be discovered. It sometimes 
extends from within the cranium. It may be excited by* external violence to the 
spine, of which a good specimen has been recorded by Sir Charles Bell. — A 
■\vagoner sitting on the shafts of his cart, was thrown otf by a sudden jerk, and 
pitched upon the back of his neck and shoulders. He was taken to the Middlesex 
Hospital, where he lay for a week, without complaining of any thing except stifll^ 
ness of the back part of the neck. He could move al] his limbs with freedom. On 
the eighth day after his admission he was seized with general convulsions and locked 
jaw. He then became affected with a singfular convulsive motion of the jaw, which 
continued in violent and incessant movement for about five minutes. This was fol- 
lowed by maniacal delirium. He then sank into a state resembhng typhus fever; 
and after four days was found to be palsied and insensible in his lower extremities. 
The day before his death he recovered sensation in his legs. 

On dissection, a great quantity of purulent matter was found within the spinal 
canal. It appeared to have formed about the last cervical and the first dorsal ver- 
tebrae, and to have dropped down, by its own gravity, to the lower part of the canal; 
where it produced palsy and anaesthesia of the inferior Hmbs by the pressure it 
occasioned. 

[CEREBRO-SpiiirAL Mexixgitis has iattracted considerable attention recently from the cir- 
cumstance of its liaving occurred as an epidemic in different parts of France and Ireland. 
In 1844 the disease prevailed extensively among the civil population of Gibraltar. Accord- 
ing to M. Rollet, who describes the disease as it occurred at Nancy, (Bulletin de VAcad. Roy. 
de Med. viii. 43,) cerebro-spinal meningitis occurs in two forms ■ in the one, there are no 
signs of lesion of the nervous centres themselves, no affection of sensation or motion, though 
there are all the symptoms of inflammation of the membranes ; at first, rigors, then maliase, 
tinnitus aurium, vertigo, violent pain in the head, extending along the vertebral column j agi- 
tation or restlessness, slight delirium, and moderate fever, or absence of fever. In the second 
form there is affection of the intellectual faculties, and also of the functions of sensation and 
motion, and more or less complete abolition of all the senses. In this latter form the appear- 
ances upon dissection were, great vascularity of the cerebral arachnoid ; a layer of plastic 
purulent matter covering the whole inner surface of the pia mater and the brain, and a con- 
siderable collection of the same matter at the base of the brain, about the pons varolii and 
medulla oblongata. The cerebrum was slightly punctated, but not softened. The choroid 
plexus was injected; the cerebellum softened; and the arbor vitae of a blood-red colour. 
Beneath the spinal arachnoid there was the same kind of purulent matter as beneath the 
cerebral arachnoid ; and opposite the third dorsal vertebra, a considerable collection of pus, 
as well as opposite the last dorsal vertebra. The substance of the spinal cord appeared 
healthy. The lesions here described exactly correspond with those described by MM. Faure- 
Villar, Cbaulfard, and Forget, by whom accounts of the disease have been given as it pre- 
vailed in Versailles. Avignon, and Strasburg. 

Morbid changes from inflammation have also been noticed in the alimentary canal, but 
these M. Rollet regards as merely accidental coincidences. M. Forget, however, attaches 
great importance to them. 

M. Rollet remarks, that, in those cases in which the stibstance of the brain is affected, 
there is an almost continual tendency to intermission, or, at least, remission, which alternates 
about every three hours with an exacerbation; this he regards as merely characteristic of the 
encephalo-meningitis, and not as an evidence of the disease partaking of the nature of remit- 
tent fever, which is the view taken by M. Gassaud. 

According to Dr. JVIayne, by whom an interesting account is given of the disease as vt 
occurred in Ireland during the year 1846, (Dublin Quarterly Journal of Medical Sciences, for 
August, 1S46,) its gaiK^ral pathological characters were nearly uniformly the same, wherever 



SPINAL CORD. 



293 



examined. The serous membrane covering the brain and spinal marrow was invariably 
found to be the seat of extensive inflammation, and unlike the more ordinary forms of arach 
nitis, the spinal arachnoid always suffered much inore severely than the cerebral. In the 
post-mortem examinations made by Dr. Mayne, the scalp and dura mater exhibited but little 
undue vascularity ; the pia mater covering the hemispheres of the brain was congested, and 
the large veins in their way to the several sinuses appeared remarkably turgid. The free 
surface of the cranial arachnoid felt dry and clammy, and had lost its transparency in many 
places, particularly at the base of the brain, but there was no lymph or other inflammatory 
eflusion in the sac of the arachnoid. Lymph of a yellowish or greenish hue appeared on the 
surface of the encephalon, beneath the serous tunic : this occurred sparingly on the upper sur- 
face of the hemispheres, and there only along the sulci ; but at the base of the brain it was 
found in greater quantities, especially in the sub-arachnoid space corresponding to the circle 
of Willis, where many of the cerebral nerves at their origin were fairly imbedded in it. In 
the spinal canal, a similar exudation filled the sub-arachnoidal space ; it there existed in 
sufficient abundance to envelope the cord completely; it also extended down to the lowest 
extremity of the cauda equina, investing each of the spinal nerves at its source ; but in the 
vertebral canal, as iri the cranium, the cavity of the arachnoid contained none of this morbid 
secretion. The substance of the brain and spinal marrow appeared remarkably free from 
lesion, there was no unusual vascularity, induration, or softening apparent, nor did the ven- 
tricles betray any evidence of inflammation. 

In many of the cases reported, however, the brain and spinal marrow are stated to have 
been occasionally implicated ; in some, the ventricles of the brain contained inflammatory 
effusions, and the choroid plexus appeared unusually vascular ; in others, more or less of 
the substance of the brain and spinal marrow was found in a state of softening; in a certain 
number, sero-purulent effusion was detected at tlie base of the brain, and in the theca verte- 
bralis ; but in every instance the serous membrane was the part essentially engaged, whilst 
the nervous material seldom suffered, and when affected it was only accidentally involved, 
the disease having been, in such cases, evidently propagated to the substance of the cerebro- 
spinal axis from its membranous investments. 

A remarkable feature of this malady is the class of persons on whom it has seized. In 
Ireland, so far as has been ascertained, boys under twelve years of age have been, with few 
exceptions, its only victims ; the seven cases reported by Dr. Darby were all boys, and only 
one of them had passed his twelfth year; in Belfast ten cases of the disease were noted, all 
occurring in boys from seven to twelve years of age ; and in Dr. Maynes' experience, indi- 
viduals of the same description were alone attacked. Dr. Gillkrest, in his account of the 
epidemic at Gibraltar, (Med. Gaz., July, 1844,) states, that in die majority of cases the dis- 
ease occurred in patients between two and fifteen years of age, and few only were attacked 
severely above the age of thirty. It is a curious circumstance that in France the disease 
occurred, for the most part, among the conscripts who had lately joined their regiments. 
Although females have been very rarely attacked, yet they are not exempt from it : one of 
Mr. M'Dowel's patients at the Hardwicke Hospital was a girl of seventeen, and the other a 
woman of thirty-six years. 

The symptoms by which the disease commences are, in general, of a very formidable 
character, and its accession is usually sudden and quite unexpected ; in the majority of 
cases the patient was in his ordinary health and sj^irits up to the very moment of the seizure, 
and had experienced no premonitory symptoms to warn him of his danger. In four of the 
cases at the South Dublin Union, the boys had eaten a hearty dinner, and retired to bed in ap- 
parent health, when the disease, all at once, declared itself In many instances it commences 
with severe pain in the abdomen, followed immediately by vomiting, and not unfrequently 
by purging. In the worst cases, these symptoms are accompanied by marked collapse, the 
extremities are cold and bluish, the puise is at this time a mere thread, and altogether the 
disease assumes very much the aspect of cholera. After the lapse of a few hours, reaction, 
more or less perfect, ensues ; the muscular system then presents characters which may be 
considered almost pathognomonic. The muscles of the extremities, and those of the neck in 
particular, become remarkably rigid, the head is drawn back upon the vertebral column, and 
firmly fixed in that unnatural position ; no efforts of the patient can bend it forward, neither 
can the attendants do so, at least by the employment of any justifiable force. The counte- 
nance at this period often assumes very much the tetanic expression ; twitchings of the mus- 
cles of the face sometimes ensue ; the patient loses, in a great measure, the power of moving 
his extremities, so that he is quite unable to assume the erect position; the surface becomes 
hot, the pulse full and frequent, from 120 to 140; the stomach often continues irritable, 
whilst an insatiable thirst torments the sufferers, and the epigastrium evinces marked ten 
derness upon pressure. 

Symptoms of a still more distressing nature quickly siipervene ; the patient maybe seized 
with general convulsions of a frightful severity, requiring personal restraint to protect him 
from injury, or he may be in a semi-comatose condition, constantly moaning and grinding his 
teeth, or even crying incessantly. Towards the close of his sufferings, he generally merges 

z3 



294 DISEASES OF THE 

into perfect coma, the pulse becomes slow and laboured, the powers of speech and degluti- 
tion fail, his stools are passed involuntarily, and death finally closes the scene. All this may 
occur in a surprisingly short space of time ; some of the cases ran their course in forty-eight 
hours, and the greater nmTiber terminated about the fourth day, whilst some few were pro- 
longed over a fortnight or three weeks. Examples are on record of death from the disease 
in so short a period as fifteen hours. 

Notwithstanding, in some instances, an exalted sensibility of the cutaneous surface gene- 
rally was observed, such as pain more or less intense in the head, heat of scalp, congestion 
of the conjunctiva, strabismus, intolerance of light, &c. ; yet. in many, no such evidence 
occurred, until the laboured pulse, the dilated pupil, the profound coma, or the severe con- 
vulsion, told but too plainly that the death struggle was at hand. 

When the sensibility of the cutaneous surface generally was in a state of exaltation, the 
patient complained of being " sore all over," and winced, upon the slightest touch, or refused 
to change his position in bed, from the pain consequent upon the slightest movement ; (the 
observation of this symptom is due to Dr. M'Dowel;) but far more frequently a diminution 
of tactile sensibility and confirmed stupor, afibrded grounds for the worst anticipations. 

Dr. Mayne more than once noticed inegular and laboured respiration as a leading symp- 
tom ; and this, in itself, provided there was an absence of stethoscopic evidence of thoracic 
disease, would constitute a valuable diagnostic. 

Notwithstanding that the distressing tenderness of the epigastrium, associated with conti- 
nued irritability of stomach, would seem to indicate decided disease of that viscus. Dr. M. 
has nevertheless found the abdominal viscera absolutely healthy in the post-mortem exami- 
nation of two cases, in which these symptoms persisted in a very marked manner to the 
close. 

The fatality of the disease, as it appeared in Ireland, was very great. The same is true 
in regard to the French epidemics. At Avignon, M. Chaufiard lost no less than twenty-nine 
of his first patients ; and, according to statistical calculations, not less than eighty per cent, 
of the cases noted during the epidemic in France terminated fatally. M. Faure-Villar lost 
66 out of 154 cases ; M. Forget 24 cut of 40. M. Tourdes states that of 195 soldiers attacked, 
122 died. In Gibraltar, according to Dr. Gillkrest, 42 deaths occurred among 450 persons 
attacked. The line of treatment most likely to prove successful requires our fullest consi- 
deration. It is much to be feared. Dr. M. remarks, that where symptoms denoting extreme 
collapse show themselves from the commencement, all tlie resources of our art will prove 
unavailing. The prompt application of the most powerful excitants to the cutaneous surface, 
particularly mustard and turpentine, aided by heat and friction, and directed especially to 
the region of the spine, and to the extremities, seems to promise some advantage. Difiusible 
stimulants should be employed as sparingly as possible, seeing that an intense inflammation, 
affecting the very centre of animal life, must remain to be combated after reaction sets in. 
General and topical depletion, so soon as it can be borne with safety, and the early and free 
exhibition of mercury, both by the skin and stomach, should constitute our chief dependence. 
Even this active treatment will often disappoint us. In one cpse, the jugular vein was 
opened by Dr. M. within a few hours after the accession of the disease, and blood was 
drawn in a full stream, as long as the boy"s strength would permit; this was followed up, 
at short intervals, by relays of leeches to the temples and mastoid processes; the mercurial 
plan was, at the same time, most energetically pursued, and blisters, with mercurial dress- 
ings, were applied to the head, and along the spine. Yet all was of no avail ; the patient 
died in convulsions, on the fourth day. In other cases, the same measures have been 
attended with perfect success. 

The French physicians, who have described the epidemic form of cerebro-spinal meningi- 
tis, are not agreed as to the most successful plan of treating the disease. M. Faure-Villar 
tried, it is said, all rational methods, but declares that no one seemed superior to the rest. 
M. Forget recommends the antiphlogistic plan of treatment at the commencement of the 
case, and subsequently opium. M. Rollet found that all the cases of simple cerebro-spinal 
meningitis — that is to say, of inflammation of the membranes without lesion of the nervous 
centres themselves — yielded to simple but energetic antiphlogistic treatment, aided by coun- 
ter-irritants to the skin. One remedy only he found adequate to control the more violent 
cases, when the brain and spinal cord also suffered, and this was cauterization. In one case 
which is detailed, the actual cautery was applied at twelve distinct spots along the spine, 
besides counter-irritants. 

M. Gaussaud, who regards the disease as a subintrant cephalalgic fever, produced by 
marsh miasmata, affirms that, of 162 soldiers attacked, only two died after he commenced to 
treat them with medium doses of sulphate of quinia, at the same time that he employed 
purges, and, at the commencement, venesection. M. Chauffard failed to cure the malady by 
antiphlogistic means, the most prompt, direct, and energetic — by revulsives, purgatives, calo- 
mel, as well as by various tonics. Opium, however, he found to triumph over it, but it was 
necessary to give it in large doses. The sulphate of quinia was advantageously combined 
with the opium. Before this plan was adopted, only one case, we are told, was cured out 



SPINAL CORD. 



295 



of thirty. Afterwards, the disease was less fatal than in sporadic cases. M. Tourdes agrees 
with M. ChaufFard that the usual antiphlogistic means were of no avail ; but he cannot con- 
firm ail that the latter has said in favour of opium. — C] 

Inflammation of the substance of the spinal cord leads to the same changes in 
its texture which have been already spoken of as being often the results, in the brain, 
of inflammation of the cerebral matter. Softening — induration — suppuration. I 
need not, therefore, again describe the physical sharacters of these alterations. 

The symptoms which flow from inflammation of the nervous pulp of which the 
spinal marrow is composed, are by no means uniform ; nor can we expect that they 
should be so, when we recollect what has been already stated of the different effects 
that must ensue according as different parts of the cord happen to be implicated. 
The phenomena will vary likewise, according as the inflammation is acute or chronic. 
If we recollect how many parts of the body depend for their power of motion, and 
for their sensibihty, upon the integrity of the spinal cord, we shall not be surprised 
at the diversity and multiphcity of the symptoms produced by disease of the cord. 
Tracking inflammation and its events from the upper portion of the spinal marrow 
downwards, we should expect to find, and we actually do find, some such an arrange- 
ment of symptoms as the following. Convulsive affections of the head and face, 
inarticulate speech, loss of voice, trismus, difficult deglutition, spasmodic breathing, 
irregular action of the heart, constriction of the chest, vomiting, pain of the belly, 
sensation of a cord tied round the abdomen, dysuria, retention of urine, incontinence 
of urine, constipation, tenesmus, involuntary stools : and with respect to the volun- 
tary muscles corresponding to these parts of the spinal marrow, convulsions, or palsy ; 
or palsy succeeding to convulsions. 

I must again have recourse to examples, to put you, more fully than any attempted 
abstract picture could put you, in possession of such forms of inflammation of the 
cord as you may expect to meet with in practice. 

A man, fifty-six years old, was exposed to severe cold, while travelling on the out- 
side of a coach. After this he was attacked with pain in the right arm and leg, most 
severe about the shoulder, but affecting the whole side, and he had also considerable 
headache. He soon perceived some loss of power in the affected Hmbs ; and the 
progress of this was very curious. It began at the upper part of the arm, and 
extended downwards so gradually, that he was able to write distinctly, after he had 
lost the power of raising the arm, or bending the elbow. Then the leg became 
affected in the same gradual manner, and after ten or twelve days from the com- 
mencement of the disease, the whole leg and arm had become completely paralytic. 
Some pain continued in the parts, and it was occasionally severe, especially in the 
leg. Repeated blood-letting, and purgatives, and blistering, were employed. His 
mind remained quite entire. His pulse was 84, and rather weak ; after some time 
the left arm became paralytic, rather su4denly ; but it was not so completely motion- 
less as the hmb on the right side ; the left leg was not at all affected. Slight delirium 
occurred, but passed off" again. At the end of two months after the exposure to the 
cold, he again became delirious, and his pulse got feebler and rapid : he then fell 
into a state of stupor, muttering incoherently, but answering questions distinctly 
when he was aroused. He lost his speech a few hours before death. For the last 
eight or ten days there had been considerable sloughing of the sacrum. 

The brain was found to be healthy throughout. Much bloody fluid was discharged 
from the spinal canal into the cavity of the cranium before the spine was laid open. 
On displaying ^the spinal cavity itself, the cord was found in a state of complete 
softening, from the second to the last cervical vertebra. The portions above and 
below that part were quite healthy. (Abercrombie.) 

Comparing this case with the one I detailed of meningitis, we find that pain was 
present in both, but more severely so in the case of inflammation of the membranes : 
we find also, that stiffness and spasm of the muscles marked the meningitis ; palsy, 
the inflammation of the substance of the spinal cord. In neither of them were the 
intellectual functions disturbed till towards the last. I beheve that the characters 
now pointed out belong to these forms of disease respectively. 

I shall take, from the same store-house, one more case, in which both the mem* 

z2 



296 



DISEASES OF THE 



branes and the cord were simultaneously inflamed ; and which, therefore, was ana- 
logous to encephahtis. And I quote it the rather because it possesses one or two 
points of peculiar interest. A young man, of unhealthy constitution, eighteen' years 
old, had suffered for some time from ulcers in various parts of the body, accompanied 
by exfoliations of bone from the leg, thigh, and sacrum. For several months before 
his fatal attack he had a sore on his head, as big as a shilling, with caries of the 
bone beneath it. At length he began to complain of pain in the loins, without fever. 
On the 2d of October this pain had increased ; it was chiefly seated among the lower 
dorsal vertebras, and extended downwards in the course of the ureter, with a fre- 
quent desire to pass urine. Then the pain descended lower, into the sacrum, and 
the symptoms referable to the bladder ceased. But soon afterwards pain in the belly 
came on, and numbness of the inner sides of the thighs, and retention of urine ; and 
in two days after this there were perfect palsy of both thighs and legs, without loss 
of feeling, retention of urine, and involuntary stools. He had still some pain in the 
lower part of the dorsal region. He died at length, on the 14th of October, having 
continued quite sensible till about six hours before. There had not been the smallest 
approach to a renewal of power of the lower extremities, but their sensibility 
remained. There was palsy, but no anaesthesia. 

Ah was quite sound in the brain, except some old thickening of the dura mater in 
the neighbourhood of the diseased bone. In opening the spinal canal, some purulent 
matter flowed out, during the sawing, from about the middle of the dorsal region ; 
and one of the vertebrae at that place was found carious. There was an extensive 
deposit of flocculent matter, having a purulent appearance, upon the outside of the 
membranes of the cord. Bloody sanious fluid was discharged from beneath its dura 
mater, and its pia mater was highly vascular. The substance of the cord was found 
most extensively disorganized along nearly the whole extent of the dorsal portion. 
The anterior columns of this part were completely broken down into a soft diffluent 
pulp ; on the posterior part the cord was more entire. When the cord was taken 
out, and suspended, it hung together by the posterior columns of the dorsal portion, 
while the anterior part of it fell off" entirely, in a soft half-fluid state. The parts 
above and below the diseased portion were quite firm and healthy. 

The complete palsy in this instance, going along with the destruction of the ante" 
rior columns ; and the persistence of the sensibility, the posterior columns being 
comparatively entire ; invest the case with a remarkable degree of interest. We 
might infer from it that the anterior half of the cord is the channel through which 
the power to move the hmbs is transmitted, while their sensations are carried along 
its posterior half; but we are checked from so concluding, by such cases as the one 
recorded by Mr. Stanley. These apparent inconsistencies may puzzle, but they 
ought not to discourage you. That time, and our advancing science, wiU at length 
explain and reconcile them I cannot doubt.. Meanwhile they teach a lesson which 
many practitioners much need — viz., that it is unphilosophical and unsafe to draw 
general conclusions from single cases of disease. 

At the time when these cases were noted, the peculiar reflex properties of the 
spinal cord were not understood. Henceforward we shall study its diseases from a 
new point of view, and with a clearer vision. 

Much may be learned in regard to the effects of inflammation, or any other cause 
of disorganization, confined to a limited portion of the cord, by observing what takes 
place in those injuries in which the bones of the vertebral column are broken, or dis- 
placed. Of course I do not dwell upon these accidents, for they belong to surgery : 
but T have seen a good many of them, and watched them with deep interest. The 
symptom.s are much more uniform than when inflammation occurs within the verte- 
bral canal, independently of external injury; simply because the injury to the cord ' 
is more definite and local. But such cases are very valuable objects of study to the 
physician. I remember several that occurred when I was a dresser in St. Bartholo- 
mew's Hospital ; and I will state very briefly the particulars of one, as an exemplar. 
In the year 1820, a man was brought there who had been thrown out of a tilt cart, 
in consequence of a dray running foul of it. He had pitched upon his head, which 
showed, however, no trace of injury. When picked up, he was found to be power- > 



SPINAL CORD. 



297 



less, both in the upper and lower extremities. His stools passed from him without 
his being aware of it, and it was necessary to use the catheter to empty his bladder. 
He breathed entirely by the diaphragm — that is, his thorax was motionless, and his 
abdomen rose and fell with every alternate act of inspiration and expiration. These 
symptoms are perfectly distinctive of injury to the cord between the origins of the 
phrenic and intercostal nerves. He suffered pain about the middle part of the neck 
behind. He went on exceedingly well for four or five days, and then the nurse very 
foolishly acceded to his request to be turned on his side, which caused his death in 
a very few minutes. This is not the only instance that I have known, in which life 
has been suddenly extinguished by similar imprudence. The lesson may be useful. 
There was another patient in the same hospital, who had fractured the cervical por- 
tion of the spinal column. Among other remedial measures, the surgeon had 
directed that his head should be shaved. The barber had performed half his 
task, and was turning, with his hands, the unfortunate man's head into a more con- 
venient position for completing it, when he suddenly expired. The twist was fatal 
to him. 

On the examination of the body of the patient whose case I was mentioning, a 
very remarkable state of the spinal column was found. The fifth and sixth cervical 
vertebrae were dislocated from each other without any fracture : a thing which has 
sometimes been pronounced impossible. The articular processes were fairly sepa- 
rated ; and the vertebrae were also forced asunder by the detachment of one of them 
from, the intervertebral substance. The nervous matter of the cord opposite the 
point of dislocation was quite soft. 

There is one very common and distressing consequence of such disease of the 
spinal marrow as produces paraplegia, not particularly noted in any of the cases 
which I have related, but always to be looked for. The muscles, by means of which 
the bladder empties itself, are liable to participate in the palsy ; and then the bladder 
empties itself no longer. The urine accumulates in it, and distends it, and even the 
ureter becomes distended ; and in this way not only the present but the prospective 
danger is increased. For the foundation of future disease in the kidneys is often 
thus laid, even when such distension of the bladder by its retained contents occurs 
independently of any disease of the spine ; as it may do from stricture ; from en- 
largement of the prostate ; or even from the voluntary retention of the urine beyond 
a certain period, through feelings of delicacy. You are to look out, I say, for this 
distension of the bladder, and reheve or prevent it by the introduction of a catheter 
through the urethra. You must not be deceived by being told that the patient passes 
plenty of water ; that it even runs from him. Incontinence of urine is, in fact, in 
these cases, though it may sound paradoxical, a sign of retention of urine. The 
urine dribbles away because the bladder admits of no further distension ; it over- 
flows and runs out at the natural orifice, but the bladder remains constantly full and 
stretched. You must make an examination, therefore, of the hypogastric region 
with your hand. If you find that part of the belly hard and resisting, and giving 
out a dull sound on percifssion, you may be sure, in these cases (where there is para- 
lysis of the lower extremities, and the water dribbles away), that the bladder is full, 
and has lost the power of expelhng its contents. Sometimes you may recognize the 
fluctuation of the urine in the distended bladder, and ascertain the globular shape of 
that organ. It will rise even beyond the umbilicus. But what I chiefly wished to 
point out to you is the circumstance that the bladder becomes diseased, and the urine 
altered in quahty, under this state of palsy. The urine becomes thick, ropy, and 
alkaline, and exhales a very offensive ammoniacal smell ; and the inner surface of 
the bladder is found, after death, to be thickened, red, and covered with adhesive 
mucus — in a state of chronic inflammation, in short. 



298 DISEASES OF THE BRAIN. 



LECTURE XXVIIL 

Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment, 
Apoplexy. Its General Symptoms and Diagnosis. Different forms of the 

attack. Predisposition to Apoplexy — Natural^ and Accidental. Precursory 

Symptoms. 

Allow me to repeat that the structural diseases of the spinal cord will most clearly 
reveal themselves, by their symptoms, to him who most distinctly perceives, and 
most accurately bears in mind, the physiology of that part of the nervous system. 
But to the best informed, and the most sagacious, they are too frequently obscure and 
perplexing. 

Disease occupying a portion only of the cord, but affecting the whole thickness of 
that portion, from centre to circumference, will be hkely to disturb, or suspend, the 
functions of sensation and voluntary motion in all the parts supphed with motor or 
sentient nerves from that portion of the cord, and from the portion beyond it. So 
that a great variety of symptoms depend, when the amount of disease is the same, 
upon the place of the disease. A total interruption of the conducting function of the 
cord, in the neck, above the origin of the phrenic nerves, extinguishes h'fe by stop- 
ping the actions of respiration. A similar interruption in the cervical part of the 
cord, above the origin of the intercostals, but below the origin of the phrenic nerves, 
destroys life as certainly, but not so rapidly, nor in exactly the same manner. We 
find the lungs loaded with frothy serous fluid in such cases ; we find the bladder 
inflamed ; and, often, sloughing of the integuments and muscles of the nates and 
hips. A similar interruption below the dorsal vertebrae is not necessarily fatal, 
even when it is attended with permanent paralysis : but it usually is so, sooner or 
later. 

It is commonly behoved that disease affecting the anterior columns only of the 
cord, will be hkely to disturb, or to suspend, the power of voluntary motion in the 
corresponding parts ; to produce spasm oi- palsy : and that disease affecting the pos- 
terior columns alone will be likely to alter or abohsh the faculty of sensation in the 
corresponding parts : to cause pain, tingling, numbness or complete anasthesia. But 
I have mentioned certain facts which contravene this opinion. Suspend your judg- 
ment respecting it. Neither the minute anatomy nor the physiology belonging to 
the question is yet conclusively settled. 

There seems no reason to doubt that disease affecting the latercd half only of the 
cord will be likely to derange both the sensibihty and the power of movement, in 
the corresponding part on the same side of the body alone. 

If you impress upon your recollection the facts thus summarily stated, you will 
find in them, I think, a key to many of the phenomena which accompany, and 
denote, more or less plainly, disease of the spinal marrow. 

Inflammation of the membranes of the spine is most apt to declare itself hj pain, 
increased on motion, of the spine and of the limbs ; and by rigidity and spasm of 
the muscles of the neck and back. Inflammation of the cord itself, which readily 
passes into, or rather produces, softening of its substance, is most commonly marked, 
first, with convulsive movements of some parts of the body ; secondly, by palsy of 
those parts, with or without anaesthesia. The same may be said of suppuration 
when it occurs as an event of inflammation ; and the pus may be collected into an 
abscess in the nervous matter of the cord, or it may be diffused and mixed with 
softening. 

Now I need not dwell upon the treatment proper to be adopted in inflammation of 
the spinal cord and its membranes. Mutatis mutandis, it is the treatment already 
recommended in inflammation of the brain and its membranes. When the inflam- 
mation is acute, we must take blood freely ; from the arm, or by cupping-glasses 
along the sides of the spine. Blood enough may be taken by cupping along this 
tract to produce the effect of general bleeding as well as of local. Perfect rest in 



APOPLEXY. 



299 



the horizontal posture must be strictly enjoined. Mercury will generally be 
proper. 

In more chronic forms of inflammation within the spinal canal, we still have a 
capital remedy in cupping : and counter-irritation in various ways, but more espe- 
cially by means of issues made on one or both sides of the spinous ridge, is also, in 
many cases, of most essential and unquestionable service. 

Great care must be taken, when there is palsy of the bladder, not only (as I 
admonished you in the last lecture) that the urine be regularly drawn off, but also 
that the patient be kept dry and clean : for if great attention be not paid to this point, 
sores will form where the urine remains in contact with the skin, to the great increase 
of his suffering, and of his danger. Indeed, take what pains we may, there is gene- 
rally a strong disposition to the formation of sloughs upon the sacrum and hips in 
cases of paraplegia. They result from the perpetual pressure made upon those 
projecting points ; from the feeble state of the circulation in the palsied parts ; and 
(often) from the irritation of the urine and feces, which are passed without the 
patient's consciousness. 

When the patient is kept clean and dry, and the surfaces on which the weight of 
his body has been supported begin to be red and angry, you may protect them by a 
plaster : or by rubbing them with brandy you may sometimes prevent the skin from 
breaking: or, what is best of all, you may put your patient upon one of Dr. Arnott's 
hydrostatic beds; and then the pressure will be equally distributed over all that 
portion of the body which comes in contact with the water-proof material of the bed. 

To bring this outline of the diseased states of the spinal cord up to that point in 
which we left those of the encephalon, I may state that, like the brain, the spinal 
marrow may become hardened by chronic inflammation ; and, like the brain, it may 
be encroached upon by tumours ; fibrous, scrofulous, or malignant. With respect 
to these, all that I can now say likely to be of any practical benefit to 3^ou, is that 
the symptoms they occasion are those of slowly increasing paralysis, without fever 
or what is called reaction : and that the locahty, and extent, and effects of the para- 
lysis, will vary according to the part of the cord in which these changes occur, and 
the depth to which they affect it. 

I proceed, in the next place, to a perfectly distinct class of diseases of the brain 
and spinal cord ; to the apoplectic affections : and especially to cerebral hemorrhage, 
and spinal hemorrhage. 

When a person falls down suddenly, and Hes without sense or motion, except that 
his pulse goes on beating, and his breathing continues, he is said to have been 
attacked with apoplexy. He appears to be in a deep sleep ; but this is not all, for 
you cannot awaken him by the same means which would rouse a healthy man. He 
is not in a state of syncope, for his pulse beats, perhaps with unnatural force ; and 
often his face, instead of being pale, is flushed and turgid ; and his respiration goes 
on, though it may be laboured and stertorous. What I now denominate apoplexy, 
is the very same state which has so frequently been mentioned already in these lec- 
tures : it is coma occurring suddenly, or coming on (at least) with rapidity. What 
is coma ? it is that condition in which the functions of animal life are suspended, 
with the exception of the mixed function of respiration ; while the functions of 
organic life, and especially of the circulation, continue in action. There is neither 
thought, nor the power of voluntary motion, nor sensation : but the pulmonary 
branches of the par vagum continue to excite, through the medulla oblongata, the 
involuntary movements of the thorax. When this upper part of the cranioVspinal 
axis becomes involved in the disease, and its reflex power ceases, the breathing 
ceases also, and the patient is presently dead. 

It is a common question — how would you distinguish apoplexy from the effects of 
a narcotic poison ? If you were summoned to a person in the state I have been de- 
scribing, how could you tell whether he was affected with apploplexy, or labouring 
under the influence of a large dose of opium, or merely dead-drunk ? Why, so far 
as the condition of the cerebral functions is concerned, you cannot discriminate the 
one from the other. In each case there is profound coma ; but the cause of the 



300 



DISEASES OF THE BRAIN. 



coma is different in each, and you must seek to ascertain that cause in the history 
and other circumstances of the patient : you inquire whether he is known to have 
been drinking, you try if you can perceive the odour of spirits, or of wine, in his 
breath ; or you endeavour to make out whether he has been low-spirited, or in 
known difficulties ; in short, whether it is likely that he may have swallowed poison. 
But from the actual condition of his sensorial functions, you cannot solve the question. 

Yet let me say, thus in the outset of our remarks upon apoplexy, that it is often 
of great importance that the diagnosis should be determined. A man was found 
lying in Smithfield in a state of total insensibilit}^ and motionless, except that he still 
breathed. He was carried into St. Bartholomew's Hospital. The house-surgeon 
thought he smelt the smell of gin in his mouth ; and thereupon very properly made 
use of the stomach-pump. By means of it he discharged a large quantity of ardent 
spirit ; and in the course of a few minutes the man revived, shook his ears, and 
walked away. If the gin had been suffered to remain in his stomach, and if the 
remedies of apoplexy had been vigorously put in force, the absorption of the poison 
would have been thereby accelerated ; and the debauch would probably have had a 
fatal termination. The same remarks apply still more urgently to the case in which 
opium, or any other strong narcotic poison, is lying in the stomach. Even when 
there is no great danger, either in the person's state, or in the remedies used for it, it 
is not a very pleasant or creditable thing to make a false point of this kind. If we 
do err, however, we had better err on the safe side. The father of the late Professor 
James Gregory, of Edinburgh, (who used to relate the case in his lectures,) was once 
called out very late in the evening to visit an old gentleman of that place. He found 
him in a completely comatose condition ; his wife crying, and his household all 
plunged in grief and distress. They told him that the patient, whom he now saw 
in a fit, had come home, and upon the servant's opening the door to him, had fallen 
into the passage, on his back, in a state of insensibility. Dr. Gregory learned, how- 
ever, that he had been at the "Club," and he knew well enough that this club was 
composed of choice spirits, fond of their cups ; although the gentleman's wife did 
not know as much. Therefore he ventured to express his " hopes" to the wife that 
her husband was drunk : a charitable view of the case, at which she was extremely 
affronted and indignant. He persisted, however, in his opinion, and not long after- 
wards the patient began to recover his senses. It turned out that he had partaken 
more hberally than the rest of the club, and was the first to be intoxicated. Two of 
his companions carried him home quite incapable of motion ; but not hking to intro- 
duce him themselves to his wife in that predicament, they placed him with his back 
against the door, rang the bell, and decamped. Of course when the servant came to 
open the door, his master tumbled senseless on the floor. I need not point out to you 
the ridicule which the physician would have brought upon himself, and the damage 
he might have inflicted upon his patient, had he busily apphed, in this case, the 
ordinary remedies of apoplexy. 

The state of coma, such as I have described as being characteristic of apoplexy, 
may terminate in one of three ways. It may cease, more or less rapidly, and leave 
the patient in perfect heakh. What is the exact condition of the encephalon during 
the continuance of the coma, in such cases, no one can positively tell. But the oc- 
currence of temporary coma, under the influence of a narcotic poison, and the 
perfect disappearance of the coma as the effects of the drug pass off, teach us that the 
functions of the brain may be almost totally suspended for a time by causes which 
do not injure its texture. It is possible that, when there is no poison at work, the 
coma may depend upon that presumed disturbance of the balance of the arterial 
and venous circulation within the cranium, which I mentioned in a former lecture. 
It may be that the force and rapidity of the circulation in the cerebral vessels un- 
dergo some great akeration. It is still more probable (to ray mind) that a temporary 
stress upon the cerebral blood-vessels (produced by a determination of blood towards 
the head, through the arteries, or by a detention of blood in the obstructed veins) 
may really exercise pressure enough to cause transient coma. But these are mere 
conjectures. 

In the second place, the apoplectic coma may terminate, more or less quickly, iu 



APOPLEXY. 



301 



({eath. And on examining the brain, we may find a large quantity of extravasated 
blood ; or a considerable effusion of serous fluid in its ventricles, or beneath the 
arachnoid ; or we may detect no deviation whatever from the healthy structure and 
natural appearance of the organ. The congestive pressure (if it indeed existed) has 
left no prints of its action. 

Fatal coma, without obvious disease in the brain to account for it, results, not un- 
frequently, from an inbred poison, of which the agency was not recognized until a 
recent period : the poison of unpurified blood. When speaking of the general 
pathology of dropsy, I mentioned a peculiar renal disease — first detected and 
described by our distinguished countryman, Dr. Richard Bright — which unfits the 
kidney for what is probably its most important office ; that of removing urea from 
the system. When this excrement, thus retained, accumulates in the blood beyond 
a certain amount, it is very apt, among other injurious tendencies, to cause death in 
the way of coma. 

Dr. Abercrombie has given to that form of apoplexy, which destroys life, but 
leaves no traces behind it, the name of simple apoplexy. And this name, for its 
convenience I shall retain. Of the other two kinds of quickly fatal apoplexy, that 
in which blood is found extravasated, is more common than that in which there is 
effusion of serum only. The one has been called sanguineous apoplexy ; a better 
term is cerebral hemorrhage : the other has been named serous apoplexy. 

Thirdly, the apoplectic coma may terminate in partial or imperfect recovery. One 
or all of the cerebral functions may be left impaired ; the mind enfeebled ; the 
power of motion limited or lost in some parts of the frame ; the faculty of sensation 
benumbed or extinguished : the unhappy subject of the attack remaining more or 
less crippled in body, and more or less maimed in intellect. In these cases, when at 
length w^e have an opportunity of examining the brain, we almost always find that 
there has been extravasation of blood, to a small or moderate extent. 1 say almost 
always, because I have myself, in more than one instance, carefully looked for 
such appearances, after such a series of symptoms, without finding them. Oc- 
casionally, instead of a clot of blood, we meet with circumscribed softening of the 
brain. 

The attach of apoplexy does not always occur in the same manner : and Dr. 

Abercrombie has pointed out three several ways in which it is apt to come on. I 
am confident, from the result of my own observation, that the distinctions laid 
down by Dr. Abercrombie are just and true ; and it is of importance that you 
should be aware of them. "In the first form of the attack, the patient falls down 
suddenly deprived of sense and motion, and lies like a person in a deep sleep ; 
his face generally flushed, his breathing stertorous, his pulse full and not frequent, 
sometimes below the natural standard. In some of these cases convulsions occur ; 
in others, rigidity and contraction of the muscles of the hmbs, sometimes on one 
side only." 

Now, respecting persons seen in this condition, the immediate prognosis is un- 
certain. Some die in a short time, and much blood is found extravasated within the 
cranium. Some die after a rather longer interval, and then we often find serous 
efiiision only, and that of no great amount. And in some that die early, no effusion 
either of blood or of serum can be detected. Some recover altogether, without any 
ill effect of the attack remaining. Others recover from the coma, but are left- para- 
lytic of one side, and with some imperfection of speech, or of one or more of the 
senses. And this paralysis and imperfection may disappear in a few days, or gra- 
dually subside, or remain for life. 

In the second form of the attack, the coma is not the earliest symptom. The dis- 
ease generally begins with a sudden attack of pain in the head. The patient 
becomes pale, faint, and sick, and usually vomits ; and sometimes, but not always, 
falls down in a state of syncope, or resembhng syncope, with a bloodless and cold 
skin, and a feeble pulse. This also is occasionally accompanied by some degree of 
convulsion. Sometimes he does not fall down, the sudden attack of pain being 
accompanied only by shght and transient confusion. In either case, he commonly 
recovers in a short time from these symptoms, and is quite sensible, and able to 



302 



DISEASES OF THE BRAIN. 



walk ; but the headache does not leave him. After a certain interval, which may 
vary from a few minutes to several hours— and Dr. Abercrombie records cases in 
which it was even much longer — the patient becomes heavy, forgetful, incoherent, 
and sinks into coma, from which he never rises again. In some instances, paralysis 
of one side occurs ; but perhaps more often, there is no palsy observed. 

The disease, when it comes on in this way, is much more uniform, and of much 
worse omen, than when it commences after the former fashion. It is of great use 
to know this ; for to an inexperienced eye the cases do not seem so terrible as those 
in which the patient becomes profoundly comatose from the very first. The appa- 
rent amendment is fallacious, and apt to lead one into giving a false prognosis. 
Very few persons come out of the coma, and a large quantity of blood is usually 
found extravasated in the brain. These cases are not, as Dr. Abercrombie well 
observes, apoplectic in the outset. They differ remarkably from the first set of cases. 
If there be at the very beginning some loss of sense or motion, it goes off again in 
a very few minutes, or perhaps in a few seconds : the prominent symptom, at the 
commencement, is sudden and violent pain in the head, with faintness, sickness, and 
often with vomiting. The pain continues, and is sometimes confined to one side of the 
head ; the face is pale and ghastly, the pulse weak, and often frequent or irregular ; 
but the patient is quite conscious, and in full possession of his intellect. At length 
he recovers his natural temperature, his countenance improves, and the pulse becomes 
stronger and steadier : then his face gets flushed, he feels oppressed, answers ques- 
tions slowly, and at last sinks into stupor and fatal coma. The period between the 
first attack and the commencement of the coma is variable. Sometimes the stupor 
succeeds the pain and faintness so rapidly, that the case comes greatly to resemble 
those in which coma is the first symptom, and takes place suddenly ; but still a short 
period of sense, commonly with complaint of great pain, may be observed. But the 
interval may be a quarter of an hour, or many hours, or even two or three days. 
" Upon inspection," says Dr. Abercrombie, " we find none of those varieties and 
ambiguities, which occur in the apoplectic cases, but uniform and extensive extra- 
vasation of blood." [I should state that he calls the first class of cases apoplectic 
cases, the coma being present from the first : and the second class, which we are 
now considering, he calls cases not primarily apoplectic^] The symptoms in this 
form of attack depend, no doubt, upon the giving way of some one of the cerebral 
vessels. At the moment when the vessel is ruptured, a shock is given to the brain ; 
a temporary derangement of its functions occurs ; but this passes off. The circu- 
lation then goes on as before, until such a quantity of blood has escaped from the 
ruptured vessel as is sufficient to produce coma. There is no part of Dr. Aber- 
crombie's book more admirable and clearly put than that which is occupied with 
these important distinctions, which I give you very much in his own words. He 
points out the close analogy which exists between this variety of apoplexy, and the 
result of external injuries, when they occasion extravasation of blood on the surface 
of the brain. The hurt person recovers from the immediate effects of the accident, 
walks home perhaps, and after some time becomes stupid, and at last comatose. 
The surgeon trephines the skull, and discovers blood upon the dura mater; and the 
blood being removed, the coma goes off. We cannot help our patients by a similar 
expedient; though the opinion has been broached that trepanning the skull will, at 
some future period, be a common practice in apoplexy. Dr. Abercrombie conjec- 
tures that after the rupture has taken place, the hemorrhage is sometimes stopt by 
the formation of a clot at the orifice in the vessel, but at length the blood bursts out 
again, and proves fatal. He relates two cases in which this probably happened ; in 
one of them an interval of three days, and in the other an interval of a fortnight, 
elapsed between the first attack, and the supervention of coma. The portions of 
blood extravasated at the two distinct periods may sometimes be distinguished by 
their appearance—their colour and consistence. 

The third form of attack is characterized by sudden loss of power on one side of 
the body, and frequently by loss of speech, without loss of consciousness ; or at most 
with a very temporary suspension of consciousness. The patient is sensible, hstens 
to and comprehends your questions, and answers them as well as he is able, either 



APOPLEXY. 



303 



by words, which in most cases he articulates imperfectly, or by gestures. The 
further progress of the cases that commence in this way is marked by considerable 
variety. Sometimes the hemiplegia passes gradually in a short time into apoplexy. 
Sometimes the patient soon gets well, the palsy leaving him entirely. Or a gradual 
recovery takes place, which is not complete for some weeks or months. Or the 
patient rallies up to a certain point, and there the improvement stops ; he regains the 
power of moving his leg, but it drags somewhat after him ; or the leg recovers, but 
the arm remains feeble, or his speech continues to be inarticulate. And in another 
variety of this form the patient neither improves on the one hand, nor becomes apo- 
plectic on the other, but is confined to his bed, paralytic, and perhaps speechless, 
though in possession of his faculties in other respects, and dies at last worn out and 
exhausted, some weeks, or months it may be, after the attack. In the outset of these 
cases there is not always complete hemiplegia, sometimes the arm only is affected, 
sometimes (but much more rarely) the leg only. Or some other voluntary muscles 
are the first to lose their power. 

Now the appearances discovered after death, in cases that have thus commenced 
(Dr. Abercrombie calls them the class of paralytic cases), are, as in the apoplectic 
cases, inconstant. Much the most common of all — according to my own experience — 
is the extravasation of blood, to a moderate or small amount, and definite extent, in 
the substance of the brain. But sometimes nothing is found, upon dissection, to 
account for the symptoms, or slight serous effusion only. The same symptoms attend 
some cases of softening of the brain also ; or inflammation and its consequences. In 
a vast majority of cases, I repeat, this sudden hemiplegia marks an attack of cerebral 
hemorrhage. " 

You will not find that all cases of apoplexy commence exactly in the one or the 
other of the three ways which I have been describing. But most attacks range 
themselves in one of these classes, and by attending to the points of distinction, I 
make no doubt that you will often derive much assistance from them in regard to 
diagnosis and prognosis ; and that the distinctions themselves will give a higher inte- 
rest to your study of this complaint, than it would possess if all the forms of attack 
were jumbled together in one common description. 

In treating of this large subject, this multiform disease, the main points will best 
be made intelligible by my breaking what I have to say into separate heads. I have 
told you the different ways in which the disease may make its assault. J will next 
say something of the persons who are most hable, ceteris paribus, to attacks of 
apoplexy : and afterwards of the symptoms which in many cases, though not in all, 
precede the seizure, and lead us to fear that it may be impending. It is of great 
importance to attend to these threatenings ; for, as you will readily conceive, the 
chief good that medicine can do in such cases, is in the way of prevention. After the 
attack has taken place, the effect of our treatment must be very uncertain. A large 
effusion of blood upon the brain will be fatal in spite of us : and a smaller amount of 
extravasation we cannot remove ; and the best that the patient can expect in too many 
cases, is long-continued or permanent palsy, a weakening of the mental powers, and 
sometimes a state nearly approaching to idiocy. Also, when once an apoplectic fit 
has happened, it is the more hkely, on that very account, to happen again. These 
are quite sufficient reasons why we should not neglect the warnings ; the symptoms 
which are apt to precede and herald the attack of apoplexy. 

The classes of persons in whom, cscteris paribus, attacks of apoplexy are espe- 
cially to be apprehended, are those whose ancestors have suffered the same disease ; 
those who possess a particular conformation of body ; and, above all, those who 
have reached a certain period of life. No doubt apoplexy may and does occur in 
persons whose progenitors have escaped it ; in persons of every conceivable shape 
and make ; and in persons of all ages. But it is much more frequent in the classes 
I have specified, than it is among persons not comprehended in those classes. 

The first and second class sometimes concur, i. e., a particular conformation of the 
body is transmitted from parent to child, and with it is transmitted a prochvity to 
apoplectic disease. But even when there is nothing particular in their bodily form, 
or in their habits of fife, practical men of large experience declare that they who 



304 



DISEASES OF THE BRAIN. 



come of an apoplectic stock are themselves more than ordinarily liable to apo- 
plexy. 

The pattern of body which is most prone to apoplexy is denoted by a large head 
and red face, shortness and thickness of the neck, and a short, stout, squat build. 
This remark is as old as the time of Hippocrates. However, apoplexy is common 
enough in men and women who are thin, and pale, and tall. Cseteris paribus, cor- 
pulent people are more in danger of apoplexy than spare people ; but it attacks both 
the one and the other. 

Advanced life is certainly a very strong predisposing cause, and the reason of this 
will be apparent when we come to inquire more particularly into the morbid appear- 
ances presented after death by apoplexy. The disease begins to be common after 
60: but it does sometimes occur even in young children. I am speaking principally 
of that form of apoplexy M'^hich depends upon cerebral hemorrhage, which is by 
far the most frequent of all its forms. 

Of sixty-three examples of cerebral hemorrhage, collected and carefully examined 
by Rochoux (who has written a very good treatise on this affection), two only hap- 
pened between the ages of 20 and 30 ; eight between 30 and 40 ; seven between 
40 and 50 ; ten between 50 and 60 ; twenty-three (or more than one-third of the 
whole) between 60 and 70 ; twelve between 70 and 80 : and one between 80 and 
90. To analyze this table a httle further : it appears that of the sixty-three cases 
seventeen only took place before 50 ; forty-six after that age. There are also twice 
as many victims to the disease between the ages of 60 and 70, as between 70 and 
80. And from this fact Rochoux has drawn, I conceive, an erroneous conclusion ; 
and I mention it that, in case his treatise falls in your way, you may not be led by 
it into what I imagine would be a mistake. There being twenty-three cases between 
the ages of 60 and 70, and only twelve between the ages of 70 and 80, Rochoux 
infers from this that the disposition to cerebral hemorrhage decreases after the age 
of 70 ; which would be a most unaccountable thing, and quite inconsistent with 
what I believe to be the true pathology of the disease. But I make no doubt that 
the difference in the actual numbers observed in these two decennial periods de- 
pended upon the number of persons alive, at the same time, of the ages of 60 and 
70 respectively. There are always more persons living whose age ranges from 
60 to 70, than from 70 to 80 ; and therefore more persons die of apoplexy in the 
former period. In all probabihty, if the exact truth could be ascertained, of a given 
number of persons, there are more attacked with apoplexy between 70 and 80 than 
between 60 and 70. 

All these three kinds of predisposition are beyond our power. We cannot exter- 
minate the hereditary tendency ; nor remodel the plan upon which the body is con- 
structed ; nor arrest, or put back, the clockwork of human life. But we may guard 
and caution persons, thus predisposed by nature towards apoplexy, against many of 
its exciting causes. 

A strong predisposition to apoplexy is, moreover, engendered by certain other 
diseased conditions ; and over some of these conditions our art enables us to exercise 
more or less control. 

One of these I referred to just now — the kidney disease discovered by Dr. 
Bright. 

Disease of the cerebral blood-vessels is a very common and a very pregnant cir- 
cumstance of predisposition. I shall revert to this when I describe more particularly 
the anatomical characters of cerebral hemorrhage. 

Diseases of the chest influence very materially and injuriously the circulation in 
the head. Without going into detail respecting complaints with which I am obliged 
to suppose that you are as yet unacquainted, I may state, by anticipation, that impe- 
diments to the free transmission of blood through the heart and lungs constitute the 
mode in which thoracic disorders predispose to apoplexy. The plethora capitis 
produced by such impediments is frequently visible in the turgid and livid features, 
and in the distended jugular veins. 

The cessation of habitual discharges, of the catamenia, of bleeding piles; the 
drying up of old sores ; the healing of long established issues and setons ; all have 



APOPLEXY. 



305 



an unquestionable tendency, by causing or augmenting plethora, to generate a pre- 
disposition to apoplexy. 

And large observation of the habits of those who fall victims to this terrible ma- 
lady, leaves no room for doubting that intemperance often paves the way for its inva- 
sion. The continued abuse of ardent spirits, in particular, lays the foundation of 
many of those morbid conditions of the sanguiferous system, and of the viscera, 
which constitute the predisposition we are now considering. 

Among the premonitory symptoms, headache is of frequent occurrence : but the 
same symptom is abundantly common in persons who are in no danger of apoplexy : 
it derives its minatory character from the concurrent circumstances. Headaches 
awaken our fears when they begin to be troublesome in advanced life. They are, 
then, still more formidable if they are accompanied by vertigo; or, without any 
other evidence of gastric derangement, by nausea and retching. Sometimes, as I 
just now told you, severe headache ushers in, and almost forms a part of the apo- 
plectic attack. 

Vertigo itself, even without headache, is a very common precursor or warning of 
an approaching seizure. It is sometimes shght and transient; sometimes almost 
habitual. Although vertigo may depend upon other causes than mischief within the 
head, we cannot regard it without apprehension when it often occurs in old persons. 
It should teach us to obviate as entirely as we can all the known exciting causes of 
apoplexy. The principle of these I shall by-and-by describe to you. 

Transient deafness, or transient blindness, bhndness or deafness for a few seconds 
or minutes, is another of these warning symptoms. The late Dr. Gregory, of Edin- 
burgh, used always to mention in his lectures the case of Dr. Adam Ferguson, the 
celebrated historian, as affording one of the strongest illustrations he ever met with 
of the benefit that may be derived from timely attention to the avoidance of those 
circumstances which tend to produce plethora and apoplexy. It is, perhaps, the 
most striking case of the kind on record. Dr. Ferguson experienced several attacks 
of temporary blindness some time before he had a stroke of palsy ; and he did not 
take these hints so readily as he should have done. He observed that while he was 
delivering a lecture, his class, and the papers before him would disappear, vanish 
from his sight, and reappear again in a few seconds. He was a man of full habit ; 
at one time corpulent and very ruddy, and, though by no means intemperate, he 
lived fully. I say he did not attend to these admonitions ; and at length, in the 
sixtieth year of his age, he suffered a decided shock of paralysis. He recovered, 
however, and from that period, under the advice of his friend, Dr. Black, became a 
strict Pythagorean in his diet, eating nothing but vegetables, and drinking only water 
or milk. He got rid of every paralytic symptom, became even robust and muscular 
for a man of his time of life, and died in full possession of his mental faculties at the 
advanced age of ninety-three ; upwards of thirty years after his first attack. Sir 
Waker Scott describes him as having been, " long after his eightieth year, one of the 
most striking old men it was possible to look at. His firm step and ruddy cheek 
contrasted agreeably and unexpectedly with his silver locks ; and the dress which he 
usually wore, much resembling that of the Flemish peasant, gave an air of peculi- 
arity to his whole figure. In his conversation, the mixture of original thinking with 
high moral feeling and extensive learning, his love of country, contempt of luxury, 
and especially the strong subjection of his passions and feelings to the dominion of 
his reason, made him, perhaps, the most striking example of the Stoic philosopher 
which could be seen in modern days." 

This anecdote, which I have made use of as a wrapper for some medical instruc- 
tion, will not be the less acceptable to you when I add that the remarkable man to 
whom it relates was the great-uncle of my friend and present colleague in this 
school, Dr. Robert Ferguson. 

Very frequently slight and partial paralysis is the forerunner of an attack of apo- 
plexy. Double vision is one form in which such limited palsy is apt to show itself. 
It is evidently connected with some degree of squinting ; i. e., some one or more of 
the muscles that move the eyeball are paralyzed ; the person cannot direct each 
eye to the same object at the same time. This is a very suspicious symptom. Dr 
20 2 a2 



306 



DISEASES OF THE BRAIN. 



Gregory was acquainted with a sportsman who one day, when out shooting-, disputed 
with his gamekeeper as to the number of dogs they had in 'the field. He asked how 
he came to bring so many as eight dogs with him. The servant assured him there 
were but four; and then the gentleman became at once aware of his situation, 
mounted his horse and rode home. He had not been long in the house when he 
was attacked with apoplexy, and died. 

Sometimes the slight and local paralysis shows itself in a faltering or inarticulate 
mode of speaking. The rapidity of the movements of the tongue requisite for dis- 
tinct utterance is so great, that the slightest weakness of any one of its muscles is 
rendered obvious. We see this in one very common form of what may in truth be 
considered a kind of apoplexy ; viz., in drunkenness. In many persons the very 
first symptom of their becoming intoxicated is their inability to speak plainly. " Clip- 
ping the King's EngHsh " is the slang expression for it ; and the same thing often 
takes place in respect to the more proper forms of apoplexy. 

It is a curious circumstance, b}'' the way, and one which is illustrative of what 
we meet with in disease, that different sets of muscles are chiefly affected by inebri- 
ation in different persons ; the same sets being always the first affected in the same 
persons. Thus, some men, when drunk, lose (as I have just stated) the proper 
command over the muscles of the tongue, and falter in speech, while they can 
walk very well : others reel and stagger, having lost, in a greater or less degree, the 
power of moving and governing their hmbs, and of balancing themselves, who yet 
can speak quite fluently and plainly : and in a few cases, drunken persons become 
delirious, who still retain the power of distinct articulation, and of directing their 
steps aright. This being so, we need the less wonder at the variety in the nature 
of the warnings that precede the apoplectic attack. 

In many instances there is numbness or debility, or total palsy of one limb, or of 
a single finger, or even of a sohtary muscle, as of the levator palpebr^. The patient 
cannot grasp your hand with firmness, or sign his name in his usual way, or pick 
up a pin, or snuff' a candle, or manage an obstinate button, or tie a knot in a thread 
cleverly : or, perhaps, one of his eyefids droops, and the eye is half closed. Some- 
times, on the contrary, the patient stares at you, frightfully, with one eye, which he 
cannot shut. 

The numbness also assumes various characters, according to its place and degree. 
One patient wifl tell you that he feels as if his limbs were muffled in flannel ; ano- 
ther, that he is uncertain whether, in walking, his foot has reached the ground or 
not. A gentleman, since dead of apoplexy, assured me that, when sitting, he did 
not know how far his breech covered the seat of the chair. 

All these symptoms are modifications of the function of voluntary motion ; or of 
the function of sensation. Nor are manifestations wanting, among these precursory 
circumstances, of a derangement of the other and nobler function, of which the brain 
and nervous system form the material instrument. I mean the function of thought. 

Thus one very deplorable warning is the loss of memory. Ail persons find, as 
they grow older, that they do not retain so tenaciously in their recollection things 
which have recently occurred, as things which happened when they were young. 
This partly depends upon the degree of attention which we pay to different circum- 
stances. Those events which strongly excite the curiosity, and rivet the attention 
of the boy, become familiar to the man, and he gives them but little notice, and is 
very apt to forget them. But the loss of memory that threatens apoplexy is some- 
thing more than this. It is sometimes partial, and extends to certain sets of things 
(<nly. For example, some persons entirely forget certain words, while they recollect 
others perfectly. Common words are often thus forgotten, while unusual or remark- 
able words are remembered ; or a wrong word is chosen. One word is used for 
another that sounds something like it. Thus one of my patients, meaning to accuse 
a certain individual of perjury, always called it purging: and many other words he 
changed after the same fashion. But in truth the modifications of a partial loss of 
memory that have been known to precede apoplexy are both odd and endless : some 
people forget their own names, or the names of their children. Dr. Gregory, who 
had paid particular attention to these precursory symptoms, and who had a large 



APOPLEXY. 



307 



practice for a great number of years to furnish them, used to mention a case of this 
kind. After some efforts his patient could recall to his recollection what his Chris- 
tian name was, but he could not think of his surname. About twelve months after 
his memory began to fail in this strange manner, he was found dead in his bed. 
Another gentleman, for some time before his death, could never recollect the name 
of the street in which he lived. Upon one occasion of his visiting Edinburgh, he 
called on Dr. Gregory, and partook of a hearty breakfast, having forgotten that he 
had breakfasted before he came out. On the same day he attended, with Dr. Gre- 
gory, the funeral of a young lady who had been his ward ; the funeral took place in 
the country ; and when they returned together in the carriage, the doctor found that 
his friend had forgotten all that he had been doing. Next day he met him in the 
street, and saluted him with all the kindness of an old acquaintance at first meeting; 
saying he was happy to have fallen in with him now that he was in town, and 
totally forgetful of their former interviews. 

Connected with this failure of memory, there is often an unnatural degree of 
drowsiness. Sometimes, without any permanent affection of the memory, there is a 
temporary confusion or suspension of thought ; the patient suddenly loses the train 
of ideas in which his mind had been occupied ; stops short in the middle of a sen- 
tence, and endeavours, in vain, to recover the broken thread of his discourse. 

Among the mental conditions that bespeak a tendency to apoplectic disease, I 
have several times noticed a strange and vague dread, of which the person can give 
no reasonable explanation ; a sense of apprehension and insecurity not accounted 
for by the apparent state of his general powers and functions ; a painful degree of 
indecision and irritability ; with a dislike and fear of being left alone. One patient 
of mine described his " nervousness" of this kind, by telhng me that in descending 
a staircase, especially a winding one, he was obliged to turn round, and come down 
backwards, as one descends a ladder ; or even to sit down, and so shp, stair by stair, 
from the top to the bottom. Yet with the assurance given him by a friend's arm, 
or by a convenient baluster, he could walk down stairs without difficulty. He had 
no actual vertigo. 

I say, all these, and many other signs that indicate a disposition to apoplexy, are 
well worth your study ; because a knowledge of them may enable you to ward off 
the threatened attack by medicine, by regimen, and by admonition to the patient on 
the subject of such exciting causes of the disease as are within his own control. 
They show that, even before the stroke descends, there is some morbid process going 
on within the head. 



LECTURE XXIX. 

Apoplexy continued. Symptoms characterizing the Apoplectic State. Pressure 
the ordinary Physical Cause. Hemiplegia. Affection of Involuntary Muscles. 
Anatomical Characters. Situation of the Clot of Blood. Disease of the Cere' 
bral Blood- Vessels, 

We were engaged with the subject of apoplexy. I requested your particular 
attention to the three-fold mode in which that fearful disorder has been observed to 
make its attack. In the first, the coma is sudden and deep ; the condition of the 
patient, thus struck in an instant senseless and motionless, warranting those epithets 
which the ancients applied to the victims of this disease, of attoniti and siderati, as 
if they were thunder-smitten or planet-struck. In the second form of the attack, the 
earhest symptom is acute pain of the head, with sickness and faintness ; the coma 
supervening usually in no long time. The third form is ushered in by sudden 
hemiplegia, which may or may not lead to loss of consciousness or stupor. The 
cases which range themselves under the one or the other of these three forms of 
attack are called respectively, by Dr. Abercrombie, apoplectic cases; cases not pri- 



308 



DISEASES OF THE BRAIN. 



marily apoplectic; and paralytic cases: and so as you bear in mind what these 
terms really imp]}^ they appear unohjectionable. 

I next pointed out the classes of persons in whom an attack of apoplexy is chiefly 
to be apprehended : those, namely, in whose famihes that disease has been known 
to be common : those who have large heads, thick necks, red faces, square shoul- 
ders, and a short stature ; although persons of quite the opposite configuration are 
by no means exempt from it : and lastly, and above all, those who have passed the 
middle period of hfe, and are advancing towards old age : and more particularly is 
apoplexy to be apprehended in people of this description when they have already 
suffered what are called head symptoms ; which symptom.s have reference to the 
three great functions of the brain and nervous system : voluntary motion, sensation, 
and thought. Such symptoms consist, therefore, in slight and often transient para- 
lytic affections, double vision, a dropping of one eyelid, occasional inarticulate speech, 
weakness, perhaps, of a single finger : headache, giddiness, unnatural sounds in the 
ears, numbness or tinghng of the extremities, which last are all modifications of sen- 
sibility : some impairment of the intellect, shown most commonly by partial and 
strange defects of memory, and temporary confusion of thought. When several or 
any of these symptoms occur, and especially when they become habitual in persons 
in the dechne of life, we have reason to dread the supervention of apoplexy ; and to 
exhort and protect our patients against its ascertained exciting causes. 

When the apoplectic state is fully formed, in what manner soever the attack may 
have commenced, it is marked by most or all of the following circumstances. The 
patient lies totally unconscious of all that may be going on about him. He replies 
to no questions, he is unmoved by the cries and lamentations of his family ; in fact, 
he does not hear them. His pulse is infrequent, often full, perhaps intermitting. 
His breathing is pecuhar, being slow, sometimes interrupted or irregular, attended 
with snoring or stertor during ?72spiration, and a puffing out of the cheeks, like the 
action of one who smokes a pipe, during ea:'piration. Both these pecuharities are 
referable to the same principle, and both denote a profound sensibility to ail external 
impressions. There is no longer any voluntary attempt to breathe, yet the involun- 
tary movements of respiration subsist : the medulla oblongata still responds to the 
impressions which reach it from the lungs and from the skin, still prompts contraction 
of the muscles that enlarge the capacity of the thorax ; but the loose curtain of the 
palate, and the lips and cheeks, are passive. By the vibrations of the one the stertor 
is occasioned ; the mouth is closed by the mere elasticity of the others, and the flaccid 
cheeks flap outwards with the explosion of the air, as it escapes when the chest again 
collapses. The countenance is frequently turgid, and livid ; the blood which tinges 
it is already but half arterialized ; the pupils are commonly contracted. The hmbs , 
lie motionless : either they are all absolutely palsied ; or (what probably is often the j 
case) the capacity of motion remaining, the will to move them is wanting. If you , 
raise one of them it falls passively down again, when you leave hold of it, like a dead i 
limb. Sometimes, however, they are rigid and stiff'. Sometimes one is stiff", and 
the others hmber. And sometimes one or more of them, or those of one side, tremble, 
or are distinctly convulsed. You find perhaps that the patient is unable to swallow. 
If you put fluids into his mouth, they appear to choke him, or they run out again at 
the corners of his lips. His bowels are usually torpid ; but if they act, the evacua 
tions are passed in the bed without his knowledge or concern. His urine also flows 
involuntarily ; or is retained in the distended bladder until it fairly Oi;e?'flows, and 
dribbles away perpetually. 

When the attack terminates in death, that event is preceded, I beHeve in almost j 
every case, by profuse perspiration, which bursts forth from every part of the surface, 
and is often cold and clammy. The pupils are sometimes at this period dilated : and 
I have more than once seen them of unequal size. The pulse becomes more fre- 
quent, the breathing more rare, and at last it ceases altogether. 

In this description you will perceive that something more is included than pure 
coma. The absence of consciousness — implying the suspension of thought, of sen- 
sation, and of vohtion — marks plainly the affection of the cerebrum. The symptoms 
which diversify the apoplectic state, and distinguish one case of the disease from 



APOPLEXY. 



309 



another, proceed from an associated or consecutive affection of the spinal cord. 
There may, indeed, be merely coma ; profound and invinsible sopor only. In this 
condition a morsel of food, or a spoonful of drink, passed far back into the pharynx, 
is instantly carried onwards by an act of deglutition : the excrements are duly 
retained, and duly voided : the limbs are simply passive and motionless ; neither 
stiff, nor convulsed. But in the severe cases, inabihty to swallow, laxity of the 
sphincters, spasms, rigidity, tremors of the voluntary muscles — more or fewer of 
these adjuncts to the coma — are very apt to present themselves : and they denote, I 
say, the direct or indirect extension of the morbid influence on which the apoplexy 
depends, to the cranio-spinal axis. 

An easy and interesting criterion of the degree in which the reflex apparatus may 
be concerned has been pointed out by Dr. Hall. The orbicularis is the sphincter 
muscle of the eyelid. Touch the eyelashes, and the lids involuntarily close ; even 
during sleep the movements of the shut lids are apparent. If, in apoplexy, they do 
not respond to this mechanical stimulus, we know that the true spinal functions are 
gravely implicated. 

On the other hand, many of the morbid phenomena just mentioned may occur, 
without any affection, from first to last, of the intelligence. But to these forms of 
disease, although the nature of their exciting cause may be the same, the term 
apoplexy cannot properly be applied. 

This state, so appalling and painful to look upon, but fortunately so devoid of 
suffering for the patient — this suspension of the functions of animal life — depends, 
we have reason to believe, upon pressure appHed to the brain, the organ subservient 
to those functions. 

That excess of pressure is a vera causa is obvious, and that it is adequate to the 
production of coma is capable of demonstrative proof. It is not enough to show that 
they often exist together, for the coincidence must be casual. Neither does their 
occasional disjunction, real or apparent, furnish any conclusive argument against the 
general proposition, that coma, in many and in most cases, is the resuk of pressure 
upon the encephalon. 

Coma may exist without pressure. In other words, coma acknowledges other 
causes also, besides pressure. It is produced by many narcotic poisons ; by the cir- 
culation of venous blood through the arteries. In these cases we have no proof of 
any compression of the cerebral substance. 

The other disjunctive condition is much more puzzHng, and has led some persons 
to question or deny the general proposition. Can there be unnatural pressure, yet 
no coma ? It would seem so. Serum, pus, blood, have been met with in the brain, 
foreign matters have penetrated the cranium, and coma has not occurred. 

The force of this difficulty is lessened by the consideration that foreign substances 
may be present within the skull, without occasioning any preternatural degree of 
pressure. We read of bullets being carried about for some time in the brain. In 
such instances it is probable that a portion of the contents of the skull was forced out 
at the time of the injury ; or that coma has come on, and gone off again, in conse- 
quence of the gradual absorption of the cerebral matter to make room for the foreign 
body. The same explanation may be applied to the chronic accumulation of water 
within the cranium, and to the slow growth of tumours. 

Further, it is open to conjecture that it is not on every part of the brain that the 
same degree of pressure made will produce the effect ascribed to it. It is stated in 
Mr. Mayo's Physiology, as the result of actual experiments on animals, that lateral 
pressure against the hemispheres of the brain produces no observable ill conse- 
quence ; but that vertical pressure, pressure downwards, occasions stupor, "which 
is attributable to the compression of the medulla oblongata." Now it is obvious that 
some injuries of the brain may tend more than others to cause pressure in that 
direction. 

I confess that the difficulty is not wholly relieved by these considerations. But it 
is a difficulty which cannot invalidate the evidence of numerous facts that attest the 
agency of pressure, as, at least, one cause of coma. The presumption of such 
agency ariaes wlienever coma immediately succeeds to pressure ; and it is converted 



310 



DISEASES OF THE BRAIN. 



into certainty if, upon the removal of the pressure, the coma immediately departs. 
Now the annals of physi(f are full of instances of this kind. In experiments upon 
animals, stupor has been brought on, and made to cease, at the pleasure of the ope- 
rator, by applying pressure to the exposed brain, and by remitting that pressure. 
Nay, the experiment has been tried on the human brain itself. A man who had 
undergone the operation of trepanning, and had recovered, was in the habit of exhibit- 
ing himself for money in Paris, where Haller saw him. He suffered the spectators 
to make pressure upon his brain, where it was covered by the integuments only. 
This always put him into a state of coma or deep sleep ; but sensibihty and the 
power of voluntary motion returned at once when the pressure was taken off. 

A most remarkable example of the occurrence of coma from pressure upon the 
brain, and of the removal of the coma by removing the pressure, was afforded by a 
patient who was in St. Thomas's Hospital under the care of Mr. Chne. Mr. Green, 
who was Mr. Cline's nephew, was in the habit of relating the case in his lectures 
here. It is quite pertinent to my present purpose. One of Mr. Cline's apprentices 
was visiting the depot at Deptford, and discovered there a man who had been for 
some lime in a state of unconsciousness : and he had him removed to St. Thomas's. 
His main symptoms were apparent insensibility to all surrounding objects, and a 
total incapacity to make any communication to those about him ; except that his 
attendants learned to infer, from certain instinctive movements or gestures, that he 
felt hunger, or thirst, or a want to relieve his bowels. His fingers were permanently 
bent towards the palm of the hand, and his eyes were turned upwards, so that the 
corneas were completely concealed beneath the upper lids. 

Upon examinmg this man's head, Mr. Chne found that there had been fracture 
with depressure of one of the parietal bones. He trepanned that part, and elevated 
the bone. The patient seemed to feel the operation ; and as soon as it was con- 
cluded, his eyes and fingers were restored to their natural position. On the evening 
of the same day, he sat np in bed, and though at first stupid and incoherent, soon 
became rational and well. 

When he had entirely recovered his senses, it was ascertained that the last thing 
he remembered was his serving on board a vessel which made a capture off Minorca. 
He was wounded in the engagement, and carried afterwards to the hospital at Gib- 
raltar. All this happened upwards of twelve months before the operation. So that 
one whole year of this patient's life was a complete blank, because during that 
period, a little piece of bone was pressing upon his brain. 

Cases of this kind show very convincingly, the connection that subsists between 
pressure on the brain and coma, and their relation to each other as cause and effect. 
The pressure and the coma begin together ; the coma continues as long as the pres- 
sure continues ; and it ceases when the pressure is removed. The old definition of 
the cause of a morbid condition is completely satisfied : " Prtesens morbum facit, 
mutata mutat, sublata tollit." 

From this digression — not altogether foreign to our subject — ^I return to the consi- 
deration of the pathology of apoplexy. 

If the patient recovers from the coma, he may live a few hours, or days, or he 
may live for many years. Sometimes, as the coma departs, all the natural functions 
are gradually restored ; but much more commonly paralysis remains. You already 
know that it is apt to affect one moiety of the body only. If a line be drawn from 
the vertex to the perineum, dividing the body into two halves, which, as far as the 
exterior is concerned, are symmetrical, all the voluntary muscles that lie on one side 
will be found powerless ; or if they are not all so, those which are palsied are 
situated on the same side of the line. And this state of things is called hemiplegia. 
Paraplegia, that condition in which all the parts below a tranverse line are palsied, 
though it sometimes results from cerebral disease, is much more commonly the con- 
sequence of mischief in the spine. 

Now, of this hemiplegia, when it is complete, there are several particulars worthy 
of your notice ; and there are many things worthy of your notice when it is incom- 
plete. But we will take one of these predicaments at a time. By complete hemi- 
plegia, I mean palsy of all the voluntary muscles of one side. The patient may 



APOPLEXY. 



311 



will the motion of his leg, or arm, but they no longer obey the act of volition ; if 
they are lifted by another, and then let go, they drop down hke logs of wood. You 
will find that, in well-marked cases, the intercostal muscles of the palsied side do 
not contract. The muscles of the face, also, are some of them inert on the same 
side. I have known many persons who have thought that the muscles of the face, 
in hemiplegia, when they were affected at all, were affected on the opposite side of 
the body from that to which the palsied limbs belonged. But they never could have 
examined actual cases of hemiplegia with any attention. How the error arose I 
cannot tell, but I have known a professed anatomist make it. I guess that it may 
have arisen from one of two causes. An anatomist who had not looked closely upon 
disease, would expect, and not unnaturally, that the face and hmbs would be a^ffected 
on opposite sides of the body, seeing that the nerves which supply the muscles of 
the face are given off above the place where those fasciculi of nervous matter which 
are called the anterior pyramids, decussate each other. And a common observer, 
who was not an anatomist, would be apt to conclude that the side towards which the 
mouth was drawn was the affected side : whereas it is just the reverse. The face is 
drawn to the heakhy side, because the muscles on that side are no longer counter- 
acted and balanced by the corresponding muscles of the palsied side. The blank 
half of the face is that which answers to the paralyzed limbs. On that side the 
patient cannot frown, or smile. He presents a singular spectacle, which I do not 
dwell upon now, because I shall return to it again when I have to speak of certain 
important varieties of local palsy. What I wish you to bear in mind at present is, 
that when the muscles of the face are affected in hemiplegia, the rule is that they 
are palsied on the same side with the limbs. But there is no rule, they say, without 
an exception : certainly the exceptions to this rule are very uncommon. I have not 
had leisure to look over the records of the very many cases of this disease which my 
position as physician to an hospital has brought under my observation ; but I do not 
recollect more than two exceptions : and one of them, as it happens, is now exhibited 
in the person of one of my patients in the Middlesex Hospital. Some of you have 
seen the w^oman. It is a well-marked exception : but in this instance the hemiplegia 
followed a blow on the head, and I suspect that a double injury was inflicted ; that 
the palsy of the face results from mischief on one side of the brain, and the palsy of 
the limbs from mischief on the other. This I only conjecture ; because the pheno- 
menon is so rare.* 

Then, again, with respect to the tongue : when put out beyond the lips, its point 
is commonly turned to one side. To which side ? Why towards the palsied side. 
For what reason? Clearly because the muscles that protrude the tongue are power- 
less on that side, and in full vigour on the other. That half of the tongue which 
corresponds with the sound side is pushed further out than the other half, and there- 
fore the tongue bends to the palsied side. Such is the usual fact, and such the ex- 
planation of it. But there are more numerous exceptions to this than to the paralysis 
of the external facial muscles. Sometimes the tongue comes out straight ; some- 
times the patient cannot protrude it at all ; and sometimes, even, it deviates towards 
the sound side. But the rule is as I have stated it. 

This also has been noticed of the tongue in such cases ; that the patient has been 
able, after some effort, to thrust it suddenly out, and then has required a certain 
interval of time before he could do so again ; as if the spent nervous power was 
slowly regenerated. With these different affections of the tongue, the patient's 
speech is variously altered. His voice is thick, muttering, inarticulate, or unintelli- 
gible. Sometimes, even though he may be quite conscious and rational, he is unable 
to utter a syllable ; and seems vexed at finding that his attempts to speak are fruitless. 

Supposing the patient to recover, wholly or partially, from the paralysis, it is the 
leg, in nine cases out of ten, ay, and in a much larger proportion than that, which 
recovers first and fastest : sooner and quicker than the arm, I mean. And another 
fact, quite analogous to this, is, that when one of the extremities alone is affected 



* This patient died afterwards, at her own home ; and no opportunity was given of iu- 
gpecting the body. 



312 



DISEASES OF THE BRAIN. 



with paralysis, it is, in nineteen cases out of twenty, the arm that is so affected. I 
give you again the rules ; they are Hable to occasional exceptions. The reasons that 
have been assigned in explanation of this curious circumstance I shall lay before you 
by-and-by ; after 1 have had an opportunity of describing the morbid appearances 
discovered within the cranium in these cases. 

This, then, is one way in which the hemiplegia may become, or be from the first, 
incomplete : viz., in extent. One Hmb may be powerless and the other strong. 
But the palsy may also be incomplete in degree. The patient may be able to move 
and use his limbs, but they are feeble. He cannot bend his fist firmly ; nor lift his 
arm beyond a certain height. Or his leg feeJs heavy to him, and trails a little behind 
as he walks : he is unable to stand upon that limb ; or to plant his foot securely, or 
with the usual precision. In short, there are innumerable gradations of paralysis, 
from slight weakness of the affected muscles to perfect immobility. 

Besides the palsy, there is often anassthesia also. But this is by no means so con- 
stant a symptom as the paralysis. The function of sensation (wherefore I cannot 
tell) is less frequently abohshed or perverted than the function of voluntary motion. 
When the sensibility is lost, or blunted, or any how modified, it is so, commonly, in 
the same parts that are affected with paralysis. But sometimes there is ansssthesia, 
and no palsy ; and, more strange still, there has been sometimes ansesthesia of one 
side, and palsy of the other. As a general rule, the ansesthesia is less common, and 
Jess intense than the palsy ; and is much sooner recovered from. 

The mental faculties are, in some few instances, quite unhurt by the attack : too 
frequently, however, they suffer irreparable damage. Of many persons, a striking 
alteration is evident in the whole character and temper. The brave man has become 
timid ; the prudent man foolish ; the calm and cheerful man peevish and impatient. 
There is no longer the same power of attention, the same capacity for business, the 
same clearness and comprehension of thought. And whatever other changes may 
be observable, there are two ways, especially, in which the patient, after he has 
emerged from the coma, is very apt to be affected : viz., by a defection of memory, 
more or less partial ; and by a peculiar tendency to emotion, particularly the emo- 
tion of grief: he will weep for very shghl causes, sometimes long after the attack of 
apoplexy has passed over. This is very curious. I should have stated before that 
the same readiness to shed tears, and to be immoderately affected by trifling causes 
of emotion, is sometimes noticed among the precursory symptoms of apoplexy. 

Tracing these cases onwards still further — such cases, I mean, as do not perfectly 
recover — we find that the palsied hmb wastes. Inaction of the muscles, according 
to the principle which I explained to you in a very early part of these lectures, leads 
to lessened nutrition, and a consequent diminution of bulk : in one word, to atrophy. 
Sometimes, indeed, the size of the helpless limb is maintained, or even augmented, 
by the supervention of oedema. The motion of the blood in its veins not being aided 
by the play of its muscles, the areolar tissue becomes infiltered with serous liquid. 

Again, these palsied hmbs are usually colder than their fellows. This probably 
is owing to the diminished circulation of blood through the capillaries : there is not 
so much blood converted into venous from arterial ; and less animal heat is deve- 
loped. This has been observed even when the main artery of the part has beat as 
forcibly as in the corresponding part on the other side. 

It is necessary to be aware that these palsied parts do not resist the influence of 
cold or of heat so well as the sound parts. When the sensibihty is blunted, we can 
readily understand how the hmb may become burned, from the absence of any warn- 
ing pain that an injurious degree of heat is applied : but this is not all. A lower 
degree of temperature than would injure a sound part has often been found prejudi- 
cial to a palsied part : and if these palsied parts get chilled by frost, they more 
readily vesicate and inflame, on the return of heat, than other parts : merely warm 
water will sometimes act upon them hke scalding water. I say a knowledge of 
this fact is of practical moment. That degree of warmth which the palsied limb 
fails to generate for itself, we must accumulate for it by warm clothing: and we 
must take care that it is never exposed to any artificial temperature which exceeds a 



APOPLEXY. 



313 



certain point. We sometimes see mischief done by applying hot bottles or bricks— i 
too hot — to such hrabs. 

In speaking of the palsy, I have dwelt especially on the loss of action and power 
observed in the voluntary muscles ; but the strictly involuntary muscles do not alto- 
gether or always escape. The pulse, as I have stated, will often become slow or 
irregular in the apoplectic attack : and the bowels are usually very obstinately cos- 
tive ; their peristaltic motion, which results from the contraction of involuntary mus- 
cles, is suspended or diminished. Now the old writers on apoplexy puzzled them- 
selves with devising explanations of the fact that the involuntary muscles are so little 
affected in this disease. But the true reason is not far to seek. The involuntary 
muscles — so called because they nf-yer acknowledge the mandates of the will— • 
appertain to the functions of organic hfe. Their movements (as I have heretofore 
had occasion to show you) are not necessarily dependent upon any influence derived 
from the nervous centres; and might continue, provided a due supply of arterial 
blood were kept up, though there was no brain at all. FcEtuses having no bmin, 
nay, some unfurnished with either brain or spinal marrow, have nevertheless grown, 
in other respects, to their full size. It is well known that the action of the heart 
may go on for some time, even after its removal from the body. 

In truth it seems, at first sight, more difiicuk to explain why the organs of invo- 
luntary motion are sometimes affected, in apoplectic and paralytic diseases, than 
why, in general, they are not. But some elucidation of this matter I have also 
attempted to give in a former part of the course. The organs of involuntary motion, 
though not dependent upon the brain and nervous system, are yet liable to be influ- 
enced through their medium ; as we know by the effect produced upon those organs 
by certain emotions of mind. Dr. Wilson Philip has shown clearly, by his experi- 
ments, that the way to affect the action of the heart, and of the other involuntary 
muscles, through the brain and nervous system, is ; to act upon a large portion of 
that system at once. Hence any disease which inflicts extensive damage upon the 
encephalon will be likely to disturb and weaken the functions of the heart and ali- 
mentary canal. 

Conversely, when we find, in a case of apoplexy, the involuntary muscles sensi- 
bly affected, we may infer, I beheve, that the injury done to the nervous matter is 
great and serious. 

Let us next, with the view of further elucidating the pathology of this disease, 
direct our attention to the appearances which are met with after death, in the most 
common forms of the complaint. 

I shall pass over those cases in which no morbid condition is detected, simply 
reminding you that the altered relation of the venous to the arterial circulation in the 
brain may perhaps account for the symptoms, and for the extinction of life : or the 
altered velocity of the blood circulating in the brain may account for them : or, what 
is more probable still, a determination of blood towards the head, or a detention of 
blood in the head, sufficient, by tightening the full vessels, to occasion extraordinary 
pressure upon the nervous pulp, may account for them : or the presence of some 
poisonous substance in the circulating blood (such as urea) may account for them. 

I pass over, likewise, those cases in which serum only is found effused beneath 
the arachnoid, or into the ventricles. A moderate quantity of serous fluid poured 
out rapidly during Hfe w^ould certainly occasion a degree of pressure adequate to the 
production of fatal coma. How the serum comes to be so effused, it is not always 
easy to say. Yet there is one condition of the blood-vessels of the brain which, 
when it can be proved to exist in a given case, is sufficient to account for the effu- 
sion. Any real or virtual retardation of the blood in the cerebral veins would lead 
to what is tantamount to dropsy, there, as well as in any other part of the body ; 
and intelligible causes of such retardation are known sometimes to be in operation. 

But I wish to consider more particularly the appearances that are met with in 
the brain after death by cerebral hemorrhage, which, after all, is the most common 
source of apoplectic and paralytic disorders. 

In the first place (as I have more than once stated before) the popular notion that 
hemorrhage is owing to the giving way of a considerable blood-vessel — although this 

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314 



DISEASES OF THE BRAIN. 



notion seldom has reference to the hrain, because the blood cannot reach the ex- 
ternal surface of the body, and therefore does not strike the popular sense — 
I say this notion is more true of cerebral than of any other hemorrhage. Much 
more true, especially as regards the brain than as regards the lungs, to which 
latter organ the bursting of a blood-vessel is, in vulgar parlance, most commonly 
ascribed. 

* This comparative frequency of hemorrhage from the actual rupture of vessels 
may, in some ftieasure, be accounted for by their peculiarities of texture and re-* 
lation. The blood-vessels distributed within the cranium are long and slender. 
Excepting the sinuses, the coats of both arteries and veins are thinner and weaker 
than in other parts of the body : the middle tunic of the arteries has not more 
than one-half its ordinary thickness ; and the outer or cellular coat is of such ex- 
treme tenuity that doubts have been entertained concerning its existence. These 
vessels, moreover, are not protected, as elsewhere, by investing sheaths of cellular 
membrane, and receive but shght support from the soft and dehcate substance by 
which they are immediately surrounded. They are likewise very subject to a par- 
ticular form of disease, by which their natural fragility is much increased : and lying 
near to the heart, and in the primary direction of the blood as it is driven from the 
left ventricle, they have been thought especially liable to sustain the additional mo- 
mentum arising from the more forcible contractions of that chamber ; whether these 
are determined by occasional transient causes, or depend upon permanent organic 
disease of the heart itself. On this point, however, I shall have something more to 
say hereafter. 

Still there is no reason, I think, for doubting, that hemorrhage by exhalation 
may take place, though rarely, from the free surface of the brain, or rather of its 
investing membranes. But the rule is, that it proceeds from the mechanical rupture 
of a blood-vessel. 

In cerebral hemorrhage, the blood may be effused in one or other of three differ- 
ent situations ; viz., upon the external surface of the brain, i. e., upon or hetiveen the 
membranes ; or into one or more of its ventricles ; or into the very substance of the 
brain itself. In the two former situations it is sometimes, perhaps, poured out by 
exhalation : in the latter, which is infinitely the most common, it always proceeds 
from the rupture of one or more blood-vessels. 

It is necessary to remember that even when blood is found spread over the surface, 
or distending the ventricles of the brain, it frequently has not been originally poured 
out in those situations. If the hemorrhage into the substance of the brain be con- 
siderable in amount, the blood generally forces a passage, by laceration of the cerebral 
tissue, either into the ventricles, or (less frequently) to the surface ; or even in both 
these directions at once. 

In some rare cases blood is found effused beneath or into the pia mater, over a 
small space only, as between one or two of the convolutions, and nowhere else. 
Sometimes it is spread in a thin layer over the whole of one hemisphere, and is found 
nowhere else. Sometimes blood is discovered in one or more of the ventricles, and 
nowhere else ; but all these are comparatively unfrequent events. 

When the blood is effused into the substance of the brain, and does not break a 
passage out, either in the one direction or the other, its pressure is not necessarily 
or immediately mortal. The patient, as T have already explained, may survive for 
weeks, or months, or years ; and the clot of blood will, in fhe mean time, undergo 
very remarkable changes. 

The cell, or cavity, in which the extravasated blood is contained, varies much as 
to its size. It is sometimes scarcely of sufficient capacity to receive a large pea : 
sometimes it occupies nearly the whole of one hemisphere. It is seldom, however, 
I repeat, that a communication is not formed between the original cavity and the 
surface in the one direction, or the ventricles in the other, when much blood has 
been shed. Frequently a direct opening is made by the blood from one lateral 
ventricle to the other through the septum lucidum ; sometimes it passes from the one 
to the other through the foramen of Monro ; and even the chamber of the septum 
lucidum itself has been found distended by a certain quantity of blood. 



APOPLEXY. 



315 



If the clot of blood in an isolated cavity be examined soon after its effusion, it is 
found to be of a soft gelatinous consistence, and of a dark colour, much like black 
currant jelly. The sides of the cavity are irregular and ragged ; and the cerebral 
substance of which they are formed is generally, to the depth of a line or two, 
moist, soft, and as if stained of a reddish or yellowish colour, which is fainter in 
proportion as it is more distant from the coagulum, and gradually loses itself in the 
natural tint of the surrounding parts. This latter condition would seem to depend 
upon a slow imbibition of the serous portion of the effused blood, mixed with some 
of its colouring matter. It begins to manifest itself about the third day from the 
attack, and is most apparent from the eighth to the twelfth day ; at which period, 
under ordinary circumstances, the whole of the serum has been removed, and the 
process of absorption seems to be in active operation. By degrees this stain dis- 
appears ; the coagulum becomes more and more compact ; assumes first a brovt^nish, 
and subsequently a pale red or even yellowish hue ; diminishes continually in mag- 
nitude; and at length may be entirely reabsorbed. 

In the mean time the walls of the cavity are becoming less uneven, and clothe 
themselves, by degrees, as they contract upon the shrinking coagulum, with a dis- 
tinct membrane of a yellowish colour, sometimes of extreme delicacy, and resem- 
bling the serous membranes ; sometimes thick and apparently fibrous. When the 
opposite sides of the cell at length meet, they adhere together, and a true cicatrix 
ensues, the place of which is marked by a sort of fibrous knot, forming a remark- 
able contrast with the softer texture around it ; or less frequently by a similar indu- 
ration of a linear form. In this case, the sides of the collapsed cavity are sometimes 
found to be merely applied to each other, without actual adhesion. When, from the 
great extent of the original cavity, or from some other cause, its parietes are not 
ultimately brought into mutual contact, there remains a kind of cyst, lined by a smooth 
yellowish membrane ; sometimes traversed by a few slender threads of areolar 
tissue which cross each other in various directions ; sometimes filled with a soft, fine, 
orange-coloured spongy tissue, in which a number of minute blood-vessels ramify ; 
sometimes containing a gelatinous or serous liquid ; and sometimes apparently empty, 
having been occupied by some kind of aeriform fluid. 

It is impossible to assign the precise period within which these remarkable 
changes may be accomphshed. Dr. Abercrombie has detailed an instance in which 
a coagulum, that must have been of Yevy considerable size, had entirely disappeared 
in less than five months. In another of his cases it was seen to be partially absorbed 
at the end of three months. " On the other hand, Moulin found a small coagulum 
not quite gone at the end of a year : and Riobe observed some of the blood still 
remaining in a cavity of small extent after twenty months. In two cases Serres 
found a hard coagulum of blood remaining; in one at the end of two, and in the 
other at the end of three years." 

It has been said that the cicatrization of the cavity takes place much more slowly 
and imperfectly when the effused blood has passed across and torn the fibres of the - 
brain, than when it has been poured out in a direction parallel to those fibres, so as 
to separate without breaking them. 

Dr. Abercrombie states that he had never seen any thing to satisfy him that the 
cysts are capable of being obliterated by cicatrization. Neither have I. But Dr. 
Sims, Dr. Bright, and several of the French pathologists of approved credit and ac- 
curacy, agree in their description of this obliteration of the cells. And you should 
bear in mind that a small cicatrix in the brain may very easily escape notice, if not 
expressly sought for ; especially as the examination of that ojgan is often conducted, 
viz., by cutting away thick slices from the hemispheres in rapid succession, in order 
to arrive as soon as possible at the lateral ventricles and the base of the brain. 

It frequently happens that a patient has suffered, during life, several distinct attacks 
of apoplexy or of cerebral hemorrhage ; and that as many cells are met with after 
death, exhibiting respectively various stages of that process of repair which has just 
been described." 

These are the changes that mostly take place in the coagulum, and its containing 
cell, when the hemorrhage does not prove fatal, and the patient recovers more or 



DISEASES OF THE BRAIN. 



less completely. But the same changes do not always, or necessarily, occur. Instead 
of bemg gradually removed by absorption, the extravasated blood appears occasionally 
to become a soKd, organized, and consequently living mass, deriving its nourishment 
from the arteries of the brain. A man, whose case is related by Andral, was smitten 
with apoplexy, and remained thenceforward, for many years, hemiplegic. At length 
he died, of some other complaint, in the wards of La Charite. Vv^hen his brain was 
examined, there was found, in one of the hemispheres, a mass of a pale red colour 
and fibrous appearance, traversed by numerous small blood-vessels which anasto- 
mosed with those of the brain : the surrounding nervous matter retained its natural 
aspect ; and there was no appearance of any cyst. 

I have yet to mention another, and a fatal consequence of hemorrhage into the 
substance of the brain. It is not, I think, a very frequent consequence ; yet it de- 
serves attention the more, because the risk of its occurrence may perhaps be lessened 
by judicious treatment in the outset. The clot sometimes provokes suppurative 
inflammation of the cerebral matter around it : or it may be that the nervous pulp, 
being bruised or torn by the first violent irruption of the blood, suppurates spontane- 
ously afterwards. It is affirmed (by what French author I forget) that the patient 
cannot be considered secure against this consecutive mischief, until eight days of 
safety have elapsed from the period of the apoplectic seizure. 

Instances of this result of cerebral hemorrhage, according to my experience, are 
not, i say, very common. I have before me some memoranda of the last case of it 
that I saw. 

I received on the 3d of September, a note, written in a remarkably clear and neat 
hand, desiring that I would call upon the writer, as he had had a severe attack of 
apoplexy a day or two before. 

I concluded that the note had been penned by some member of the patient's 
family, and I expected to see him in his bed, paralytic probably, or manifestly ill. 
But I found a stout active gentleman, walking about in his drawing-room, apparently 
in perfect health, and declaring that he felt so. He showed me, however, a paper 
written by a surgeon, who on the previous day had brought him to town from a dis- 
tance, and who had been obliged to return immediately. The paper stated that 

Mr. had suffered a sudden and decided fit of apoplexy on the 30th of August ; 

that he was then freely bled ; that perfect consciousness was not restored, nor the 
force of the pulse subdued, till twenty ounces of blood had issued from his arm ; 
and that on the evening of the same day sixteen ounces more -were drawn. 

My patient spoke of going down to his country-house, where he had, he said, " a 
good deal of shooting to do." I dissuaded him from this, and enjoined perfect quiet 
for at least a fortnight to come. 

The next day, after a long and imprudent conversation with a friend, he suddenly 
lost the thread of his discourse, and could not recover it. Then he became confused, 
and misapphed words. I asked him how he felt. He answered, "not quite right," 
and this he repeated very many times, abbreviating it first into "not right," and at 
length into " n'ight." Wishing to mention " camphor," he called it " pamphlet." 
I mention these as specimens. On the 5th it was evident that his right arm and leg 
were weak in comparison with the others ; but their sensibility was unimpaired. By 
slow degrees the weakness degenerated into complete palsy, and the right side of 
the face became motionless. Gradually also he grew heavy, stupid, comatose, 
unable to swallow, with a fixed pupil ; and so, on the morning of the 15th of Sep- 
tember, he died. 

We examined his head the next day. On the left side, the dura mater adhered 
to the skull-cap with morbid firmness. During the endeavour made to detach it, a 
tablespoonful, or more, of a dirt3^-looking, greenish, very offensive pus spurted forth. 
This was found to have proceeded from an abscess, which must have contained 
two ounces of pus, and which was situated in the upper part of the left hemisphere 
of the cerebrum. The walls of the abscess looked as if they were coated with a 
layer of yellowish plaster. In the centre of this cavity was a small, fibrous, tough 
mass of a dull red colour ; the coagulum, doubtless, of blood effused on the 30th of 



APOPLEXY. 



317 



August. In front of the abscess the brain seemed natural, but its consistence was 
that of hquid custard. 

It has long been known that hemorrhage does not occur in all parts of the sub' 
stance of the brain indifferently. Morgagni had remarked the frequency of sanguine- 
ous effusions in or near the corpora striata and optic thalami ; and more extensive 
subsequent research has amply verified the general correctness of his observation. 
Rochoux, in the treatise on apoplexy which I mentioned before, published in 1814, 
has given a tabular account of the morbid appearances observed by himself in the 
heads of 41 persons, dead after attacks of cerebral hemorrhage. 

In so many as 24 of these, i. e., in three-fifths of the whole number, the blood 
was extravasated in the corpus striatum ; in two others in the optic thalamus ; in 
one it was efiiised into the substance of both the corpus striatum and the optic thala- 
mus of the same side ; and in another, beneath the corpus striatum : so that alto- 
gether there were 28 cases out of 41, or seven-tenths of the whole number, in which 
the clot was confined to the corpora striata, optic thalami, and their immediate neigh- 
bourhood. In the remaining three-tenths the blood was found collected in several 
other parts of the cerebral mass ; five times in the middle of one of the hemispheres ; 
twice towards the posterior part of the ventricles ; twice in the inner and anterior, 
and three times in the inner and posterior portion of the hemispheres ; and once in the 
middle lobe. 

In Andral's Pathological Anatomy you will find a much more extensive table 
relating to the same subject, and constructed by him from various authentic sources. 
It leads to the same general conclusions. Thus, among 392 cases of hemorrhage 
into the nervous substance, there were 202 (or more than one-half) in which the 
blood was extravasated at once into the corpora striata, the optic thalami, and that 
part of the hemispheres of the brain which is on a level with those bodies. In 61 
cases (or about one-seventh of the whole number) it was confined to the corpus stri- 
atum. In 35 (or one-eleventh of the whole) it was limited to the optic thalamus ; 
making, in all, 298 instances (or more than three-fourths of the whole number) in 
which the sanguine effusion occupied the corpora striata, optic thalami, and their 
immediate vicinity. 

The result of my own observation coincides entirely with this, although I cannot, 
at present, reduce it to a numerical statement. 

From the same table we may infer also the comparative infrequency of hemor- 
rhage into the cerebellum. It is mentioned as having occurred in 21 of the 92 cases ; 
or in about 1 in 19. 

Dr. Craigie states that the parts which are the seat of the hemorrhage may be 
arranged, in the order of frequency, as follows : — the corpus striatum ; the optic 
thalamus ; the hemispheres ; the pons varohi ; the crura of the brain ; the medulla 
oblongata ; and the cerebellum. 

It is natural to seek for some physical explanation of the causes which determines 
the extravasation of blood in certain parts of the brain more frequently than in 
others. Some light may, perhaps, be thrown upon this inquiry, by a consideration 
of the sources of hemorrhage, in various forms of its occurrence. 

I stated before that the blood may sometimes be poured out by exhalation, in 
those less frequent forms of cerebral hemorrhage to which M. Serres has applied the 
term meningeal apoplexy, and in which the blood is found distending the ventricles, 
or spread, like a cap, over the surface of the hemispheres, without any laceration of 
the cerebral matter. This supposition rests, however, rather upon the analogy drawn 
from what is known to occur in other parts of the body, than upon any decisive and 
unequivocal evidehce. Blood has not unfrequently been discovered in each of these 
situations, when the most careful scrutiny has failed to trace its source to any ruptured 
vessel. Yet we cannot doubt that such rupture may have existed — either in some 
one or more of the numerous vessels of the pia mater, in the one case, or of the 
plexus choroides in the other — and yet have escaped detection by the most vigilant 
eye. In Dr. Abercrombie's book there are two interesting examples of extra vasa- 

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318 



DISEASES OF THE BRAIN. 



tion upon the surface of the brain, without any obvious source of the hemorrhage ; 
the one detailed by Dr. Hunter, of Edinburgh, the other by Dr. Barlow, of Bath. 

That the hemorrhage proceeds from rupture of some of the vessels composing the 
choroid plexus, rather than from the membrane that hnes the inner surface of the 
ventricles, when the effused blood is confined to those cavities, is the more probable, 
because the vessels have been actually found broken (as in cases of ventricular he- 
morrhage, described by De Haen and Cruveilhier), and because they are hable to 
well-marked disease of a nature to render them more than usually fragile. The 
arteries, for example, which belong to that plexus, are subject to a peculiar kind of 
alteration that I shall presently mention as frequently pervading the whole arterial 
system of the brain ; and its veins are often partially enlarged and varicose. This 
latter condition has sometimes been mistaken for a collection of small hydatids. 

But hemorrhage into the substance of the brain depends always upon rupture of 
some one or more of its blood-vessels ; and it is to this fact of the rupture of vessels 
that we must chiefly look for an explanation of the peculiar hability to hemorrhage 
of certain portions of the brain ; the corpora striata, namely, the optic thalami, and 
the parts immediately adjacent to these. The corpora striata are not only of much 
softer consistence than most other parts of the brain, but they are also traversed by 
more numerous as well as by larger blood-vessels than are other parts. These facts, 
and the conclusions to which they point, did not escape the sagacity of Morgagni. 
" On some occasions (says he) when I have cut the corpora striata into pieces hori- 
zontally, I remember to have observed in the external anterior part of each, a little 
pit, as it were, across which lay a very conspicuous blood-vessel. And on other 
occasions, upon cutting obliquely and slowly, I have remarked, in the same situation, 
man}?- red hnes, like threads, which were in fact blood-vessels running parallel to one 
another, and of a larger size than elsewhere." In truth, you may often notice the 
open mouths of a cluster of such vessels that have been divided. Morgagni saw in 
this anatomical fact a probable solution of the pathological fact that the parts in ques' 
tion are the most common seals of extravasation. In corroboration of these views it 
is worth remarking that the corpora striata are especially subject to laceration and 
sanguine effusion, while the surrounding parts remain unhurt, in violent concussions 
of the brain. And when injections are forced into the cerebral blood-vessels in the 
dead body, it is in the very same parts, the corpora striata above all others, that a 
sort of factitious hemorrhage is produced by the rupture of vessels, and the escape 
of their contents. 

I have mentioned some original peculiarities of texture and relation, which may be 
thought to predispose the blood-vessels of the brain, more than others, to laceration. 
But the main predisposing cause of that event is, doubtless, their great liability to 
disease. Except the commencing portion of the aorta itself, there are no arteries in 
the body so frequently found in a morbid state as the cerebral arteries. And the 
change to which they are most subject is that deposition between their tunics, some- 
times of a substance resembling albumen or soft cartilage, sometimes of actual phos- 
phate of hme, to which we commonly apply the term ossification. This earthy or 
cartilaginous deposit exists usually in whitish patches of a roundish or oblong form, 
disposed at various distances from each other : sometimes in a succession of bony 
rings, with healthier portions of the artery between them. One effect of this morbid 
condition is to diminish the bore of the affected artery, and to make it of unequal 
capacity. And as this variation of cahbre impedes the free passage of the blood, it 
tends indirectly to increase the pressure of that fluid against the sides of the vessel. 
Another effect is to deprive the coats of the artery of their natural elasticity, and to 
diminish their power of cohesion ; and thus to render them v>^eak and frangible, and 
at length unable to sustain the increased impulse of the blood. Tiiis condition occurs 
in the smaller ramifications as well as in the larger trunks of the cerebral arteries. 

There is yet another occasional cause of hemorrhage. The arteries at the base 
of the brain are subject to aneurism, and to consequent rupture. Morgagni has 
reported cases of aneurism affecting the internal carotid and basilar arteries. Serres 
has described a case of apoplexy resulting from perforation of the basilar artery, 
which was dilated, not far from its superior bifurcation, into an aneurismal pouch as 



APOPLEXY. 



319 



big as a hen's egg. Dr. Baillie records an instance where both the internal carotids, 
on the side of the sella turcica, were distended into little aneurisms, one of the aneu- 
jisms being about the size of a cherry, the other somewhat smaller: and similar 
examples are related by other writers. I have seen two such myself; a beautiful 
preparation of one of them is preserved in the museum of the College of Physicians. 



LECTURE XXX. 

Apoplexy continued. Relations between the Symptoms and the Appearances found 
in the brain after death. Exciting Causes. Prognosis. Treatment. 

I LEFT off in the last lecture, after having described the appearances discoverable 
within the head, at different periods subsequent to an attack of cerebral hemorrhage; 
and pointed out the various sources of the hemorrhage ; and endeavoured to explain 
how it happens that the blood so much more commonly proceeds from a ruptured 
vessel in or near the corpus striatum and optic thalamus, than in any other part 
of the brain. 

Some account of the connection traceable, in these cases, between the physical 
injury done to the brain and the symptoms, has already been given by anticipation. 
I proceed to touch upon certain points, relative to that connection, which have not 
yet been noticed. 

One of the most remarkable circumstances which dissection teaches us, when 
there has been partial palsy, is, that the palsy is ®on the one side of the body and 
the hemorrhage of the brain on the other. This is a very general law. But excep- 
tions to it are said to have been observed. Morgagni mentions such. Dr. Bright 
has recorded a somewhat doubtful case of exception. I have never met with any : 
and I cannot help suspecting that in some of those which are said to have occurred, 
mistakes have been made : that either they have been incorrectly observed, or inac- 
curately described. You may consider the rule as almost, if not altogether, universal. 

This crossing over of the morbid effect of the extravasated blood, or of any other 
diseased state, has long been attributed to that crossing over of nervous fibres which 
takes place at the upper part of the spinal cord. Just where the medulla oblongata 
and the medulla spinalis unite, the anterior pyramids decussate each other, and send 
their fibres mutually to the opposite side of the body. All this of course you know. 
The right anterior pyramid is continued into the centre of the left half of the spinal 
cord ; and the left anterior pyramid into the centre of the right half of the cord. 
Now supposing, as we have every reason to suppose, that the nervous influence, 
whatever may be its nature, travels in the course of the fibres of the brain, we see 
in this decussation of the anterior pyramids an easy and pleasing solution of the 
phenomena in question. But then comes this serious difficulty. How does it happen 
that the muscles of the face and tongue — which are supplied by nerves that arise 
from the nervous centres above the place of decussation — how does it come to pass 
that these muscles sustain the same cross injury, and are paralyzed on the same side 
on which the limbs are paralyzed ? And again, how does it happen (as it certainly 
does) that hemorrhage into the cerebellum should have a similar cross influence ? 

These seeming anomalies have never been satisfactorily explained. Indeed I do 
not know that any one has undertaken to explain them except Mr. Mayo : whose 
peculiar speculations concerning hemiplegia — first promulged, as they were, in this 
place ; coming, as they do, from so eminent a physiologist ; and being, as I deem 
them, in many respects, erroneous ; — demand here a brief consideration. 

He takes some pains, in the first place, to show that the morbid influence is com- 
municated from one side of the brain to the limbs of the other side of the body, by 
means of the fibres of decussation already described. This point did not, I think, 
require any laboured demonstration ; but he has made a happy use of two facts 
previously ascertained, which, taken together, afford a very neat proof that the trans • 



320 



DISEASES OF THE BRAIN. 



ference of the morbid influence, or privation of influence, from one side to the other, 
actually takes place in that very part of the nervous system where the decussating 
fxbres meet. The facts are stated by Dr. Yelloly, in the Medico- Chirurgical Tran- 
sactions. Sir Astley Cooper divided the right half of the spinal cord of a dog, in 
the space between the occiput and the atlas ; immediately, that is, after the cord has 
emerged from the skull through the foramen magnum : the result of this division of 
the cord was hemiplegia, paralysis of the hmbs, on the same side with the injury. 
The bridge by which the morbid effect crosses over must therefore be above that 
point. We have got a limit on one side. And a case observed by Dr. Yelloly gives us 
a limit on the other. He examined the head of a man who had died hemiplegic ; 
and he found a tumour, as big as a filbert, imbedded in and pressing upon the right 
side of the annular protuberance. The palsy had existed on the left side. The 
bridge of communication must consequently lie below that point. It must lie, there- 
fore, between the two points now indicated ; i. e., it must be either in the medulla 
oblongata, or just at the junction of the medulla oblongata with the medulla spinalis. 
Now in this very interval, and here alone, a decussation of the nervous filaments is 
found to exist. There can be no doubt that the decussating fibres form the channel 
of communication. 

Supposing (what perhaps is questionable) that the prevalent notion respecting the 
uses of the anterior and posterior columns is correct, Mr. Mayo next explains, more 
clearly than I have found it explained by any previous writer, that the decussation 
of the anterior pyramids accounts both for th6 palsy and for the aneesthesia, which 
are apt to accompany cerebral hemorrhage into the opposite side of the brain ; inas- 
much as the decussating fasciculi, on plunging into the opposite column of the spinal 
marrow, strike into its centre ; and implicate themselves nearly as much with the 
posterior, as with the anterior, i. e., nearly as much' with what is thought the sen- 
tient, as with what is thought the motor portion of the cord. The wonder seems to 
be why the numbness is not more constant ; why it is infrequent in comparison with 
the affection of the voluntary muscles. 

Mr. Mayo holds that palsy does not result from "the interruption of the ordinary 
supply of nervous stimulation furnished by the brain " — for this reason, that in living 
animals the brain has been gradually removed, sliced away, yet sensation, and the 
power of voluntary motion, have subsisted ; and that instances of acephalous human 
infants, which have survived their birth, show the medulla oblongata and spinal cord 
to be sufficient, without the brain, for the production of sensation and voluntary 
motion. He conjectures, therefore, that the immediate cause of the hemiplegia is 
"a depressing influence, or shock,''^ (a withering influence he elsewhere calls it,) 
" originating in the brain when in certain states of lesion, and propagated from it to 
the medulla oblongata and the spinal marrow." 

Now it can scarcely be doubted, at least I cannot doubt, that the inference here 
drawn from the movements observed in acephalous monsters, and in animals after 
amputation of their brain, is a wrong inference. They are purely automatic move- 
ments, independent of sensation and of the will, and derived from the reflex endow- 
ment of the cord : and if this be so, the main foundation of Mr. Mayo's argument 
is cut away. His prime error, which has led him still further astray, is that of attri- 
buting sensation and volition to the spinal cord. For my own part, I can form no 
distinct conception of any positive and persistent depressing influence, except 
pressure. But mere pressure Mr. Mayo repudiates ; asserting that in many cases 
of hemiplegia from cerebral disease there is no pressure. And this maybe granted: 
although even in cases of softening, such as he refers to, the mere absence of sup- 
port in some parts of the brain might lead to the subsidence or settling down of other 
parts, so as to cause pressure upon the medulla oblongata. I took some pains, in 
the course of the last lecture, to show you that pressure is adequate to the produc- 
tion of coma and general paralysis ; and pressure on a nerve in its course we are 
sure is capable of occasioning local paralysis : so that the theory would, not seem 
very wild, which should ascribe the hemiplegia resulting from cerebral hemorrhage, 
or cerebral disease, to the benumbing influence of pressure. 

Now, if Mr. Mayo's notion, that some " shock " or " withering influence " is trans- 



I 



APOPLEXY. 



321 



mitted from the injured brain, could be proved to be true ; or, on the other hand, if 
it could be established that this influence is no other than the benumbing influence 
of pressure ; either supposition would plausibly account for these facts, viz., that 
" in general hemiplegia from cerebral lesion, the palsy of the leg is (commonly) less 
complete, and is sooner recovered from, than palsy of the arm," and that when one 
of these Hmbs only is affected, it is (commonly) the arm alone. The shock, or the 
pressure, would be most felt in proportion as the part was nearer the origin of the 
pressure ; and less felt in proportion as we receded from the source of the injurious 
influence. 

But, unfortunately, I was obliged to insert the word [commonly) in the statement 
just made of the facts : which word Mr. Mayo does not employ. To make either 
his theory, or the theory of pressure, perfectly satisfactory, either the arm alone 
should be affected ; or the affection of the arm should always accompany and be 
more intense than, or at any rate not less intense than, the affection of the leg. But 
this is not the case. Since Mr. Mayo's observations were published, I have met 
with two or three instances and pointed them out to him, in which the leg alone, or 
the leg first, has been palsied, from cerebral disease. And Andral, among seventy- 
five cases of cerebral hemorrhage collected for another purpose, which I shall pre- 
sently advert to, met with twelve in which the leg only was affected. It is a great 
pity that these stubborn facts should thus cross and thwart what might else be 
esteemed a very pretty theory. 

I confess that, to my mind, the phenomena of hemiplegia are the most easily 
accounted for by the very hypothesis which Mr. Mayo rejects, viz., that the paralysis 
depends upon a simple interruption of the nervous influence, a breaking up, or an 
obstruction, of the road by which the changes leading to sensation travel in the one 
direction, and the mandates of vohtion in the other. We may easily conceive that 
the conducting fibres which lie between the sensorium and the muscles of the leg 
may alone be torn across, or severed by a process of softening, or strongly compressed, 
while the residue of the conducting apparatus is entire. This notion, of some breach, 
or other impediment in the channels of communication, seems more consonant with 
what we know both of the physiology and of the pathology of the brain, than any 
other that I am acquainted with. 

I must not omit to give you Mr. Mayo's explanation of the other and main 
difficulties to which T referred — viz., that when one side of the cerebrum is injured, 
the muscles of the other side of the face are paralyzed ; and that hemiplegia, 
resulting from disease of the cerebellum, affects also the opposite side of the body : 
— and having given you it, I shall leave it, without further comment, to your consi- 
deration. 

Mr. Mayo's words are : " Where the decussating fasciculi of the anterior pyramid 
plunge into the opposite half of the spinal marrow, they are implicated, in a wonder- 
ful closeness of intermixture, with fibres which, in their upward course, bend towards 
the places of origin of the ninth and seventh, and of the eighth and fifth nerves of 
the palsied side. May it not be supposed that this interlacement may be a sufficient 
means of communicating the palsying influence to the ascending fibres, which are 
in close relation to the affected cerebral nerves ?" 

Again, " How is the fact to be accounted for, that hemiplegia of the opposite side 
is produced by lesion of one hemisphei^ of the cerebellum ? I have httle doubt that 
the following explanation of the phenomenon will eventually prove to be correct. 
The fibres of the anterior pyramids pass through the pons varolii. The pons varolii 
consists in great part of filaments which issue from each hemisphere of the cerebel- 
lum. These filaments may easily be supposed to convey a depressing influence 
from the diseased hemisphere. But in their course they come immediately upon 
the filaments of the anterior pyramid of the same side ; and they are so implicated 
with the latter, with such a singular closeness of reticulation, and often with so much 
that looks hke an actual interchange of filament, that it is far from unHkely that they 
may transmit to the descending fascicuh of the pyramid a shock which may thence 
be communicated to the same part at which a cerebral lesion exerts its paralyzm^ 
force." 

31 



322 



DISEASES OF THE BRAIN. 



I will only say further of this hypothesis, that if the explanation it furnishes of the 
facts in question be not the best and most satisfactory in the world, it is the best and 
most satisfactory that we yet possess : and that, at any rate, we may make use of it j 
to bind those facts to our recollection, until some better theory shall be devised. 

There is one very curious law asserted, by Andral, in respect to hemorrhage of , 
the cerebelhum If the blood is effused into one side of the cerebellum, and nowhere 
else, the palsy that ensues follows, I repeat, the general rule ; it takes' place in the j 
limbs of the opposite side of the body. But supposing hemorrhage to take place on ! 
one side of the cerebrum, and on the other side of the cerebellum, simultaneously : | 
.what then, think you, happens? Doubtless you would expect that there should be 
palsy on both sides of the body. Hemiplegia on the one side, from the effusion into I 
the brain proper ; hemipleo^ia on the other side, from the effusion into the cerebel- | 
lum : double hemiplegia ; that is to say, general palsy. But it is not always so, in 
fact. The cerebral affection seems to overpower and master that of the cerebellum. i 
Whatever the explanation may be, the palsy has been found to occur on the side l 
opposite to the lesion in the brain proper ; and not to occur on the side opposite to the ■ 
lesion in the little brain. This is a very singular fact, of which Andral relates four | 
or five examples. But 1 suspect that they will ultimately take their place among i 
the " anomalous" cases. As facts multiply, the law will, I conjecture, be found to | 
be a different one. I 

The complex structure of the brain, and the dissimilar consequences that ensue, 
in different cases, from its injury or disease, leads directly to the behef not only that 
the organ subserves several distinct functions, but also that separate parts or sections 
of it hold peculiar and definite relations with other portions of the body. Ingenious 
men have even attempted to settle these points experimentally. B}^ wounding or 
removing various portions in succession of the cerebral mass in living animals, and 
comparing the results, they have endeavoured to assign to each portion its particular 
province and function. But to say nothing of the remarkable differences which exist 
between the cerebral functions in man and in the inferior animals, there is an una- 
voidable source of fallacy common to all such experiments. We cannot reach the ; 
particular spot in the brain upon which the contrived injury is to be inflicted, with- 
out penetrating and hurting various other parts : and from these combined injuries 
(dangerous, indeed, and often fatal in themselves) arise symptoms which the experi- | 
menter may erroneously conclude to be characteristic of the lesion originally in his ! 
contemplation. j 

Much more accurate and satisfactory data for the determination of this interesting ; 
class of questions, would seem to be furnished by the spontaneous operation of dis- \ 
ease, and especially of the disease we are now considering. The injury done to the } 
cerebral substance by the irruption of blood is not less sudden, nor less mechanical, j 
than in the experiments or contrived observations to which I have alluded. It is | 
capable, also, in many instances, of exact appreciation in regard to its extent ; the | 
parts which lie round the seat of the effusion remain undisturbed ; and above all, 
the organ that is the subject of our observation is the human brain itself. ' 

Attempts have accordingly been made to connect particular symptoms wnth the 
disorganization of particular parts of the brain. These attempts can boast, as yet, i 
.t must be confessed, but little success. Very few, if any, of the conclusions hitherto j' 
advanced upon this intricate subject can be rehed on. Yet it is proper that you 
should be informed of them. 

Because palsy of the arm is, in general, more complete, and more persistent, than 
palsy of the leg, it has been mamtained that the former, the paralysis of the arm, is | 
to be ascribed to hemorrhage of the corpus striatum, which seems to be more com' 
mon than any other; and upon similar grounds hemorrhage of the optic thalamus 
has been supposed to determine paralysis of the leg. So much have these distinc- 
tions been confided in, that the honour of having first pointed them out has actually, 
in France, been made a subject of dispute. Now it is plain that one example of 
the contrary effect of these particular lesions, would suffice to upset the whole theory: 
but many such exceptions have, in fact, been noticed. It was with the view of set- 
iHng this question that Andral collected and collated the seventy-five cases of cere« 



APOPLEXY. 



323 



bral hemorrhage to which I lately referred. In each of these seventy-five cases the 
clot of blood was sufficiently limited to allow of that case being apphed towards the 
solution of the controverted points. 

In forty of the seventy-five, both the leg and the arm were paralyzed together. 
And where was the place of the hemorrhage in these forty cases ? Why, in twenty- 
one of them the corpus striatum was the only part injured ; and in nineteen of them 
the optic thalamus was the only part injured. Thus you see, according to the theory 
just explained, in about one-half of the cases the arm alone should have been pal- 
sied ; and in about half, the leg alone : whereas both leg and arm were palsied in 
them ail. 

Again, in twenty-three of the seventy-five cases the palsy was confined to the arm. 
Therefore, according to the theory, the injury should have been confined to the cor- 
pus striatum. What was the fact ? Why, in this class of cases also there was as 
nearly as possible an equal sharing of the injury between the two parts. In eleven 
of the twenty-three the corpus striatum alone suffered ; in ten the optic thalamus 
alone ; in two the space between them. 

Once more : there were, as I stated before, twelve out of the seventy-five cases in 
which the leg alone was palsied. Consequently, in all of these twelve, if the theory 
were sound, there should have been damage of the optic thalamus only. But in ten 
of them the mischief was confined to the corpus striatum ; in two only to the optic 
thalamus. 

Gall had conjectured that the faculty of speech was placed under the governance 
of the anterior lobe of the brain : and Bouillaud has endeavoured to support that 
opinion by a number of facts observed iji connection with cerebral hemorrhage ; but 
Cruveilhier has brought forward several curious instances in which the loss of speech 
was a prominent symptom, while the disease was not found in the anterior lobe, but 
in some other part of the brain. 

Andral, with his accustomed industry, has accumulated evidence upon this point 
also. 

In thirty-seven cases of cerebral hemorrhage observed by himself, or by others, 
in which the morbid condition occupied one or both of the anterior lobes, the power 
of speech was abolished twenty -one times, and unaffected sixteen times. 

On the other hand, he has collected fourteen cases, in which the power of speech 
was lost, yet no alteration had taken place in the anterior lobes. In seven of these 
fourteen cases the lesion was situated in the middle lobes ; and in the other seven in 
the posterior lobes of the brain. 

There can be no doubt that there are certain distinct parts of the brain which in- 
fluence respectively the upper and lower hmbs ; inasmuch as they are often sepa- 
rately palsied : and since the loss of speech is occasionally the only, or the most 
prominent symptom, while in other cases the speech is not affected at all, we cannot 
but beheve that this faculty is under the special guidance of some definite part 
within the cranium. But the facts that I have just been quoting, show, in the most 
convincing manner, that we are not able, as yet, to allot these separate functions to 
their proper spots in the cerebral mass. 

I dwelt some little time, in a previous lecture, upon the circumstances that give 
warning to the patient, or to his physician, that the former is in danger of being 
smitten with apoplexy. The great use of being acquainted with these circum- 
stances, and of looking out for them, consists in the opportunity and the authority 
which they furnish, for enforcing, upon the person in whom they manifest them- 
selves, the absolute necessity of avoiding all the avoidable exciting causes of the 
disease. But our means of advising him will be very imperfect if we have not 
carefully considered what these exciting causes are. I propose to devote a few 
mmutes, therefore, to the consideration of the circumstances that are apt to bring on 
the attack. There are many cases of apoplexy in which we cannot trace the ope- 
ration of any such causes: but in many other cases their influence is decidedly 
marked ; and the avoidance of them, while it is important to all who show a dispo- 



324 



DISEASES OF THE BRAIN. 



sition to apoplectic disease, is especially so to those who, having once suffered an 
attack, have reason to dread a repetition of it. 

In the first place, any thing which is calculated to hurry the circulation, and to 
increase the force of the heart's action, is hkely to operate as an exciting cause of 
apoplexy : simply by augmenting the momentum of the blood against the sides of 
the cerebral vessels, which in advanced Kfe are so often diseased and weak. 
Strong bodily exercise, therefore, is a thing to be avoided by all persons in whom 
the predisposition to apoplexy has declared itself. It is of much importance to make 
patients aware of this ; for many persons think, when they labour under uncom- 
fortable bodily feelings of any kind, they may get rid of them by a brisk walk ; or 
by galloping some miles over the country on horseback. 

Another dangerous state for such persons arises whenever the free escape of the 
blood from the head is suddenly obstructed. I have adverted to this before. 
Certain diseases, chiefly thoracic, which tend to keep the veins of the head inordi- 
nately full, rank among the predisposing causes of apoplexy. But, upon the very 
same principle, various conditions, which are temporary only, may operate as ex- 
citing causes. By what is called " holding the breath," whether upon an inspi- 
ration or expiration, the transit of the blood through the lungs is impeded : and the 
check is felt (through the pulmonary artery, right chambers of the heart, and great 
veins) in the vessels of the head. And this effect is increased when straining is at 
the same time performed ; that is, when a deep, breath is taken and retained, while 
some muscular forcing effort is made. 

Under this principle fall a number of bodily acts, which, however harmless in a 
healthy frame, are not without peril to a person having a predisposition to apoplexy. 
The motion of the blood in the lungs, and therefore in the head, is checked in the 
acts of coughing, vomiting, sneezing, laughing, crying, shouting, and so forth. You 
cannot have looked at a person in a violent paroxysm of coughing without seeing 
that it produced a determination of blood to the head, or rather a congested state of 
the veins of the head. The jarring pain in the head which is apt to follow each 
succession of the cough depends upon this principle : which is often strikingly illus- 
trated in young children labouring under hooping-cough. They turn purple in the 
face, and become giddy ; and not uncommonly ecchymosis of the conjunctiva occurs, 
giving fearful evidence of what might just as readily take place within the cranium. 
It is not very unusual for the whole of the white part of the eye to become sud- 
denly blood-shot in these violent fits of coughing; and convulsions even have hap- 
pened under the like circumstances. 

Straining at stool is a common exciting cause of apoplexy in those who are pre- 
disposed to it. And this is one of the worst dangers attending costiveness of the 
bowels in old people ; but it is one which it is often in our power effectually to obvi- 
ate. It is more within our control than a bad cough could be. Any kind of strain- 
ing, indeed, is equally perilous. A very good proof of this danger was recently 
afforded by a patient of my own. He was attacked with apoplexy on his way to 
Ascot races ; and upon recovering somewhat, was found to be paralytic on one side 
of the body. He was brought back to town, where I saw him. After some time 
he regained the power of using the affected limbs to a very considerable extent ; so 
as to be able to walk about and follow his business, which was that of a job-master, 
or proprietor of a hvery stable. I cautioned him seriously, i?iter alia, against strain- 
ing : but I suppose he forgot my caution. For, while dressing one morning, he 
tugged violently in attempts to pull on a damp boot, and in the midst of his efforts 
fell back insensible ; and from this relapse he never fairly recovered. 

To the same principle is to be referred a variety of things from which a patient, 
in danger of this disease, must most carefully abstain. Lifting heavy weights ; leap- 
ing ; striking a hard blow ; playing on wind instruments ; even long and loud 
talking. Dr. Abercrombie relates two instances of fatal apoplexy brought on (as it 
would seem) by a sustained exertion of the voice : one of the attacks happened to a 
clergyman during the dehvery of his sermon ; the other to a hterary man while 
speaking in a public assembly. In both cases a large quantity of blood was found 
extravasated within and upon the brain. Dr. James Gregory used to mention a 



APOPLEXY. 



325 



patient of his, an officer in the army, who had apoplexy, and in whom the attack 
had been preceded by pains of the head and giddiness, upon his giving the word of 
command, and particularly when dwelling upon the last sound : that is, when he 
made a long expiration. Precisely of the same kind is a case told by Van Swieten, 
of a singer who was obliged at length to abandon her vocation by reason of gradually 
increasing vertigo whenever she had to hold a high note. Violent emotion is another 
exciting cause. Large fires, crowded rooms, the heat even of the sun, favour the 
access of apoplexy, and therefore ought to be shunned by those who have a ten- 
dency to that disease. The warm bath is not without hazard to such persons. This 
is so well known, I understand, at Bath, that the physicians there will not allow 
paralytic patients, in whom the paralysis has been connected with apoplexy — hemi- 
plegic patients, for example — to go into their hot baths. The excitement of drunken- 
ness, and the venereal excitement, are not uncommon causes of apoplexy, especially 
in old persons. I had a man of middle age under my care during the spring of 
1837, in whom a most awful attack of apoplexy came on under circumstances such 
as I have just referred to. He had dined at a large festive party, and afterwards 
accompanied a woman, with whom he was acquainted, to a brothel: and he was 
struck with palsy during the act of intercourse. He was long unable to speak ; and 
he still remains, and probably will ever remain, a cripple ; incompletely hemi- 
plegic. 

I have been since consulted upon the case of an old gentleman residing in France, 
in whom an attempt at sexual connexion was attended with similar consequences. 

" The Gods are just, and of our pleasant vices 
Make instruments to scourge us." 

Posture, again, has no small effect upon apoplectic people. Giddiness, and some 
degree of cftnfusion of thought, are apt to be occasioned, in most persons, by long 
stooping. There is one peculiar posture or position mentioned by Dr. Fothergill as 
being very unsafe, especially for short-necked persons, viz., that position which is 
assumed when we turn the head to look backwards for any length of time, without 
turning the rest of the body ; in fact, a twisting of the neck. In this attitude the jugular 
veins are more or less obstructed. He gives an account of a man who was seized with 
apoplexy as he was crossing the Thames in an open boat ; he having kept his eye 
fixed upon a particular ship until, and after, he had been rowed past her. On the 
very same principle, tight ligatures worn about the neck, and compressing the ju- 
gular veins, may bring on apoplexy; the wearing a tight neck-cloth, for example. 
A continental writer informs us that a Swedish officer, who was desirous that his 
men should look well in the face, caused them to wear tight stocks, and the conse- 
quence was, that in a short time a great many in that regiment died of apoplexy. 
Dr. Abercrombie quotes from Zitzilius the case of a boy who had drawn his neck- 
cloth very tight, and was whipping a top, stooping and rising alternately. After a 
short time he fell down apoplectic. The neckcloth being loosened, and blood drawn 
from the jugular vein, he speedily recovered. 

There is one very powerful exciting cause of apoplexy, in those predisposed to it, 
which I need only refer to now, because the facts that have been observed in proof 
of its agency were fully detailed in a former part of the course ; I mean exposure to 
cold. You Avill recollect my telling you that the number of deaths in London, from 
apoplex:y and palsy in the month of January, 1795, which was a bitterly cold month, 
very much exceeded the number in the month of January, 1796, which was a 
remarkably mild month. The cold operates in two ways, in the production of apo- 
plexy. In the first place it drives the blood from the surface, and accumulates it in 
the large vessels of the interior of the body, and so increases the stress upon the 
cerebral arteries. And in the second place, the cold has a great influence in causing 
or aggravating affections of the chest ; and the return of the venous blood from the 
head is impeded, in the manner just now explained, by fits of coughing and ob' 
structed respiration. 

This influence of external cold, and probably certain barometric conditions also of 

2c 



326 



DISEASES OF THE BRAIN. 



the atmospliere, help to explain, what I am sure I have several times had experience 
of, namely, the epidemic prevalence, now and then, of apoplectic seizures. 

There is an alleged exciting cause of cerebral hemorrhage, which I think it the 
more necessary to consider, because I believe that very erroneous notions prevail 
about it, even among pathologists of eminence. I allude to the imputed dependence 
■of cerebral hemorrhage upon hypertrophy of the left ventricle of the heart. It has 
been supposed that the powerful contractions of a ventricle thus morbidly strong may 
drive forwards the blood with such unusual force, as to strain and burst the cerebral 
arteries. Dr. Hope, in his very complete work upon Diseases of the Heart, uses 
these words : — " Instances of apoplexy supervening upon hypertrophy have been so 
frequently noticed, that the relation of the two, as cause and effect, is one of the 
best established doctrines of modern pathology." Similar opinions are entertained 
by the most distinguished of the French writers on this subject ; Andral, Bouillaud, 
Cruveilhier. I think they are all wrong : or that at least they state their proposition 
much too broadly and generally. 

I fully admit, no less from my own observation than upon the testimony of others, 
the frequent coincidence of hemorrhage of the brain and hypertrophy of the left 
ventricle of the heart ; but I distrust the reasoning which would always connect 
these events with each other as cause and effect. They may sometimes have that 
relation : but I have long thought that in most cases, if not in all, the coincidence is 
capable of being explained upon other and more satisfactory principles. 

In the first place, hypertrophy of the left ventricle of the heart is very frequently, 
far more frequently than not, accompanied by other structural changes of that organ : 
changes which imply some impediment to the circulation : changes which involve 
or influence its right chambers also. In fact, disease of the right heart is not very 
often seen, without disease of the left ; and one of the commonest forms of alteration 
to which the left side is Hable, is hypertrophy of its ventricle. Now I have already 
pointed out to you the connection which sometimes subsists between cerebral hemor- 
rhage and such disease of the heart as obstructs the ready and regular descent of 
the blood from the head through the veins. Many of the cases of apoplexy occurring 
in persons who have previously had cardiac hypertrophy are, I really believe, cases 
of this kind. The brain affection is dependent, in part, upon disease of the heart, 
but not upon the preternatural strength of its left ventricle. The heart acts morbidly 
upon the brain through the veins, and not through the arteries. 

But there is another reason for the coincidence ; and here the arteries are con- 
cerned. 

No one can doubt that the momentum, with which the blood reaches the cerebral 
arteries, in healthy persons, under violent bodily exercise or mental excitement, must 
often exceed the momentum produced by a hypertrophic heart in the cerebral arteries 
of persons who are tranquil and at rest. But apoplectic seizures are frequent under 
the latter circumstance, infrequent under the former. We must look, therefore, for 
something more than the mere hypertrophy to explain the coincidence. Now (sup- 
posing the absence of any check to .the flow of blood from the head through the 
veins) that something is to be found in disease of the arterial system. 

When the arteries of the brain are ossified, or changed, and rendered brittle in the 
way I yesterday described, the commencement of the aorta also is found, in a great 
majority of cases, to be the seat of similar alterations ; and, often, to be sensibly 
dilated. Now the mere albuminous deposit beneath its inner tunic must seriously 
impair the elasticity of the vessel; and in this way the free passage of the blood 
out of the heart will be impeded. Dilatation of the aorta at that part will produce 
the same hindrance more certainly and in a greater measure. Still more effectually 
and obviously will any contraction of the outlet prove an impediment. It is in con- 
sequence of these mechanical obstacles to the free exit of the blood from the left 
ventricle, that the walls of that chamber, urged to more vigorous contraction, become 
thicker and more powerful. The hypertrophy is the natural compensation for the 
morbid state of the aorta; without it the heart would much sooner become unable to 
propel its contents at all : and the hypertrophy does not often, I fancy, become greater 
than is needful for its purpose. The strength of the left ventricle, therefore, in suck 



APOPLEXY. 



327 



cases, is not a true measure of the force with which the blood is driven into the 
distant arteries. Quite the contrary. It is a measure of the difficulty with which 
the blood is circulated through the primary branches, and therefore through the 
entire system of the arteries. It indicates ♦ the diminished force with which the 
blood is likely to reach the cerebral vessels. And in point of fact, you will find 
in many cases of hypertrophy of the left ventricle — I do not say in all, but certainly 
in very many — you will find the pulse at the wrist to be disproportionately small and 
feeble. So that, in these cases, instead of regarding the cerebral hemorrhage as the 
effect of the hypertrophy, (acknowledging, as I do, th^ frequent coexistence of these 
morbid conditions,) I have been accustomed to look upon the apoplexy and the hy- 
pertrophy as concomitant effects of the same cause; viz., of disease pervading the 
arterial tree. The hypertrophy of the left ventricle is the effect of the diseased con- 
dition of the aorta at its mouth ; the cerebral hemorrhage is the effect of the same 
diseased condition of the arteries in the brain. When you find each of these lesions, 
and nothing to retard the venous current, you may, I believe, safely apply this ex- 
planation of the occurrence of apoplexy. 

Having again referred to the frequent existence of disease in the cerebral arteries 
as a predisposing cause of hemorrhage within the brain, I will just point out, before 
I leave this part of the subject, the light which that fact throws upon the circum- 
stance than sanguineous apoplexy is so peculiarly a disease of advanced life. Earthy 
concretions in the coats of the arteries are so frequent in the later periods of existence, 
that they are met with, according to Bichat, in seven individuals out of ten of those 
who die beyond the age of sixty ; and Dr. Bailhe considered ossification to be much 
more common in old persons than a healthy state of the arteries. 

In the account which I have endeavoured to give you of the symptoms of apo- 
plexy, of the different modes in which the attack may commence, and of the various 
morbid appearances discovered within the cranium in the fatal cases, I have already 
embodied almost all that can be stated, with any confidence, respecting the special 
diagnosis and the prognosis of the disease. The one of these follows the other : the 
exact diagnosis being known, the prognosis is seldom difficult. By the diagnosis, 
however, I do not now mean simply the recognition of the disease as a case of apo- 
plexy : of that general diagnosis, of the means of distinguishing the coma of apo- 
plexy from the coma caused by opium or alcohol, I told you all that I know in a 
former lecture. But I use the term diagnosis now in a stricter sense, and in reference 
to the distinctions that exist between one case of apoplexy and another; and I say, 
that in proportion to the accuracy with which we may be capable of determining the 
precise condition of the contents of the skull, will be the facility of predicting the 
issue of the complaint. Let me remind you, then, that Avhen a patient suddenly 
becomes apoplectic, we cannot tell whether there be effusion of blood, or effusion of 
serum, or no effusion at all within the cranium : and therefore the diagnosis must be 
precarious and uncertain. If, after the use of suitable remedies, the coma persists for 
many hours, the prognosis becomes worse. In those cases which begin with pain 
of head, faintness, and nausea, and which pass on to coma, the prognosis is posi- 
tively bad ; for the diagnosis is easy, and we are tolerably certain that a blood-vessel 
has given way, and that a large quantity of blood has ploughed up the substance of 
the brain. In the paralytic cases also, if coma supervenes, the prognosis is gloomy; 
but frequently coma does not supervene, and then our prognosis, so far as life is con- 
cerned, may be pronounced favourable. 

Among the symptoms that belong to the apoplectic condition itself, there are some 
which experience has selected as being most especially of evil omen ; and it is well 
worth your while to remark that these discouraging signs relate, almost all of them, 
to the automatic functions of the cranio-spinal axis. The open, fixed, unwinking 
eye; the explosive flapping of the cheeks in expiration ; the inability to swallow; 
the slow, sighing, interrupted breathing; the loosening of the sphincter muscles of 
the bladder and anus ; these are fearful, and too often fatal symptoms, and they all 
depend upon the excito-motory portion of the nervous system.. Perhaps the profuse 
sweat that so often attends the process of dissolution may be referred to the same 
source ; th^ whole tone of the various tissues being lost or relaxed. I would not say 



328 



DISEASES OF THE BRAIN. 



that no one of these symptoms is ever recovered from : but I may say that of twenty 
patients in Avhom such phenomena occur, nineteen will die. 

Now symptoms of this kind may be expected to arise, if there be hemorrhage in 
or near the medulla oblongata ; or if jhere be mischief so extensive in the brain 
as to cause pressure upon the medulla oblongata. We should reason out the 
Hkehhood that such symptoms would be of bad augury. But the fact that they are 
so was ascertained long before the theory which accounts for them was devised. 
The fact is independent of the theory, and for that reason helps wonderfully to 
confirm it. 

The older writers entertained some very false notions in respect to the distinction 
between sanguineous and serous apoplexy. They laid it down that apoplexy result- 
ing from extravasation of blood within the cranium was denoted by flushing of the 
face, and strength of the pulse ; and that it was a disease of persons in the vigour of 
life : while apoplexy resulting from the effusion of serum was marked by paleness 
of the countenance, and weakness of the pulse ; and occurred in the old and the 
infirm : and they directed their practice according to this distinction. After what has 
already been said, I need not tell you that this classification of apoplexies could not 
have been founded upon the actual observation of disease : and that our treatment, 
now-a-days, is not regulated by any such erroneous theory. 

Nevertheless, I do not mean altogether to praise the modern practice in apoplexy ; 
for it is often one of mere routine. Practitioners are too apt, in this as in other 
instances, to be guided in their choice of remedies by the name of the disease, and 
to treat all cases of apoplexy alike. I remember being much amused by the per- 
plexity which a friend of mine once told me he had felt on being summoned by 
letter many miles into the country to see a gentleman who had been struck with 
apoplexy. As he posted down he earnestly revolved in his mind what he might be 
able to advise when he should reach the house of sickness. He fek confident that 
the patient must already have been copiously bled ; cupped, or leeched ; blistered ; 
and thoroughly dosed with calomel, senna, and croton oil. Mustard poukices had 
doubtless been applied to his legs. My friend was distressed to think that while 
much would be expected, nothing would be left for him to do worthy of so long a 
journey, and so heavy an expense to his client. A clyster of turpentine might yet, 
perhaps, be an untried expedient. His cogitations were cut short, however, and his 
cares reheved, by an express which met him half-way on the road, to announce that 
the patient was dead. Now this is the routine of which I speak : most proper in 
many cases ; unnecessary in others ; pernicious in some. There are persons \\\iO 
seem to think that they have not done their patient justice if any part of this active 
intermeddling has been omitted. Others regard depletion as being worse than use- 
less, and trust entirely to stimulants and cordials. These are still more dangerous 
routiniers than the others : but they are fewer in number. 

Our practice would indeed be much easier than it is, if we could thus make one 
plan fit all cases which are nominally the same. But I need not now tell you that 
disease alike in name — aye, and alike in their essential nature — are often widely 
different in their circumstances. I formerly explained to you that certain symptoms 
tell us what the disease is ; but that we are often obliged to look to other symptoms ; 
Avhich may inform us what we are to do. I know of no rule so hkely to guide you 
aright as that laid down generally by Cullen, of obviating the tendency to death. 
You must examine and judge to which of the several modes of dying there may be 
any obvious approach. If the tendency be, as in cases of apoplexy it mostly is, to 
death by coma, then blood-letting and the evacuating plan will generally be requi- 
site. If, on the Other hand, the tendency be to death by syncope, you must with- 
hold the lancet, and even have recourse to stimulating and restorative measures. The 
question is of the last importance ; involving often (as Celsus taught) the alternative 
of life and death : " sanguinis detractio vel occidit, vel liberat." Now the distinction 
between these modes of dying is to be made by attending to the state, not so much 
of the nervous, as of the sanguiferous system. Insensibihty and unconsciousness 
are common both to syncope and to coma : and cases which fall under the ^lass of 



APOPLEXY. 



329 



apoplexies, and which we cannot separate from that class, are sometimes really more 
hke cases of concussion than any thing else ; the shock having been of internal 
instead of externa] origin. If the pulse be full, or hard, or thrilling (sometimes it 
feels like a tense vibrating rope), or if there be obvious external signs of plethora of 
the head, you must abstract blood. You are not to refrain from bleeding the patient 
because he is pale, if his pulse warrants it ; nor may you omit taking blood if the 
head and face be turgid, although the pulse be small ; for that smallness may depend 
upon organic disease of the heart. 

On the contrary, if his skin is pale and cold, and his pulse feeble and flickering, 
you would probably ensure your patient's death, or determine the accession of palsy, 
if you withdrew from the failing heart and blood-vesseJs a portion of their natural 
stimulus. I can only invite your attention to these broad features of distinction. 
Being once taught to look for and attend to them, your own judgment must instruct 
you as to what may be needful in particular cases. To this, as to most other dis- 
eases, the remark of Boerhaave is strictly applicable, who declares that he knows 
of nothing which can be called a remedy, " quin solo tempestivo usu tale fiat." 

Having made up your mind as to the general indications of treatment, you will 
pursue them steadily in detail. If the patient to whom you are summoned be stupid 
and drowsy rather than faint, and his pulse and appearance warrant the conclusion 
of plethora capitis, the first thing to be done is to place him in a semi-recumbent 
position, with his head raised ; to loosen any tight parts of his dress, especially his 
neckcloth and shirt-collar, and whatever might press upon the neck; and then as 
quickly as possible to bleed him from the arm. We know that in some cases the 
apoplectic state occurs, when as yet no injury has been done to the brain ; no effu- 
sion, no laceration of its texture ; and we may hope, by timely and vigorous mea- 
sures, to prevent these terrible evils. We never can be sure that there is blood 
extravasated in such cases, and we must act, in the first instance, upon the presump- 
tion that there is not. We are especially encouraged to take away a considerable 
quantity of blood by venesection when we perceive external signs that the vessels of 
the head are full ; redness and turgescence of the face, throbbing and prominence 
of the temporal arteries, distension of the superficial veins of the neck and forehead. 
Our object is to take off the strain upon the internal vessels by bleeding in such a 
manner and to such an amount as shall produce a decided effect upon the general 
circulation. Sometimes the good consequence of the bleeding is very marked indeed, 
so that no doubt of its propriety can be entertained ; the patient being so insensible 
as not to feef the puncture of the lancet, and yet emerging from his coma while the 
blood is still flowing. It is seldom, however, that we can expect such manifest and 
immediate melioration as this. 

After one sufficient feeding from the arm, the vessels of the head may be further 
relieved by cupping the nape of the neck, or the temples ; and venesection may be 
repeated if the condition of the pulse, and the symptoms generally, should require 
its repetition. It is seldomer, however, in cases of apoplexy than in cases of acute 
inflammation, that a second or third recourse to the lancet becomes advisable: un- 
less, indeed, the first blood-letting has been mismanaged. Enough blood must be 
taken, in the first instance, to produce some evident effect; and therefore no precise 
rules can be laid down respecting the absolute quantity to be drawn ; nor can we 
make any sure estimate beforehand as to the whole amount of blood which it may 
be necessary to remove. 

Even if we could be certain that a blood-vessel had given way, and that blood 
was already poured out upon the brain, there are good reasons why (no adverse cir- 
cumstances withstanding) we ought to bleed our patient largely, and at once. I 
will enumerate briefly the benefits we seek to obtain by the abstraction of blood in 
such cases. 

1. The effusion from the ruptured artery may be slowly going on. Bleeding 
from, a vein, so as to make a sensible impression on the general circulation, will 
diminish the stress upon the cerebral arteries, and so tend to put a stop to the he- 
morrhage. Both of these tw^o objects are of primary importance. 

3. By early and free bleeding we lessen the hazard of inflammation supervening 

3c3 



330 DISEASES OF THE BRAIN. 

I 

upon the mechanical injury done to the brain by the sudden tearing and contusion 
of its texture by the effused blood ; and 

3. We thereby bring the system into the most favourable condition for the rapid 
absorption of the extravasated blood, and for expediting the patient's recovery from 
those symptoms which depend upon the presence of the clot in the brain. 

But although, in that form of disease which we are now considering, bleeding is 
our sheet-anchor, it may be carried too far, or repeated too often. We must not lose 
sight of the fact that many of these patients are old, and will not survive undue deple- 
tion ; and that if they survive at all, they will need all the strength that we dare 
suffer them to retain for carrying on the vital actions, when the chief instrument of ) 
the most important of the animal functions is so greatly damaged : nor of the fact 
that if there be blood extravasated, we cannot touch it, except indirectly, by the 
abstraction of more blood from the arm : nor of the fact that a patient may be bled 
into convulsions, and fatal syncope. In short, after the first free bleeding, you must 
be guided by the special circumstances of the case, and particularly by the pulse. 
The woman at present in the Middlesex Hospital, with paralysis of the Hmbs on one 
side, and of the face on the other, attributes her palsy (erroneously most Hkely) to 
her having been cupped. She had had a blow some weeks before, and suffered , 
headache from that time. At length she was cupped, from the neighbourhood of | 
the head ; and* the next morning she was paralytic. This might have been an acci- I 
dental coincidence. But T remember being sent for, a few years ago, to see a patient 
at Greenwich, who had already three physicians about him, and was apparently in »| 
danger of apoplexy, of which he had for some time experienced distinct warnings. 
The three physicians had agreed that he ought to be cupped from the back of the 
neck; to which I assented; and while blood was being rapidly extracted in that r 
manner, he became all at once hemiplegic. Similar cases have been noticed by : 
other persons. Therefore we are not to bleed without measure or discretion. 

The pulse may be small, and the arterial action feeble, while yet the veins are 
turgid, and the capillaries of the head and face loaded with blood. Changes may ; 
have occurred in the heart, such as to obstruct the stream which it is its healthy ; 
office to transmit. These are cases to which the local abstraction of blood from the 
head, by leeches and cupping-glasses, is peculiarly adapted. I 

Again, the v/hole state of the patient may approximate more or less nearly to the j 
state of syncope ; the pulse being weak, the aspect pinched and bloodless, and the l 
skin cool. In this condition, no good, but the contrary, is to be expected from blood- 
letting of any kind. You will do better to apply warmth, cautiously, to the surface, 
and cautiously to administer what are called diffusible stimuh, of which the prepa- [ 
rations of ammonia afford the most eligible forms. Five grains of the sesquicarbo- 
nate or half a drachm of sal volatile, mixed with camphor julep, are ordinary doses. 
Stand by till the first stunning effect of the internal shock passes off; and carefully 
watch meanwhile for symptoms of reaction. 

In more ambiguous cases, when you scarcely can tell which way the balance ! 
inclines, I would advise you to wait the effect of the next remedies I have to men- j 
tion, viz., purgatives, about giving which you need not entertain the same doubt and 
hesitation. \ 

Purgative medicines are of signal service in apoplexy. They empty the intes- 
tines, which are oftentimes loaded, and which, by distending the abdomen, have i 
occasioned, perhaps, undue pressure against the diaphragm, embarrassed the breath- ' 
ing, and through it the cerebral circulation. Another very important purpose of 
hard purging, which I have frequently pointed out before, is the producing of copi- , 
ous watery dischar2:es from the bowels, whereby the blood-vessels are drained, and 
the tendency of blood to the head especially relieved. If the patient can still swal- 
low, you may give him half a scruple of calomel, and follow it up by a black dose. ! 
If the power of deglutition be lost, the croton oil becomes a most valuable remedy, i 
Dr. Abercrombie suggests that it may be conveniently introduced into the stomach, : 
suspended in thick gruel or mutilage, by means of an elastic gum tube. But really j', 
this is not necessary. If two or three drops of the oil be put upon the tongue, as far I 
back as is possible, it will produce its specific effect very readily and well. But we I 

I 

I, 



APOPLEXY. 



331 



are not to wait for the operation of aperients given by the mouth. Strong purgative 
and stimulating enemata must be thrown into the rectum : half an ounce or six 
drachms of turpentine suspended, by the help of the yolk of an egg, in gruel or 
warm water. We very often witness decided signs of amendment upon the free 
operation of a purgative. I may mention one instance of this while it is fresh in my 
recollection. I was asked, a few evenings ago, by a medical friend, to see an old 
general, a patient of his. I found him in bed, comatose, though capable of being 
roused when loudly spoken to : but he presently fell off again into stupor. His respi- 
ration was peculiar. For a minute or two he would breathe, snoring strongly: then 
the breathing would cease altogether for half a minute or thereabouts : and then the 
stertorous respiration recommenced : and so on alternately. 

He had been found by his servant on the floor, nearly insensible, in the morning, 
having either fallen out of, or upon rising from, his bed. He had very properly 
been cupped ; and calomel and aperient medicine had been given : but the coma 
had been growing more profound all the afternoon. His bowels had been but scantily 
moved ; and the feces and urine were passed as he lay. His extremities were 
coldish. The pulse was neither full nor strong. 

I learned that for four or five years he had had some very significant warnings ; 
and within that period had suffered one or two shght apoplectic seizures, which had 
left him with impaired mind and memory. 

I recommended blisters behind the ears, and two drops of croton oil, with two 
drachms of castor oil, in a draught. The next morning I expected to hear that he 
was dead ; but I found him quite conscious, speaking somewhat inarticulately, with 
the right side of his face chopfallen and inexpressive. There seemed no particular 
weakness of the corresponding extremities. The oils had been followed by copious 
evacuations from the bowels. The day afterwards he was sitting up, and so well 
that I took my leave. 

In combination with blood-letting and purgatives, cold lotions to the head are often 
found useful in this disease, especially if its surface is hot. I need not trouble you 
by rehearsing the modes in which the application of this remedy may be managed. 
Blisters near or upon the head, are also frequently of service, after due abstraction 
of blood, in rousing the patient from his state of coma. 

Formerly, at the suggestion, I fancy, of Dr. Fothergill, it was much the fashion 
to give an emetic in the outset of the treatment of apoplexy. But this also is a 
ticklish remedy, capable of doing good or harm according as it is well or ill timed. 
If there be already extravasation of blood, or even plethora capitis, the act of vomiting 
will be likely to increase the existing mischief, and to enhance the danger. On the 
other hand it may rouse and rally the nervous power when the patient is pale, and 
cold, and faint. Yet this can never be regarded as a legitimate purpose of emetics 
in apoplexy. They can safely be recommended in those cases only in which the 
coma may appear to depend, wholly or in part, upon a loaded stomach. Hence the 
propriety of giving an emetic will deserve consideration whenever an attack of apo- 
plexy follows close upon a heavy meal. 

When the immediate danger has passed by, and parslysis remains, we are not to 
be over-busy. If the palsy is to get gradually well, it must be by virtue of time, 
and the resources of nature. To young and strong persons I should, under such 
circumstances, give small and repeated doses of mercury : and in all cases I should 
prescribe aperient medicines, so as to keep the bowels freely open twice or thrice a 
day ; enjoin perfect quiet ; and put the patient upon very short commons. Diuretics 
are also very proper when the urine is not plentiful without them. 

You will often have to contend against the ignorance and impatience of the sick, 
or of their friends, on these occasions. They think that weakness is to be remedied 
by strengthening food ; by meat and drink, and tonic medicines ; or if they are not 
so foolish as this, they will want to be electrified, or to be put into a warm baih. 
Certainly in the earlier states of the palsy that remains after apoplexy, none of those 
measures ought to be permitted. If, after some time, when all febrile action has 
ceased, the palsy seems stationary, it may be warrantable and right to attempt to 
stimulate the torpid nerves, and to accelerate the acquirement of power by the mind 



332 



SPINAL HEMORRHAGE. 



over the muscular contractions ; but when any means for attaining these objects are 
employed at all, they must be used with the utmost caution ; for they are much 
more hkely to stimulate the vascular system, and so to do harm : or even to renew 
the apoplectic attack. Electricity, and strychnia, are the remedies most relied upon. 
In cases of long-standing palsy, it may also, no doubt, be proper to try to awaken, 
by stimulating frictions, the dormant powers of the muscles, which by protracted 
inaction becomes forgetful, as it were, rather than incapable, of their natural office : 
and in these old cases we sometimes are able to benefit our patient's condition by the 
cautious exhibition of some of the preparations of iron. 



LECTURE XXXI. 

Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Ansesthesia ; their 
Symptoms, Prognosis, and Treatment. Other Forms of Local Paralysis, and 
Local Anaesthesia. 

I HAVE done with apoplexy as it respects the brain ; which is the same thing as to 
say that I have done with apoplexy. You will find the same term applied, indeed, 
to effusions of blood in other organs of the body ; but this use of the word is a per- 
version of language. Apoplexy, as I have frequently observed before, is the abohtion 
of the functions proper to the brain ; of sensation, voluntary motion, and thought. 
In short, it is coma, coming on under certain circumstances. 

I shall not speak therefore of spinal apoplexy (though that would be less improper 
than pulmonary apoplexy, or hepatic apoplexy), but of spinal hemorrhage. Of 
this I really have little to say, except that it is well known occasionally to occur ; and 
that the symptoms to which it gives rise are by no means peculiar or distinctive. 
They consist of paiyi in some part of the spine ; convulsions ; palsy ; that is, they 
are the very same symptoms which inflammation, softening, mechanical injury, and 
other disorders of the same part may produce. Spinal hemorrhage is much more 
rare than cerebral hemorrhage. Dr. Abercrombie had met with only one case of it. 
He gives the heads of seven others which have been recorded by different authors. 
Dr. Bright has never seen it : but he pubhshes the particulars of one case, which 
were communicated to him by Dr. Stroud. 

I will read you one or two short examples of spinal hemorrhage, as specimens. 
A girl, fourteen years old, was attacked with headache, jo«m in the back, and a ten- 
dency to sickness in the erect posture. At the end of a week the pain in the back 
became suddenly and very greatly aggravated ; and this was followed by general 
convulsions, which proved fatal in five or six hours. The spinal canal was found 
filled with extravasated blood, in the lumbar region, where she had fek the pain. The 
brain and all the other viscera were sound.' The case is detailed by Mr. ChevaHer 
in the third volume of the Medico-Chirurgical Transactions. 

Take one more instance from Ollivier, whose work on the spinal marrow you may 
read hereafter, when you have leisure, with advantage. 

A gentleman, aged sixty-one, had just arrived in Paris after a long journey, when 
he was seized with pain of the back, all the way down from the cervical vertebras 
to the sacrum. In the course of a few hours he became paraplegic, and was unable 
to retain his urine or feces. He then sent for a physician, and died while talking to 
him. A very extensive extravasation of blood was found in the spinal canal, beneath 
the membranes of the cord. The lower part of the canal was filled with a bloody 
mass, in which the substance of the cord could not be distinguished. Above the 
third dorsal vertebrje the cord was entire, but of a deep-red colour, and very soft. 

The suddenness of the symptoms may lead you to suspect the true nature of 
these cases ; but I cannot pretend to point out any other feature by which they may- 
be distinguished from other morbid conditions of the spine, already spoken of. I 
show you one preparation; of which, however, I do not know the history. 



PARAPLEGIA. 



333 



I have nothing to add, to what I have already said, respecting that species of palsy 
which is called^ hemiplegia : and I have only a very few further observations to 
make in regard to paraplegia. 

The cause of this kind of palsy is sometimes obvious ; sometimes most obscure. 
If we find, in the spina! canal, blood effused, softening of the substance of the cord, 
traces of inflammation of its investing membranes, tumours pressing upon it, pressure 
from disease or displacement of the bones, we have a sufficient explanation of the 
paralysis of those parts of the body, the nerves of which come from the spinal 
marrow at or below the place of the disease. There are three preparations on the 
table of tumours that pressed upon the cord ; scrofulous tumours I believe they are : 
each of the three persons from whose bodies they were respectively taken was more 
or less completely paraplegic. 

But in very many cases we detect no alteration that seems adequate to explain the 
paraplegia. The palsy creeps on slowly and insidiously, without any particular pain, 
or violent symptoms : there is no tenderness or bending of the vertebras. The 
weakness commences mostly in the legs, which appear to the patient heavier than 
usual, and of which the healthy sensations are often perverted. The toes tingle, or 
are numb : he experiences a feehng in them as if a number of ants were crawhng 
on the skin. This is so common a circumstance as to have given a name to the 
symptom, formication. The patient straddles as he walks. His legs are lifted 
awkwardly, the toes being often the last part to quit the ground : they are then flung 
obliquely forwards and outwards, and the feet flap dow^n heavily and uncertainly at 
every step. By degrees the weakness of the lower Hmbs increases: the palsy 
creeps upwards, affects the bladder and rectum, at length invades the arms, and 
ultimately the patient dies : yet very faint traces of disease, or no traces at all, may 
be visible upon inspecting the brain and spinal cord. The commonest morbid con- 
dition is softening of some portion of the cord ; and this is also the condition which 
is the most hable to be overlooked. 

Very recently I had a patient with these symptoms in the Middlesex Hospital. 
He went out contrarily to my wishes ; he was discharged, in fact, by mistake : he 
took refuge in St. Bartholomew's, where he died after a few days. I have been 
informed that serum was found beneath the arachnoid, and that the whole brain had 
a wasted appearance ; but nothing satisfactory was made out. The palsy had by 
slow degrees ascended from his legs to his arms ; he had had no head symptoms 
beyond some occasional confusion and vague uneasy feehngs there. At this 
present time a patient in a similar condition comes to the hospital every Thursday, 
dragged by a friend in a hand-chair. He looks very well in the face, but is help- 
less below. 

It is in these cases that you may expect to witness the very remarkable pheno- 
mena which I mentioned before as evincing the separate existence of a " true spinal 
marrow," distinct from the brain and its prolongations into the spinal canal, endowed 
with special and pecuhar properties, and performing functions that are independent 
of sensation, of consciousness, and of the will. If you pinch or tickle the surface of 
the paralytic members, or apply a hot spoon to the sole of one foot, the limbs will, 
in many cases, start up and move strongly, not only without any voluntary effort on 
the part of the patient, but in spite of him ; or even (in those instances in which 
there is anaesthesia as well as palsy) without his knowing it. The legs often spring 
up of their own accord as it seems; but, no doubt, the apparently spontaneous 
movement is frequently an excited movement, and takes place in obedience to the 
law that governs the automatic motions of the body. Some impression, made first 
upon the peripheral extremities of afferent nerves, runs through the nervous arc of 
connmunication, and exhibits its ultimate effect at the extremities of the corresponding 
efferent motor nerves. We can imagine many such accidental and unsuspected 
sources of excitement ; a casual touch, the varying contact of the bed-clothes, the 
bite of a flea, for aught I know to the contrary, may suffice. Even the passage of 
faeces or of flatus along the lower bowel, or of urine through the urinary passages, 
may be enough (as we are taught by unquestionable facts) to produce these move- 



334 PARAPLEGIA. I 

ments. They are more readily excited, ceteris paribus, in proportion as the inter- a 
fering influence of the will is more completely cut off. j) 

I knew a gentleman, who had retired from the medical profession, and who, j: 
though not paraplegic, laboured, T believe, under some morbid condition of the spine, p 
He had been, in early life, a hard drinker^ and had suffered delirium tremens. Every \ 
night, sometimes more than once or twice, the trunk of his body, and all his hmbs, ij 
became for a while fixed and stiff, from rigidity of the muscles. A few days before I 
his death, he told me this curious fact. Whenever he scraped his shoes on the I 
scraper at the door, his leg flew up, with a spasmodic suddenness from the iron, not- V 
withstanding his endeavour to prevent it. He died suddenly. I believe he was i 
found dead in his bed. \ 

In some cases of paraplegia involuntary retractions of the palsied hmbs can be 
excited ; in some cases they cannot. When the influence of the cerebrum is quite 
excluded by the operation of disease affecting the spinal cord itself, then is the sus- 
ceptibihty of excited movements the most lively. But the increased susceptibility j 
which has this inverse relation to the voluntary power, is limited to that portion of 
the body, the nervous arcs belonging to which lie beyond the seat of the disease ; , 
more distant, I mean, from the brain. Hence it follows that we may determine, i 
approximately, the place of the disease, by the test of these reflex actions. The I 
mischief may be situated, or may extend, so low down, that there are no unin- i 
terrupted nervous arcs below it. Supposing it to lie as low as, or to reach, the com- 
mencement of the cau3a equina, we should have no involuntary movements. 
Conversely, when no involuntary movements can be excited, the spinal disease is, 
at least, as low as the upper lumbar vertebras. Thus, I say, we have another mode, 
in addition to those pointed out in a former lecture, of determining, in a given 
case of spinal palsy, whereabouts, or to what extent, the cord is implicated in the 1 
disease. 

We do not so often observe these reflex movements in cases of hemiplegia ; 
apparently for this reason, that in hemiplegia the sensorial influence is not, usuafly, 
so completely shut out as it is apt to be in paraplegia. Yet I have seen some of 
these phenomena in several hemiplegic patients. One of them, whose right hand 
and arm were quite passive under the strongest efforts of his will to stir them, took 
notice himself, as did his nurse, that whenever he yawned and stretched himself the f 
fingers of the palsied hand participated in the action, and were thoroughly.extended : ' 
and I could, by tickhng the sole of his foot, excite some starting of the leg, long 
before any power of voluntary movement returned. 

Emotion has sometimes the same singular effect upon limbs and muscles over i 
which volition has no dominion whatever. An artist with whom I am acquainted, i 
and whose arm was almost completely powerless after a recent attack of paralysis, 
so that no effort of his will sufficed to raise it from his side — was one day startled, | 
as he was hobbling across a road, by the unexpected approach of a carriage. He i 
noticed, with wonder, that during his endeavours to get out of the way, the palsied ' 
arm was suddenly jerked up above his head. But he could not again lift it there ' 
after the fright was over. 

Paraplegia has been ascribed to some primary morbid condition of the nerves \ 
which belong to the spinal cord. That the functions of the efferent, or motor, nerves i 
may be impaired, and even arrested, by exposure to cold, and by other injurious 
influences, is both possible and probable. But a diseased or disordered state of the 
afferent nerves has been assigned as a cause of the palsy. This is less clearly con- 
ceivable. Coexisting disease of the kidneys, and coexisting enteritis, have been i 
thought sufficient to produce and keep up a paralytic condition of the lower hmbs. 
The extremities of certain incident nerves being affected, a morbid impression is 
transmitted to the cord, suspensive of its central function. The efforts even of voli- 
tion, which come from the brain, are no longer successful. Such is the theory. I 
do not say it is an erroneous theory ; but I am bound to tell you that I think it 
unproven. My own experience has furnished me with no facts which go to j 
support it. 

^ Do not forget the important fact that, in many, nay, in most cases of paraplegia, ; 



PARAPLEGIA. 



335 



the urine at length becomes ropy, alkaline, and stinking ; and that the bladder, after 
death, presents appearances such as chronic inflammation might produce ; rough- 
ness and redness of its inner surface, and thickening of its coats. What may be the 
order and relation of these changes, I confess I do not know : whether the quality 
of the urine is first altered, and then the bladder suffers from the perpetual contact 
of this unnatural secretion ; or whether the bladder becomes diseased in consequence 
of the palsy, and pours forth unhealthy mucus, whereby the quality of the urine is 
affected ; has not, I believe, been clearly ascertained. The minute particulars of 
such cases require more careful investigation than they have hitherto received. In 
support of the latter proposition I have heard the following facts affirmed. The 
urine voided being alkaline, the bladder was washed out bythe injection and with- 
drawal of warm water. Then the next portions of the urine that descended from the 
kidneys were immediately removed and tested, and found to be acid. So also, after 
death, the urine has proved to be alkahne and mucous in the bladder, acid in the 
pelvis of the kidney. But in other instances of paraplegia, the urine is said to have 
been secreted alkaline. Disease, in these last cases, *hay perhaps have been propa- 
gated from the bladder, backwards. Or the disorganization of the bladder, and the 
alkahne quahty of the urine, may both have been common results of the interruption 
of the nervous influence. I would suggest to you to inquire, whenever opportunities 
occur, at what period of the spinal disease or injury the urine began to be secreted 
alkalescent. 

We have reason to beheve that the defect in some of these cases of paraplegia is 
merely functional : independent, I mean, of any such change in the nervous matter 
as is cognizable by our senses. It may be brought on by various causes : by cold ; 
by intemperance in drinking ; by excessive sexual intercourse : or, still more surely, 
by self-abuse. I have had the last cause assigned to me voluntarily by patients 
themselves. In such cases we may presume that the loss of function is confined to the 
spinal marrow. But there is another way in which paraplegia may be accounted 
for, although its physical cause is very liable to be overlooked. It may result from 
serous eff^asion into the spinal canal ; which effusion may have originated there, or, 
what seems sometimes to be more probable, may have been poured out within the 
cranium, and descended by the force of gravity to the lower part of the cavity of 
the spine. Dr. Bail lie read a paper on this subject before the College of Physi- 
cians : it is contained in the sixth volume of the Medical Transactions. He was 
not the first person to whom this mode of explaining certain obscure cases of para- 
plegia suggested itself; but he was the first I believe who pubhshed upon it. This 
effusion may very readily be overlooked. Commonly the brain is examined first ; 
and no great attention is paid to the escape of fluid from the vertebral canal. It 
would be better to lay open the spinal cavity first, at its lowest part, and to puncture 
the theca, and then to observe what quantity of fluid runs out when the body is 
placed upright. There should be a certain quantity : but if much serum so escaped, 
we might conclude that it had existed in hurtful abundance during life, and had 
caused the paraplegia. In most of these obscure cases you may trace some head 
symptoms ; giddiness, transient confusion of thought, loss of memory; and it really will 
be worth your while to make the examination in the way I have pointed out, when- 
ever you have occasion to inspect the body of a patient who has died paraplegic. 

I regret very much that I had not the opportunity of doing this in the case of the 
man whom I had been for some time watching in the hospital. 

Cases, such as I have now been describing, are by no means uncomijion. They 
are usually slow and tedious; and you will be called upon to administer to their 
rehef. 1 need not repeat the caution which I have several times given, in respect to 
the condition of the bladder ; you must take care that it does not become over dis- 
tended with urine ; and you must enjoin strict attention on the part of the jiurse as 
to keeping the patient clean and dry. Friction along the course of the spine ; blis- 
ters to the loins or sacrum, frequently repeated ; issues; and electricity: all these 
means you will generally have opportunity enough for trying, and for regretting 
their inutility. In such cases it may sometimes be warrantable and proper to employ 
strychnia ; a poison which mainly affects the spinal cord, causing, when given in a 



336 



FACIAL PALSY. 



sufficient dose, tetanic spasms of the limbs, with very little or no affection of the sen- 
sorium. I have heard of some striking instances of recovery from paraplegia undei 
the exhibition of this drug. I wish I could tell you that I had ever seen such. Let 
me caution you against its indiscriminate use ; or rather its abuse. No good can 
reasonably be expected from it, but much harm, unless the cord be free from organic 
disease. Even then I would not advise you to begin with a stronger dose of strych- 
nia, or of the sulphate of strychnia, than the twelfth part of a grain every six hours : 
this may be gradually and cautiously increased, until it gives rise to twitchings of the 
hmbs, or to some other obvious effect. The twitching is usually confined to the 
palsied limbs. This shows that it results from the agency of the remedy upon the 
excito-motory system, of true spinal marrow ; of which the reflex function is always 
more readily excited when the sensorium has lost its customary controlling power. 
When this symptom occurs, you had better go on with the same dose ; it would be 
unsafe to increase it : and the progress of the case will soon inform you whether 
any benefit is likely to accrue from a continuance of the medicine. The out-patient 
now attending has taken the strychnia. It made the palsied limbs start and extend 
themselves ; but no permanent power has been gained. 

There is one other drug which I should recommend you to try in such cases, viz. ; 
the tincture of cantharides. It certainly has sometimes a very beneficial- effect. 
Generally, when it does good, it acts as a diuretic ; and Dr. Seymour has thrown 
out a suggestion that it is most likely to be useful in those cases of serous effusion 
into the spinal cavity, of spinal dropsy^ which T just now described. He recom- 
mends the tincture as a good diuretic in several forms of dropsy : and supposes that 
it benefits paraplegia by tending to produce absorption of the serum effused within 
the vertebral canal. 

Moreover, there is another principle upon which this medicine may be sometimes 
advisable. Cantharides are well known to have a pecuhar effect upon the bladder; 
which effect is doubtless produced through the corresponding part of the spinal 
cord. If, by means of the Spanish fly, we can excite, though but from time to time, 
the function of that part, we may obviate, in a great degree, the distressing conse- 
quences of incontinence of urine, arising from paralysis of the sphincter vesicae. 
Dr. Marshall Hall relates a very interesting fact, bearing directly upon this^ point. 
A young lady had a tumour within the tenth and eleventh dorsal vertebrae. It 
gradually, but completely, severed the spinal marrow, and induced perfect para- 
plegia. The bladder lost its power of retention. But on giving a dose of the 
tincture of cantharides, the power of retaining the urine was always restored for the | 
time. That power would cease, and again be restored, on suspending and repeating ; 
the medicine. { 

Dr. Hall remarks that the cantharides obviously acted through the segment of the | 
excito-motory system left below the division of the spinal marrow. | 

The tincture may be given in half-drachm doses. I 

The forms of paralysis that have hitherto been noticed are forms of partial para- ' 
lysis. When the palsy is still more limited, although the epithet partial Avould be 
equally applicable, the term local palsy is more commonly used. There is one of 
these local palsies which is exceeding interesting, and of much importance : I mean ! 
palsy as it affects, exclusively, one side of the visage : facial palsy. It is sometimes 
called, not very correctly, paralysis of the portio dura of the seventh nerve. The 
most common kind of facial palsy is indeed paralysis of the muscles supplied by 
that nerve. But the word paralysis is misused when it is intended to express any 
other loss of function than that of the faculty of motion in muscular parts. It is 
incorrect to speak, as some authors do, of palsy of the kidney ; it is equally inexact 
to speak of palsy of a nerve. 

I say that facial palsy, and facial anaesthesia (for the two should be considered 
together), are very interesting affections, because they elucidate, in the human 
subject, some of the most curious speculations of modern physiology : and they are 
important affections for you to study and understand, inasmuch as, though always 
distressful and alarming to the patient and his friends, and sometimes, indeed, in- 



FACIAL PALSY. 



337 



dicative of extreme danger, they often are merely inconvenient and disfiguring, and 
bespeak no peril at all. 

Let us first consider that affection in which the majority of the muscles on one 
side of the face alone are palsied. I have already briefly touched upon this form 
of palsy when it constitutes a part of hemiphlegia. But it is of more consequence 
to attend to it when it occurs without any similar affection of the limbs. If the arm, 
or leg, or both, are paralyzed at the same time with one side of the face, we know 
that the whole results from disease in the brain, or in the upper end of the spinal 
cord. But it is not necessarily so when the face alone is palsied ; and it is often of 
great moment to the comfort and the safety of the patient, that we should be able to 
tell whether the palsy does imply disease within the skull, or not. 

The appearance presented by patients affected with facial palsy is peculiar, and 
very striking. From one half of the countenance all power of expression is gone ; 
the features are blank, still, and unmeaning. The other half retains its natural 
cast, except that, in some cases, the angle of the mouth on that side seems drawn 
a little awry. This is apt to be mistaken for proof of a spasmodic condition of 
that part; but it is owing simply, as I stated before, to the want of the usual 
balance or counterpoise from the corresponding muscular fibres of the palsied 
side. The patient cannot laugh, or weep, or frown, or express any feeling or 
emotion with one side of his face, while the features of the other may be in full play. 
One half of the aspect is that of a sleeping, or of a dead person : the other half is 
alive and merry. The incongruity would be ludicrously droll, were it not so 
frightful also, and distressing. To the vulgar, who do not comprehend the pos- 
sible extent of the misfortune, the whimsical appearance of such a patient is 
always a matter of mirth and laughter. On the other hand, his friends and rela- 
tions imagine that he has had a fit, and are in great alarm for his life. In the 
majority of these cases there is not, however, any real danger of that kind to be 
apprehended; a circumstance which, of itself, would render the exact diagnosis 
of the complaint peculiarly interesting. In general there is no deficiency of sen- 
sation. And, vice versa, we sometimes have loss of sensibihty in the same parts, 
without any diminution of the power of motion. The best way, I beheve, to 
place the phenomena of these curious affections plainly before you, will be by 
examples. 

A housemaid, Jane Smith by name, twenty-eight years old, became one of my 
out-patients at the Middlesex Hospital, with the following symptoms. She had lost 
all power of moving the right side of her face. When she endeavoured to raise 
her eyebrows, the right side of the forehead remained smooth, and the left was 
wrinkled. When she attempted to close her eyes, the right eye was but partially 
covered, the eyeball rolling upwards, and carrying the cornea within the curtain 
of the upper lid, which descended a httle to meet it. When she tried to snuff in 
air through the nose, not being able to keep the right nostril stiff and open, its sides 
came together, and no air passed up on that side. When she smiled, the right side 
of the face remained perfectly still, like a mask : and it wore at all times a vacant 
and inanimate character. When she was told to perform the action of blowing, her 
right cheek was puffed out like a loose bag, and the breath issued, whether she 
would or no, at the right angle of her mouth. The same thing happened with her 
food and drink ; she could not prevent their escaping at the right corner of her 
mouth : nor could she convey morsels of food from the right to the left jaw, without 
the aid of her hand applied externally in support of the paralyzed cheek. The 
masseter and temporal muscles, however, acted as strongly on the one side as on the 
other ; she could chew perfectly well on the palsied side, and the sensation of the 
palsied parts remained perfect ; and there was no paralysis of any other part of the 
body. 

All these phenomena are invariably met with in all complete cases of this kind. 
I will contrast them with the phenomena presented by another of my patients 
who was in the hospital, and whose name was Ann Church. I give their names, 
that I may the more readily distinguish the one from the other. When this 
woman. Church, applied for admission, she complained of intense pain, with 
23 2d 



338 



FACIAL PALSY. 



some swelling in the right temple, and extending thence generally over the right 
side of the face and head. It was soon discovered, however, that although she 
complained of most severe pain in these parts, they had entirely lost their ordinary 
sensibility to external impressions. She felt nothing when her forehead, or cheek, 
or nose, or chin, was touched on that side. In short, there was complete anses- 
thesia of the right half of the face ; just as in Smith's case there was complete 
palsy. The insensibility was very exactly limited to the right half, and termi- 
nated abruptly at the middle line. It was remarkably evident in a part in respect 
to which the bystanders could scarcely be deceived, even if there had been any 
reason (which there was not) for distrusting the patient's own statement. The 
surface of the eyeball is proverbially sensitive, even to shght impressions. But 
you might place your finger upon this woman's right eye, or you might brush it 
with a feather, without giving her the smallest pain, or producing any sensation at 
all : whereas, on the left side, the lightest touch caused involuntary shrinking, 
and closure of the eyehds, and a gush of tears. She declared also that she had 
no feeling in the right half of her mouth ; she neither tasted sapid substances, nor 
was she at all conscious, from any sensation produced by them, that they were 
placed there. Her Hps on the same side, were equally destitute of sensibility; 
so that when she drank, having no perception of the contact of the cup with her lips 
beyond their middle point, she felt as if she were drinking from a vessel with a 
broken rim. This is a circumstance which all persons who are thus affected are 
much struck with : and it almost always forms a part of their voluntary account 
of themselves. 

Besides this defect of sensibility, the power of contracting the masseter and tem- 
poral muscles on the right side was entirely abolished in this patient. You may 
deceive yourselves on this point, if you do not investigate it carefully, and with 
certain precautions. At least I have known persons doubt, because, having directed 
the patient to open and shut his mouth, they have confounded the movement of the 
whole jaw with the action of the masseter muscle. But if you tell the patient first 
to close his mouth, and then to perform the action of grinding with his teeth, 
placing your fingers at the same time on the corresponding muscles on each side, 
the difference, when it exists, will be very striking. In the woman of whom I 
speak, no swelling of the masseter or temporal muscle on the affected side took place 
when she forcibly closed her jaws. There was no other paralysis. 

Now we cannot separate the physiology from the pathology of such affections as 
these. Nor ought we. The morbid conditions of which the two cases just de- 
scribed furnish samples, illustrate in a very beautiful manner the modern doctrine 
respecting the special uses of particular nerves. In the first of the two cases the 
palsy resulted from suppression of the function of the hard portion of the seventh 
pair of cerebral nerves ; and the anaesthesia, in the last of the cases, depended upon 
suspension of the function of the fifth pair. You know the experiments performed 
upon Kving animals have proved that the division, by the scalpel, of the portio dura, 
before it spreads out into that remarkable nervous net-work on the side of the face, 
paralyzes all the muscles the combined play of w^hich gives variety and significant 
expression to the countenance ; and that, on the other hand, the division of the fifth 
nerve deprives the same parts of their sensibility. In these two cases, and in such 
as these, for they are by no means infrequent, a similar set of experiments upon the 
same nerves, in the human living body, is performed before our eyes by the agency 
of the disease, or accident; and the resuk justifies most completely those conclusions 
Avhich had been deduced in the first instance, from contrived observations made upon 
the lower animals. ■» 

There is one point in the history of these cases upon which I must dwell a mo- 
ment longer; for it is a most interesting point. That the condition of the temporal 
and masseter muscles should be reversed in two patients so oppositely situated, was 
no more than might have been expected. But in each these muscles were affected 
in a manner the very contrary of that which the general circumstances of the case 
would, a priori, have prepared us to anticipate. Where the superficial muscles 
^ere paralyzed, and the principal movements of the face suspended, there the mas- 



FACIAL PALSY. 



339 



seter and temporal muscles were in full power and action ; and where the loss of 
sensation was the predominant phenomenon, and the ordinary motion and expression 
of the countenance remained, there these muscles were in a state of complete palsy. 

A few years only ago, this difference and apparent inconsistency would have been, 
quite inexphcable. The progress of modern science has removed the difficulty, by 
establishing a general agreement between {he functions of different nerves, and cer- 
lain observed peculiarities in their anatomical relations and arrangements. 

Suffer me to remind you (for I know that these interesting points of physiology 
must have already been taught you) that the nerves which proceed from the spinal 
column on each side are connected with it by two fascicuh of nervous fibrils — two 
roots, as they are metaphorically called — of unequal size ; that when the larger of 
these, which is situated posteriorly, and is furnished with a ganghon, is divided in a 
Jiving animal, the parts to which the nerve is distributed lose the faculty of sensa- 
tion, while the power of voluntary motion remains unimpaired ; and that when the 
smaller and anterior, which has no ganghon, is alone cut, the same parts are instantly 
palsied, but retain their sensibility. In other words, the posterior fasciculi minister 
to the faculty of sensation, the anterior to that ol^motion. 

Now the fifth pair of nerves was observed to have a similar origin ; to be com- 
posed, that is to say, of two fascicuh or roots, one larger than the other, and invested 
Math a ganglion ; the other smaller, and having no ganglion. It was natural to infer 
that the function of these roots would be analogous to those of the corresponding 
portions of the spinal nerv^es ; that the ganglionic fasciculus would relate to sensa- 
tion, and the other to motion. And such is found to be the case ; and the arrange- 
ment here is very curious. The smaller portion of the fifth nerve is exclusively 
expended upon a very few muscles ; viz., the masseter, the temporal, two pterygoid 
muscles, the circumflexus palati, and the tensor tympani. The action of the first 
two of these, of the masseter, and temporal muscles, is obvious to common observa- 
tion ; and therefore their condition is noticed in such cases as I have related. 
Again, these very same muscles have been shown, by careful dissection, to receive 
no nervous branches from the seventh nerve, which is a motor nerve, and which 
ramifies so abundantly upon the superficial muscles of the face. 

It was to be expected, therefore, that any diseased state confined to the portio dura 
of the seventh nerve, would leave the temporal and masseter muscles fully effective; 
and that disease involving the fifth nerve, but leaving the seventh untouched, would 
destroy, not only the general sensibihty of the face on that side, but also the power 
of contracting these particular muscles. And this was thoroughly exemphfied in the 
two cases that I have detailed. The girl Smith had total palsy of the superficial 
muscles ; but sensation, and the action of the deeper-seated muscles, continued per- 
fect: while in the woman Church there were default of sensibility, and paralysis of 
the temporal and masseter muscles : but the movements of the superficial muscles 
were unimpeded. 

Total interruption of the function of the portio dura will paralyze these superficial 
muscles of the face : and such interruption may be occasioned either by sudden 
injury done to the trunk of the nerve ; or by disease affecting its proper structure ; 
or by pressure, the consequence of disease in the parts contiguous to it. And it is 
of great importance to observe that the morbid condition which causes the interrup- 
tion may be situated in any part of the course of the trunk of the nerve : while it is 
yet within the cranium ; or during its passage through the petrous portion of the 
temporal bone ; or after it emerges upon the face, through the stylo-mastoid foramen, 
to be ultimately spread in meshes over the cheek and temple. The nerve is often 
compressed or hurt while still within the skull ; but in most cases of this kind other 
portions also of the nervous matter are involved in the mischief, and other sets of 
voluntary muscles testify this by their immobility or their irregular action. This is 
sometimes the case when facial palsy occurs as a part of hemiplegia. In many 
instances, however, of hemiplegia, there is but slight distortion of the countenance, a 
mere hanging of the cheek, with no paralysis of the orbicularis muscle of the eye. 
In these cases, it has been suggested to me by my colleague, Dr. Todd, that the 
seventh nerve is probably not affected at all, but the motor branch of the fifth nerve 



340 



FACIAL PALSY. 



only. When the facial muscles alone are paralyzed, it happens in a great majority 
of instances that the nervous function is interrupted in that part of the portio dura 
which Hes incased in the bone, or in the more exposed part which issues in front of 
the ear : and hence it arises that this particular form of palsy is, in general, unat- 
tended with any danger to life. 

The physical cause of this remarkable disfigurement, and the true explanation of 
its prevaihng immunity from danger, w^ere first pointed out by Sir Charles Bell : 
but both the existence of the malady as a distinct form of disease, and its compara- 
tive harmlessness of character, had been observed and described some years previ- 
ously : although the reason neither of the one nor of the other was at that time 
understood. Dr. Powell had narrated, in the fifth volume of the Transactions of 
the College of Physicians^ three marked instances of this form of local palsy ; and 
had noticed at the same time its apparent independence of any apoplectic tendency, 
or cerebral disease. 

The exciting causes of the complaint are various. Sometimes it is the conse- 
quence of mechanical violence, by which it is plain that the nerve has been lace- 
rated, or otherwise injured. Sir Charles Bell, to whom we are indebted for much 
information on the subject, mentions several examples of this kind. In one a man 
was shot by a pistol-ball, which entered the ear and tore the portio dura across at its 
root. In another, the patient was gored by an ox ; the horn of the animal entered 
beneath the angle of the jaw, and came out in front of the ear, tearing the nerve 
across. In a third, the nerve was divided by a surgeon's scalpel, in an operation 
for the removal of a tumour which lay above and around its course. In all these 
cases the injury was external and obvious. In a fourth the palsy followed a blow 
on the ear which caused hemorrhage from that part : here probably the nerve was 
hurt in its passage through the bone. Some time ago, a man was brought into the 
Middlesex Hospital who had fallen from a height, upon his head. The muscles of 
the left side of the face were paralyzed. He died in a few days ; and examination 
of the head showed a fracture in the base of the skull, passing through the petrous 
portion of the temporal bone, and rending the seventh nerve at its entrance into the 
meatus auditorius intern us. In the year 1832 I had a patient (Richard Hills) in the 
hospital with the same kind of paralysis, which seemed, in him, to have been occa- 
sioned by a mere shock or jar. He was a coachman, and one day, when he was 
off his box, his horses started away, and he ran to their heads to stop them, but was 
thrown down in the attempt, striking his hip and elbow. He received no blow on 
the head at all. Three hours afterwards he found that he could not spit properly. 
The affection is not unfrequently discovered by that circumstance. He could not 
avoid spitting on his clothes on one side : and he could not whistle. Another cir- 
cumstance worthy of notice took place in this man, which often, though not always, 
happens in these cases, and which I did not mention before. He remained for about 
two months in the hospital ; and regained, during that time in some degree, the 
power of exercising the affected muscles ; but he still was unable to bring the right 
eyelids together. The eye itself was unharmed. After he was made an out-patient 
he resumed his functions on the coach-box ; and his eye, permanently half-open and 
unprotected, was more exposed to cold and to currents of wind than it had been 
when he was an in-patient. Moreover, he got drunk ; and he soon presented him- 
self again with universal redness and inflammation of the conjunctiva. Sometimes 
the inflammation in such cases produces opacity of the cornea and a total loss of 
vision. This is one of the worst consequences of facial palsy. Fortunately it is 
only an occasional consequence : and it will occur or not, according to the quantity 
of motion which remains to the eyelids, and the degree of exposure to the ordinary 
causes of inflammation. 

Sometimes the palsy depends upon manifest external disease; sometimes upon 
disease which is hidden, and probably internal, in the bony canal. Sir C. Bell 
describes an instance in which it accompanied the disorder called the mumps. Dr. 
Maiden, of Worcester, witnessed another in which a fixed, hard, indolent tumour 
had formed between the ramus of the lower jaw and the mastoid process of the 
temporal bone. As this tumour gradually subsided, the palsy disappeared. In each 



FACUL PALSY. 



341 



of Dr. Powell's three cases the affection was apparently caused by exposure of the 
side of the head for some time to a stream of cold air. A medical acquaintance of 
mine residing in London, had a patient at Greenwich, whom he visited daily. It 
was cold weather ; and on one occasion, as he was returning in the cabin of a steam- 
boat, he was sensibly incommoded by a keen east wind, which blew through an open 
window directly upon his ear. The next day he presented himself to me with that 
side of his face fixed in the manner I have been describing. Exactly the same 
mishap befell a Scottish physician while travelling to London by a coach ; and sent 
him in great alarm to Sir C. Bell. Some years ago a marked example of facial palsy 
occurred in one of my hospital patients ; it appeared to be owing to his having been 
constantly in the streets for some days without shoes or stockings, during a cold thaw. 
It may be presumed that in these instances some swelling was produced in the soft 
parts around the nerve, compressing it where it Hes within the unyielding bone. 
Exposure to cold in this way is the commonest of all the exciting causes of the com- 
plaint, and cases thus arising are more obedient to treatment than most others. Pro- 
bably some of you saw a female patient who came under my care in the hospital in 
May last (18;38), in whom facial palsy had existed on one side for eighteen years. 
When about three years old she had the measles ; and a scrofulous tumour formed 
behind the ear, and broke ; and after some time, a portion of carious bone came 
away. Then the wound healed (of which deep traces are still visible) ; and the 
peculiarity of her features was observed. There are sliU other cases in v/hich we 
fail to discover any direct explanation of the paralysis, either in the history of the 
patient, or in his physical condition. In the girl Smith, whose symptoms I stated 
in detail as an example of the appearances uniformly present, the malady came 
on without any obvious cause, and it resisted all the means employed for its 
removal. 

That the greater number of cases of this kind are free from serious peril, is a fact 
of great practical importance. It enables us to quiet the alarm of the patient and of 
his family: and it regulates in many instances the treatment; rendering it less 
severe than it might and ought to be, if the palsy were really the harbinger of apo- 
plexy. At the same time you should not be ignorant that a similar limitation of 
paralysis to the particular muscles suppHed by the portio dura is sometimes (though 
rarely) observed, when the disease has a more inward origin ; when it affects and 
involves the brain itself. The following case caused me much anxiety, for the sub- 
ject of it was a personal friend of mine. — I was summoned to his house in the 
autumn of 1829, and found him with complete palsy of the left side of the face. It 
had existed a day or two. I shall not describe the appearances and symptoms that 
resulted from the paralysis ; for they were precisely the same as were presented by 
the girl Smith ; and they are always, and necessarily, very much ahke. But though 
the palsy was strictly limited to this set of muscles, there were other symptoms pre- 
sent which indicated that the interruption of the functions of the portio dura was 
connected with some morbid condition within the cranium: nausea and vomiting, 
twitchings of the muscles of the other side of the face, great drowsiness, and a slow 
pulse, 48 only in the minute. He lurched also, and staggered as he walked ; but 
he distinguished this from the reeling of vertigo, and denied the latter sensation 
altogether. He was deaf too, on the affected side. 

His previous history did not tend to diminish" the fears which his actual state 
excited. 

In the preceding February he had been attacked, rather suddenly, with intense 
pain just above the right eyebrow, and became extremely drowsy. Being desirous, 
on account of these feelings, to excuse himself from a dinner engagement, he found 
that he was unable to write a proper note : he could not remember how he ought to 
express himself. 

All these symptoms soon passed off; after the operation, I beheve, of an emetic. 
But he had another attack of the same kind in the subsequent May : the same 
severe pain over the right brow, with great drowsiness and confusion of mind. He 
could not recollect the first line of the iEneid. He wished a friend to look at the 
signatures of some letters that had arrived : and though he knew the root, he could 

2d3 



342 



FACIAL PAX.SY. 



not tell how the word he wished to use was formed ; whether it was signition, or 
signation, or signature. The digestive organs on this occasion were made the object 
of treatment, and he soon got well. 

There was another instructive part of his history ; and therefore I mention it. 
Before these attacks he was in the habit of eating and drinking freely ; and his 
power of digestion was supposed to be enormous. After the attack in May he 
commenced a strict course of temperance. He drank no wine till three or four, 
days before the occurrence of the facial palsy: he had then taken it again, and had 
about four glasses daily ; and on one of the days he drank two glasses of champagne. 

It was of some moment to this gentleman, not only that he should recover, but 
that he should recover quickly. He had been appointed by government to a mission 
to Ceylon, and all his equipment was already on board a vessel, which would sail in 
a fortnight. 

Cupping behind the ears, bhstering, purgatives, and small doses of calomel con- 
tinued till the gums were slightly sore, removed the paralysis, and all the other 
symptoms, in about ten days. He went to Ceylon, and performed his mission so 
ably that after his return the government appointed him to one of far greater import- 
ance in India, where he now is. He has remained perfectly well ; and possesses 
one of the clearest and strongest intellects that I am acquainted with. 

I must trouble you with one more case, to complete the history of this disease : a 
case in which the cause of the facial palsy was situated within the cranium and 
proved fatal, and becarne visible after death. 

Samuel Dobey, a tailor, fifty-seven years old, was admitted under my care into the 
hospital, in February, 1833, with complete palsy of the muscles supphed by the 
portio dura on the right side ; and of no others. There were symptoms enough, 
however, to show that some serious mischief was going on within the skull. He 
suffered intense headache, more on the left than the right side ; was dizzy and stag- 
gering ; and could not get to the ward without being led. 

The palsy had come on about ten days before, in the night. He found when he came 
down stairs the next morning that he could not spit as usual, and his friends observed 
the unnatural state of his features. He had had no fit, nor loss of consciousness ; 
but he thought his memory was failing. At the time when the paralysis was first 
noticed, he had some numbness and tingling of the right arm, extending to the last 
two fingers. He was quite deaf in the right ear. This is a point deserving attention 
in such cases. The deafness, when it occurs, marks an affection of both the por-r 
Hons of the seventh nerve ; and therefore indicates the probability of an internal 
cause. 

The whole progress of this case was very interesting; but I must confine myself 
to those circumstances which bear upon our present topic. He lived about a month 
after his admission, and during that interval he suffered great pain in the head, 
was delirious at times, and at other times in a state of coma : at one period he 
suddenly presented the ordinary symptoms of apoplexy, from which he partly 
recovered. 

I found a cancerous tumour occupying the right hemisphere of the brain ; at its 
under part was an apoplectic clot, as big as a hazel-nut. I found, also, a very satis- 
factory explanation of the deafness and of the facial palsy which had been noticed 
during his lifetime. The portio dura and the portio mollis, where they emerge as 
distinct cords from the medulla oblongata on the right side, were adherent to each 
other. The portio dura was both harder and larger than the corresponding nerve 
on the opposite side, while the portio mollis was wasted and diffluent. The same 
change was traced up to their entrance into the petrous portion of the temporal bone. 
Immediately over the medulla oblongata, and in a vertical line above the point of 
emergence of the seventh pair of nerves, a nipp4e-hke portion of brain projected 
downwards, and had apparently communicated pressure to these nerves ; and this 
projection from the lower surface of the brain seemed to have been produced by the 
general pressure resulting from the growth of the tumour. 

The remarks which I have been applying to palsy of these parts hold true also in 
respect to their loss of sensibility. The anaesthesia may or may not portend danger 



LOCAL ANAESTHESIA. 



343 



to life, according as the interruption of nervous function on which it depends is 
situated more or less near to the origin of the fifth pair of nerves in the brain. The 
patient, Church, whose case I have several times referred to in this lecture, left the 
hospital with the sensibihty of her face nearly as perfect as ever. The treatment 
consisted in. local blood-letting and counter-irritation. She had erysipelas of the 
head while in the hospital, and was in some danger from that complaint, which was 
attended with a good deal of fever and delirium. With the exception of the dehrium, 
which belonged no doabt to the erysipelas, there was no reason to suspect any affec- 
tion of her brain. 

I have incidentally adverted to the plan of treatment to be pursued in these cases 
of facial palsy. When the complaint is recent, and has an obvious cause, the appro- 
priate remedies will readily suggest themselves. When, for example, it has come 
on after exposure to a current of cold air, or after a blow, or any circumstance likely 
to give rise to inflammation, you must treat the case as you would treat inflammation ; 
bearing always in mind that a small amount of disorganization, a little thickening or 
induration of the parts around the nerve, may render the deformity and the incon- 
venience permanent. If there be inflammatory fever, bleed from the arm : if there 
be not, take blood from the neighbourhood of the affected nerve by cupping : apply 
fomentations ; or, what is better in these cases, conduct the steam of hot water against 
and into the ear : and administer mercury so as just to touch the gums. I should 
always take this latter precaution, lest any effusion of lymph should cause abiding 
pressure on the nerve. If the palsy gives w^ay before the gums become tender, the 
mercury need not be pressed further. 

Where there is any ground to suspect that the brain is imphcated, the treatment 
just described must be pursued with greater dihgence, and with such modifications 
as the nature of the case may require. If there be evidence of chronic disease in 
the petrous portion of the temporal bone, such as tenderness of the mastoid process, 
deafness, a protracted discharge from the ear, and an imperfect state of the membrana 
tympani, we can scarcely expect much good from very active treatment. We must 
then have recourse to counter-irritation, and such other measures as I spoke of when 
the subject of otitis was briefly considered. 

The examples which are met with, of local palsy and local ansesthesia, are 
numberless ; but those which I have mentioned are the most common and the most 
important. They are always deserving of attention ; but more so when any sus- 
picion arises that they may be connected with cerebral disease. Sometimes they 
evidently have no such connection. In the month of November, 1834, a coachman 
became my patient in the hospital, with incomplete paralysis affecting some of the 
muscles of the right leg alone, with numbness of the foot. He could both stand and 
walk ; but on advancing that leg, his foot flapped suddenly down, and he could not 
deliberately direct and plant it, like the other. His general health was quite good ; 
he had no headache, nor giddiness, nor palsy of any other part. But a month ago 
he had been sitting with the right leg thrown over the opposite knee ; and he con- 
tinued in that position until the foot felt numb and tinglinof, and was (what is called) 
asleep; and it had remained in the same condition from that time. After some 
general treatment (cupping and purgatives) before he came to the hospital — treat- 
ment which was quite proper in the way of precaution, but which was probably, in 
truth, unnecessary — I had his leg electrified; and in about ten days the sensation 
and the power of the hmb were almost restored. Mr. Shaw mentions a somewhat 
similar case, in which ansesthesia of the hand was produced by strong pressure made 
upon the wrist. 

There are some very curious facts connected with ansesthesia, showing that the 
voluntary exercise of the muscles is regulated in some measure by the sensations of 
the hmb that is employed. The sense of resistance prompts to such contraction of 
the muscles as is required to balance that resistance ; reminding the will (so to speak) 
of the necessity that exists for its perpetual and vigilant operation. Continued 
volition is essential to the continuance of the muscular tension. Thus Dr. Yelloly 
describes a woman who had no power of feeling in her hand and fingers, although 
the power of moving them, and of grasping any objects, was entire. This woman 



344 



REMARKABLE CASE&. 



found that she could carry glasses or plates in that hand very well and safely, if she 
continued to look at and attend to them : but if her eyes were turned another way, 
as she did not feel what she held, she was very apt to drop it. Dr. Ley met with 
just such another case. A woman had defective sensibility on one side of the body : 
she could hold her child in the arm of that side so long as her attention was directed 
to it ; but if surrounding objects diverted her from taking notice of the state of her 
arm, the flexor muscles soon began to slacken, and the child was in danger of falling. 
Ail this is exceedingly curious. 

Andral has recorded a most singular example of local aneesthesia, which preceded 
an attack of apoplexy. The patient lost, from time to time, all sensation in certain 
isolated parts of the skin upon the thorax ; there were five or six of these insensible 
spots, each about the size of a five-franc piece. You might pinch the skin in these 
places without producing the slightest feehng in the patient. In all other parts the 
sensibility was perfect and lively. 

There are other cases also on record, more remarkable still ; in which the patients 
have lost both the power of motion and the faculty of sensation in almost every part 
of the body, and yet have survived for a considerable time. Thus one person 
(whose case is related in the Bulletin des Sciences Medicales for January, 1828,) 
became first amaurotic, then deaf, and then by degrees lost all power of sensation 
and motion except in the tongue and in the muscles of deglutition and respiration. 
His speech and intellects were unimpaired. It was accidentally discovered that a 
small patch on the right cheek retained its sensibility ; and by tracing letters on this 
sensible spot, his wife and children were enabled to interchange ideas with him. He 
died at length, and his body was not examined. 

I shall finish what I have to say on this head, by relating a case of the same kind, 
which occurred under Dr. Abercrombie's notice ; and which we are sure therefore 
would be observed with care, and recorded with fidehty. 

A servant girl, about 20 years old, sprained her back in Hfting some heavy article 
of furniture. She felt no great inconvenience at the time ; but some little w^hile 
after, weakness of the legs came on, and gradually increased to complete paraplegia. 
After an interval, the afiection extended to her arms, and she then had not a vestige 
of motion of any of the parts below the head, except a very shght movement of one 
of the fingers : but the internal functions were all perfect, and her speech was 
distinct, except that in speaking she was sometimes seized with spasmodic twitches 
of the lips and lower jaw. She Hved in that state, without any change of the 
symptoms, and her general health continuing good, for about twenty years. In the 
morning she was taken out of bed, and placed in a chair, so contrived as to support 
her in a sitting postui'e. Her arms rested on a cross board which passed before her ; 
and if by any accident one of them slipped from this support, she had no resource 
but to call for the assistance of another person to replace it. Having been on one 
occasion left alone for about two hours after one of her arms had thus slipped down, 
the hand had become extensively oedematous. In the same manner, if her head 
fell forward upon the thorax, it remained in that position until raised by an atten- 
dant. Her mind was entire. She died after four days' illness with symptoms of 
low typhus fever. You may suppose that Dr. Abercrombie looked with the greatest 
interest for the cause of these most remarkable symptoms. " I examined the body 
with the utmost care, (says he,) along with Dr. Pitcairn, who had been in the habit 
of seeing her for several years ; and we could not discover any disease either in the 
brain or in the spinal cord." 

It is much to be regretted that when this case was under observation, the excito- 
motory functions were not understood, nor attended to. 

I shall next proceed to consider those diseases (and there are several of them) 
which are marked by definite symptoms, which consist essentially in some disturb- 
ance or disorder of the nervous system, but which are not accounted for by any 
physical changes that we can appreciate in any part of that system. After some of 
these diseases we do, to be sure, sometimes meet with morbid appearances in the 
brain or the spinal marrow : but none that are constant, or uniform. 



TETANUS. 



345 



LECTURE XXXII. 

Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology, 
Treatment: Opium; Blood-letting; the Warm Bath; the Cold Bath. 

In those diseases of the nervous system which have hitherto engaged our attention, 
the function of voluntary motion, when it has been affected at all, has mostly suffered 
in the way of diminution, or suspension ; the power of moving has been impaired, 
or lost ; there has been complete or incomplete palsy. Sometimes, indeed, convul- 
sion, or an irregular and involuntary action of the muscles, has also occurred. But, 
distinct from the paralytic affections, there is a class of spasmodic diseases, of which 
it is the main and leading feature, that the function of voluntary motion is (not mor- 
bidly heightened, as in the preternatural strength of a madman ; nor lowered, as in 
palsy; hut) perverted : performed in an irregular and unnatural manner. 

There are two sorts of spasm. One of these is marked by a long-continued con- 
traction of the affected muscles, not rapidly alternating with relaxation : the relaxa- 
tion taking place slowly, after some time : and then, perhaps, the contraction, after 
another interval, coming on again. This is called ^omc spasm; and, by Cullen, 
spastic rigidity. A very famihar example of it is the common cramp of the leg. In 
the other form of spasm, the contractions of the affected muscles take place repeat- 
edly, forcibly, and in quick succession ; and the relaxation is, of course, as sudden 
and frequent. This has been named clonic spasm. We find illustrations ojf it in 
convulsions. 

Sometimes the two are mixed together in the same disease ; certain muscles under- 
going convulsions ^jor clonic spasm, and certain other muscles being affected with 
rigidity or tonic spasm. But it is convenient to keep the distinction in mind. 

We recognize these disorders by the unnatural conditions of the muscles ; but you 
will please remember that the fault lies in the nervous system. 

With regard to spasmodic diseases generally, I may say that some of them con- 
stitute the most appalhng and fatal maladies to which the human body is liable ; and 
some of them, though frightful to look upon, and productive of extreme distress to 
patients and to their friends, are trivial in their consequences, and scarcely ever 
attended with any peril to life. 

I propose first of all to consider one of the most formidable and worst of these 
spasmodic diseases, viz., tetanus ; of which tonic spasm is essentially characteristic. 
Its name is derived from tsivw, to stretch. 

In respect to all those diseases concerning the exact pathology of which we are 
ignorant, and which we identify by the group of symptoms they present, raiher than 
by any organic changes of structure in any part of the body, the most convenient 
mode of proceeding will be, first to describe the distinctive symptoms. 

Tetanus, then, is characterized by an involuntary, long-continued, violent, and 
painful contraction — in one word, by cramp of the voluntary muscles of various 
parts, or of nearly the whole body. 

There is no difficulty in recognizing the disease when it is fully formed. But it 
is of much importance to be aware of the marks of its approach, and of its earliest 
symptoms ; in respect to the treatment to be then adopted. 

In general, the muscles that seem to be the earliest affected are those of the neck, 
jaws, and throat. The patient feels a difficulty and uneasiness in bending or turning 
his head ; and supposes that he has got what is called a stiff neck. He finds also 
that he is unable to open his mouth with the customary facihty. At length the jaws 
close : sometimes gradually, but with great firmness ; sometimes (it is said) suddenly, 
and with a snap. In four cases, perhaps, out of five, the disease begins in this way, 
with trismus or locked jaw ; so that this last is the vulgar name for the complaint. 
Along with this symptom, or very soon after it, the muscles concerned in swallowing 
become affected ; and in a short time there comes on, what is often the most distress- 
ing part of the disorder, an acute pain at the lower part of the sternum, piercing 



346 • TETANUS. 

through to the back. This depends, it can scarce!}^ be doubted, upon cramp of the 
diaphragm. The pain is subject to aggravation in paroxysms ; and each paroxysm 
of pain is attended with increased contraction of the other parts also that are imph- 
cated. The spasm extends to the muscles of the trunk; to the large muscles of the 
extremities ; the muscles of the face ; and last of all, in general, to the muscles of 
the tongue, and of the hands and fingers, which often remain movable at the will 
of the patient, after all the other voluntary muscles of the body have become fixed ; 
and frequently the muscles of the wrists and hands escape altogether. 

With respect to all the muscles involved, from the time when they are first 
affected to the time when the disease is reheved, or the patient dies, they continue in 
a state of contraction, and are swelled and hard in their centres. The jaw, for in- 
stance, can never be completely opened ; and the muscles of the abdomen are so 
rigid as to make it as hard as a board. But, besides this, they are all subject to 
aggravations or exacerbations of the spasm, which occur perhaps ever}^ ten minutes, 
or quarter of an hour, and last for two or three minutes at a time ; and then the 
muscles fall back into the minor degree of contraction in which they were prior to 
the exacerbation. In a very few^ instances only has a perfect remission of the spasm 
been observed. The exacerbations usually begin by an increase of the pain felt at 
the sternum. Sometimes there is no obvious exciting cause of their occurrence ; 
but frequently it is evident that they are brought on by exertions of the body ; even 
by slight movements, such as belong to a change of posture, to the attempt at swal- 
lowing, or speaking. As the disease advances, these paroxysms of aggravation 
become more frequent, and a rapid increase in the frequency of their recurrence is 
one of the most unequivocal signs that the case is severe and dangerous. The more 
speedily the intervals between the paroxysms shorten, the worse. 

It is a curious thing, that the spasm is observed to give way, sometimes at least, 
and the muscles to be relaxed, during sleep. To be sure, in the severer cases, the 
patient is seldom able to sleep ; and it may be that in the less violent instances, the 
spasm abates or ceases, and the exhausted sufferer sinks into repose, in consequence 
of this abatement. However, a similar phenomenon occurs in at least another of 
these spasmodic diseases, as we shall see hereafter. Mr. Mayo had a boy afflicted 
with tetanus, in the Middlesex Hospital. On visiting him one day, he found him 
asleep, and remarked that he lay perfectl}^ relaxed. The abdominal muscles were 
soft and yielding, and had not the least tension. The hoy was awakened, and at the 
instant the full tension of the muscles returned. Not being further disturbed, he fell 
asleep again in a few minutes, when the muscles again slackened; and again, upon 
his being a second time aroused, resumed the state of spasm. 

In most cases the strong muscles of the back are the most affected, and they 
overcome those on the anterior part of the body ; so that sometimes the patient 
during the paroxysm rests only upon his head and his heels, w'hile his body is 
raised into the shape of an arch. This form of the complaint is called opisthotonos^ 
a bending backwards. The sterno-mastoid muscles of the neck have been so 
stretched and misplaced as to become powerful extensors of the head. In a few 
instances the body is bent forwards, so that the head and knees are in contact, and 
the patient is rolled together like a ball. This is called emprosthotonos. In the 
only example of emprosthotonos which I ever saw, these two conditions alternated 
with one another. The patient was a girl in Edinburgh, under the care of a friend 
of mine, who took me to see her. It was a case of hysteria rather than of tetanus ; 
but all at once she would be drawn into a position such, that the top of her head, 
and her feet, were alone supported on the bed, while her body was bent backwards, 
like a bow ; then, after a time, with equal suddenness, the opposite posture was as- 
sumed, her forehead and knees being brought together. Still more rarely the body 
is bent to one side. This is pleurosthotonos, or tetanus lateralis ; and this I 
never saw. Sometimes, again, in the height of the spasm, the antagonist muscles 
counteract each other exactly ; and the head and trunk are rigidly extended ; and 
the term tetanus is by some wTiters confined to this form of the disease. It is called 
trismus v^'-hen the jaw only is affected. 

It is well to know that these varieties occur, and may be looked for ; but in all of 



TETANUS. 



347 



them — trismus, opisthotonos, emprosthotonos, or pleurosthotonos — it is the same dis- 
ease ; and the prognosis is not altered, any more than the diagnosis, by the variety 
that happens. 

During the fit of exacerbation, the aspect of the sufferer is often frightful. The 
forehead is corrugated and the brow knit, the orbicularis muscle of the eye rigid, 
the eyeball motionless and staring, the nostril spread, the corners of the mouth are 
drawn hack, the set teeth exposed, and all the features fixed in a ghastly grin — the 
true risus sardonicus. The tongue is apt to get between the teeth, and to be 
severely bitten. 

All the contractions are attended with intense pain. You may form some notion 
of the severity of this pain, if you have ever been troubled by spasm of the gas- 
trocnemius, or cramp of the leg, and if you can bring your mind to conceive that 
the same sensation which you then felt in the calf, involves nearly all the voluntary 
muscles of the body. The pain is worst during the exacerbations, and that which 
is experienced at the sternum is commonly the most complained of. Even to this, 
however, there are occasional, though very rare, exceptions. Sir Gilbert Blane has 
described a case of tetanus, which ran the usual course, and terminated fatally, yet 
the patient suffered no pain : the sensation excited by the violent muscular con- 
tractions was a sort of tinghng, of rather a pleasurable kind. 

So violent are the contractions sometimes, that the teeth have been broken by 
them. There is one case related in which the thigh-bones were fractured by the 
forcible action of the femoral muscles ; and another in which the psoas muscles were 
found, after death, to have been torn across. Dr. Latham tells me that he once saw 
one of the recti muscles, in front of the abdomen, thus rent asunder. 

With all this disturbance of the muscular system, there is commonly very httle 
derangement of the other functions of the body. The disorder is almost always 
attended with obstinate costiveness ; partly, perhaps, from the spasmodic closure 
of the anus, partly,' perhaps, in some cases, from the medicines that are given. 
When stools are obtained, they are usually very offensive and unnatural. There is 
no fever. The pulse and respiration are quickened, and a sweat frequently breaks 
out during the exacerbations, from the pain and anxiety then experienced ; but this 
is not the case during the intervals between the paroxysms. In the last stages of the 
fatal cases, the pulse becomes quick and feeble, and the sweat is cold, as in other 
instances of approaching dissolution. 

What is still more worthy of observation is that the mental functions are un- 
affected. There is seldom any delirium, or coma, or disturbance of the intellect. 
These symptoms only appear (if they appear at all) when other indications of the 
failure of the powers of life come on. 

The mode of death in this disease seems to be of a mixed nature. Partly it 
appears to result from apnoea ; the thorax being held as in a vice by the spasm of 
the muscles, and the breathing for a time suspended, or much embarrassed : partly, 
and chiefly, it occurs from asthenia: the power of the heart flags and is exhausted 
by the continuance of the suffering, by the fatigue and expenditure consequent 
upon the muscular action, and by the patient's inability, in many cases, to take suf- 
ficient nourishment. When death happens suddenly as it sometimes does, in a 
paroxysm, it is owing, in all probabihty, to spasm of the respiratory muscles, and 
perhaps of those of the glottis among the rest. 

Most cases of tetanus may be traced to one of two causes : which are, exposure 
to cold, especially to sudden alternations of temperature, and bodily injuries. In 
many instances both these causes co-operate in producing the disease. When it 
supervenes upon some bodily hurt, it is called traumatic tetanus; when it arises 
spontaneously, or after exposure to cold, it is held to be idiopathic. In this country, 
and Ibeheve in every other, the traumatic variety of the disease is much more common 
than the spontaneous. But in what manner soever it may originate, tetanus is far 
more frequent in hot than in temperate climates and seasons. In this case, however, 
as in so many others, the heat appears to act as a predisposing cause only ; the 
exciting cause, in addition to the wound in the traumatic species, being the appli- 
cation of cold (particularly, according to Hennen, of cold air in motion) after the 



348 



TETANUS. 



heat or during the prevalence of hot weather. Thus it is stated that after the battle of 
Muskau, in the midst of great heats, very few of the French troops were affected 
with tetanus ; whereas those who were wounded in the battle of Dresden, when the 
weather was cold and wet, just after a very hot season, were decimated by that 
complaint ; which did not spare even those who underwent immediate amputation. 

Idiopathic tetanus is extremely rare in this country. Dr. Gregory, of Edinburgh, 
used to mention in his lectures the case seen and treated by himself, of a man who, 
having fallen asleep in moist grass, awoke with a stiff neck, which afterwards went 
on into regular tetanus. A good example of well-marked tetanus, arising from ex- 
posure to cold, is narrated in the Edinburgh Medical and Surgical Journal, by Dr. 
Hall, of Berwick. 

The history of that species of tetanus which occurs in connection with wounds 
and injuries, presents nothing constant or uniform. The disease is liable to follow 
hurts of any parts of the body, and of every kind, degree, and extent ; from a slight 
cut or scratch, to a compound fracture, or a severe surgical operation. It comes on 
also in various stages and conditions of the injury. Sir James M'Grigor tells us (in 
the sixth volume of the Medico- Chirurgical Transactions) that in the Peninsular 
war the complaint supervened " in every description, and in every stage of wounds, 
from the shghtest to the most formidable : the healthy and the sloughing ; the incised 
and the lacerated; the most simple and the most complicated." Sometimes, how- 
ever, the discharge from the wound has been observed to be remarkably diminished 
or suppressed, at the coming on of the tetanic symptoms ; and sometimes the wound 
has healed completely before the commencement of the attack of tetanus. To show 
you how very trivial the injury may be, how various in kind and in place, I may 
mention a few instances that have been collected, in illustration of the manner in 
which this terrible disorder may originate. It has been known to arise from the 
sticking of a fish-bone in the fauces ; from a shght wound of the ear by a musket- 
shot ; from the mere stroke of a whip-lash under the eye, although the skin was not 
broken ; from cutting a corn ; from a bite on the finger by a tame sparrow ; from the 
blow of a stick on the neck and on the hand ; from a seton in the chest ; from the 
extraction of a tooth ; from the injection of a hydrocele ; from the operation of 
cupping. 

Nevertheless there are some sorts of injury, and some parts of the body, more fre- 
quently than others concerned in the pathogeny of tetanus. The disorder more often 
supervenes upon injuries of the extremities, than of the trunk, head or neck ; and 
upon wounds made by puncture, than upon most other hurts. Penetrating wounds 
in the sole of the foot, such as are not seldom inflicted by treading upon a nail or a 
splinter ; and laceration, or other violence done to the muscles that constitute the ball 
of the thumb, are very apt to be followed by tetanic spasm. Some have supposed 
that the disease has some special connection with injuries of tendinous parts ; but 
there can be no doubt that it is essentially a malady of the nervous tissue. 

The tetanic symptoms occur at no fixed period after the reception of the injury. 
Professor Robinson, of Edinburgh, was once at table, when a negro servant lacerated 
his thumb by the fracture of a china dish. He was seized with convulsions almost 
instantly, and died with tetanic symptoms in a quarter of an hour. Such a rapid 
progress as this is, however, quite out of the usual course of the disease : probably 
fright had something to do with it. Hennen, in his work on Military Surgery, 
states that terror is frequently the immediate antecedent of the attack. In general, 
the tetanus supervenes between the fourth and the fourteenth day after the infliction 
of the injury : some time in the second week is the most common period of all. In 
the Peninsular war it did not commence later than the twenty-second day. In some 
rare instances its accession is still longer deferred. " Of the nature of the changes 
that take place in the interval (justly remarks Dr. Alison) we have no information 
whatever." The longer, however, that the disease delays its assauk in these trau- 
matic cases, after the reception of the local injury, the milder, in general, does it 
prove, and the more room is there for hoping that it will end favourably. 

When the disorder arises from exposure to cold and damp, it comes on much 



TETANUS. 



349 



earlier ; often in a few hours. If, for example, the exposure takes place during the 
night, the complaint may begin to declare itself the next morning. 

Akhough tetanus may be excited by a wound, independently of any exposure to 
cold, or by cold without any injury, there is good reason for thinking that, in many 
instances, one of these causes alone would fail to produce it, while both together call 
it into action. 

After the disease has set in, its rate of progress is various. Almost all writers 
divide it into acute and chronic tetanus. But the difference is merely in the degree 
of severity. When the spasms come on suddenly, recur often from the beginning, 
and increase in frequency and violence, the chance of recovery is but small. The 
patient, in these cases, sometimes dies on the second, and generally before the fifth 
day. If he lives to the ninth day of the disease, his prospect is somewhat better, and 
the spasmodic symptoms may gradually abate and disappear. Some, however, have 
died as late as the sixteenth, the twentieth, and even the thirty-fifth day : but this 
last is very rare. 

The idiopathic tetanus, or that which is produced by cold, although it commences 
earlier, is more generally of a chronic character than the traumatic : that is to say, 
the spasmodic contractions take place more slowly, and the paroxysms do not increase 
in violence, and in rapidity of recurrence, as they are apt to do in the symptomatic 
variety : and accordingly this form of the malady is much oftener, I dare not say 
cured, but recovered from, than the other. 

With respect to the diagnosis of tetanus, there is only one point in which it is at 
all ambiguous or important. There is no other disease that is hkely to be confounded 
with it, except, perhaps, that extraordinary disease, hysteria, which sometimes 
mimics its phenomena. I have already alluded to one example of this kind that I 
myself saw. But there is a form of poisoning that may easily be mistaken for teta- 
nus. The symptoms produced by a poisonous dose of strychnia, or its salts, or the 
vegetables from which it is procured, are the symptoms of tetanus. And as this 
drug is now readily obtained, and its noxious quahties are well known, it is not un- 
likely to be made an instrument of suicide, or of murder. It is necessary, therefore, 
that you should be acquainted with the efiects of this poison, which constitutes the 
active principle of the nux vomica, the fama S'* Ignatii, and the upas tieute. Dr. 
Christison has excellently well described these efiects as they are observable in 
brutes ; and I have once, by accident, had an opportunity of witnessing them in the 
human body. I shall not be wandering from our present subject, if I enumerate the 
symptoms to be expected from a large dose of strychnia, especially as I have lately 
been advising you to make trial of it as a remedy in certain forms of disease. Dr. 
Christison, who had made experiments with it upon animals, tells us that the crea- 
ture " becomes agitated, and trembles, and is then seized with stifTness and starting 
of the limbs. These symptoms increase, until at length it is attacked with a fit of 
general spasm, in which the head is bent back, and the spine stiffened, the limbs 
extended and rigid, and the respiration checked by the fixing of the chest. The fit 
is then succeeded by an interval of calm, during which the senses are quite entire, 
or unnaturally acute. But another paroxysm soon sets in, and then another and 
another, till at length a fit takes place more violent than any before it, and the ani- 
mal perishes suffocated." 

Some time ago I had occasion to prescribe the strychnia for two patients in the 
Middlesex Hospital, both of whom had paraplegia. I directed one grain to be inti- 
mately mixed with crumb of bread, so that it might be divided into twelve pills : 
and one of these pills, or one-twelfth of a grain of strychnia, was to be taken by 
each patient every six hours. Unluckily, through mistake or negligence of the per- 
son who was at that time the dispenser, a grain of the poison was administered at 
once to each patient. It was given about seven in the evening. At half-past seven 
it began to produce its characteristic effect upon one of the patients. He was sud- 
denly seized with tetanic spasms ; his legs were separated widely from each other, 
and rigidly extended : and his head and trunk bent backwards. He was, in fact, 
in a state of opisthotonos. His abdomen was quite hard, and his limbs were stifl^ 
even when the violence of the paroxysms abated. He cried out with the pain at 



I: 



350 



TETANUS. 



the coming on of these spasms. Any attempt at movement, even the touching him 
by another person, brought them on. This is just what happens in the disease 
The opening of a door, a sudden current of air, the smallest bodily effort, the act of 
swallowing, nay, even the imagination of these influences, will be sufficient to renew 
the spasmodic tightening of the affected muscles. My patient spoke of a particular 
sense of constriction all over the abdomen, as if it were drawn in. His intellect was 
quite unaffected. He had two extremely violent attacks of the kind 1 have been 
describing, in which he thought he should have died : and to say the truth I was 
myself horribly afraid of the same catastrophe. Afterwards, from half-past eight 
o'clock to between eleven and twelve, he had several shghter and shorter fits. He 
was left weak and exhausted by them : but he soon recovered. I may as well tell 
you that his paraplegia was not a whit benefited by this violent action of the 
remedy. 

You may suppose that when I found one of my patients in this alarming state, I 
became very anxious to ascertain the condition of the other, who had taken the same 
quantity of the strychnia, and lay in another ward. He told me that he had been' 
for a short period very dizzy, and had trembled all over; and at the time when I 
saw him, he had a weight or uneasy sensation at the nape of his neck, which drew 
his head backwards ; and he experienced some difficulty in opening his mouth, and 
in articulating his words. But he thought these symptoms were diminishing rather 
than increasing. He was perspiring profusely. It is stated by Dr. Chrisiison, that 
if the spasms do not come on within two hours after the poison was swallowed, the 
patient is safe. It was more than two hours since this patient had taken the strych- 
nia. I gave him a full dose of purgative medicine, which acted as an emetic : and, 
after he had vomited, the unpleasant sensations about his head and neck left him. 

I scarcely knew what to do with the other patient, in w^hom the spasms had com- 
menced. There is nothing satisfactorily made out, that I know of, concerning the 
mode of treating such cases. Of course, if one saw the patient early, and knew 
what he had swallowed, the first thing to be done would be to procure its evacuation 
from the stomach. But here it had had full time to get into the circulation : and no 
emetic could have withdrawn that part of it at least, which had already found its 
w^ay into the blood-vessels. When I reached him, though the spasms were strong, 
they were less violent than they had been, and their violence seemed upon the wane : 
but they were brought on by any, almost the slightest, muscular effort, or change of 
position. I hoped therefore that the most dangerous period was passing off (and so 
it turned out), and I was fearful of doing harm by exciting those movements of the 
body which accompany the act of vomiting. I recollected, too, that another patient 
in the hospital, under the care of one of my colleagues, had once been attacked with 
opisthotonos after taking half a grain of strychnia ; and that brandy and water had 
been given to him ; and that he got well from that time, without having another 
paroxysm. So I gave my patient some brandy and water ; and he seemed the better 
for it : but whether or no it contributed much to his recovery I cannot be sure. 

KoAV how are we to tell, when we meet with such symptoms as these, whether 
they are the result of disease, or of poisoning? The symptoms are the symptoms 
of tetanus ; I know of no means of distinguishing them from the symptoms of 
tetanus caused by exposure to cold, or supervening upon a wound. Dr. Christison 
has suggested that the cases of fatal poisoning by strichnia that are quickly fatal, are 
fatal in a shorter time than the disease ever is. But if the case related by Professor 
Robinson, in which the negro was dead in fifteen minutes, is to be regarded as a 
genuine instance of tetanus, this distinction, drawn from the rapidity with which the 
poison kills, will scarcely hold. Again, persons who have taken an over-dose of 
strychnia sometimes survive the tetanic symptoms, but die afterwards from the irritant 
effects of the poison upon the mucous membrane of the ahmentary canal. This we 
do not observe in the disease. In suspicious or questionable cases, we must look 
into the history of the patient ; inquire whether he w^ere likely to wish to destroy 
himself; what he last swallowed, and when it was taken; whether he has lately- 
been Exposed to the injurious influence of cold, especially to a stream of cold air 
while he was perspiring; and whether he has recently received any bodily hurt. 



TETANUS. 



351 



By a careful investigation of all the circumstances, we shall generally be enabled to 
decide the true nature of the case ; but it is clearly necessary that our eyes should 
be open to the possibility of a case of poisoning, by some of the preparations of 
strychnia, being palmed upon us for a case of natural disease. 

The pathology of tetanus is undoubtedly obscure : but not more so, I conceive, 
than that of those nervous diseases in general which produce violent symptoms, and 
even death itself, without leaving any traces of their operation inscribed upon the 
dead materials of the body. Nay, it is not so obscure as several others. I think we 
may fairly come to the conclusion that the symptoms result from irritation of the 
spinal cord, or of its afferent nerves ; and that the brain is not involved in the 
disease. The French (at least some of the most modern writers on tetanus) hold 
that it is always an inflammatory complaint ; and that it consists essentially in inflam- 
mation of the spinal marrow : and some of them have sought to remedy it by enor- 
mous blood-lettings ; from fourteen to fifteen pounds of blood being taken in the 
course of a few days by one practitioner ; and another bleeding his patient eight 
times, and applying 792 leeches along the course of the spine, and to the epigas- 
trium. But this doctrine of inflammation being at the bottom of every case of tetanus 
is contradicted by the plainest facts ; and the practice founded upon it has been 
pushed to a most extravagant and absurd extent. Numberless instances occur of 
inflammation of the spinal cord and its membranes without any tetanus ; and equally 
numerous examples of tetanus have been met with, when no unnatural appearance 
at all could be discovered within the vertebral canal. I say we must content our- 
selves with referring the phenomena of the disease to irritation, direct or indirect, 
of the spinal cord ; or its nervous appendages ; and I am quite proof against all 
sneers against the alleged vagueness of that term. 

If you irritate, mechanically, by means of a pair of forceps, the exposed spinal 
cord of a recently decapitated animal, a turtle, for example, you produce spasmodic 
contraction of the hmbs. What difficulty is there in supposing that some mechanical 
irritation existing within the spinal canal of a living man may have a similar effect ? 
It may be, and probably is, sometimes, the mechanical irritation caused by the altered 
state of the blood-vessels under inflammation ; for we sometimes find traces of such 
inflammation in the spinal marrow after death by tetanus. 

Again, if you irritate, by pinching, one of the spinal nerves of a turtle whose 
head has just been cut off — if you thus irritate one of these nerves in any part of 
its course, what happens ? why the muscles of the limbs contract spasmodically ; 
those on the ^ide to which that nerve belongs becomes rigid, and those on the other 
side also. That property of the cord comes into play which I have so often men- 
tioned : a property which it possesses independently of the brain ; which it evinces 
when all communication with the brain is cut off ; a property, therefore, which may 
be manifested without any exercise of volition, and even in spite of efforts made by 
the will to restrain its manifestation : I mean, of course, the property whereby it is 
capable of receiving impressions through the medium of its afferent nerves, from 
parts at a distance, and of originating motion in the muscles of the trunk and hmbs 
through the medium of its efferent nerves. By the courtesy of Dr. Marshall Hall 
I have been afforded the opportunity of witnessing, in the headless turtle, the phe- 
nomena that I have been describing to you. Surely they throw a broad fight upon 
the pathology of tetanus, and of sundry other affections. We infer from them, most 
legitimately as it seems to me, that the tonic spasm which characterizes the disease 
we are considering may be caused by a diseased state of the spinal marrow itself; 
or by a morbid condition of the nerves that belong to it. In the latter case, irritation 
is set up at the free extremity, or somewhere in the course, of incident nerves ; along 
these nerves an influence is conducted to the cranio-spinal axis, in which a process 
or change takes place, whereby an answering influence is reflected to the muscles 
along the motor nerves, and the whole circle of action and reaction is run through 
with the suddenness and swiftness of fightning, or of thought. You cannot expect 
that visible marks of the irritating cause should, in all cases, be left upon the body ; 
any more than you could discern the pinch made by the forceps after they were 
withdrawn. 



352 



TETANUS. 



When, in the experiments to which I have referred, Dr. Hall plucked or com- 
pressed one of the denuded spinal nerves, spasmodic motions were excited in the 
muscles of both sides ; and above, as well as below, the junction of that nerve with 
the cord. This shows that the change (whatever it be) that is wrought in the cord \ 
by impressions made upon one of its afferent nerves, is not necessarily confined to 
the corresponding segment of the cord ; but may be instantly communicated, in both 
directions, throughout its entire course : the whole of this centre of the excito-motory 
system, responding to the influence conveyed by a single nerve, as completely as a 
tight string vibrates from end to end, when struck at any one point. We frequently, j 
indeed, find that the excited motions are more limited ; but it is important to mark ! 
this ready consent of the whole cord, under sufficient excitement. 

Dr. Hall has given certain distinguished epithets to tetanus, according to the sup- { 
posed source and locaHty of the irritation. When the irritating cause operates ' 
directly upon the spinal cord itself, he calls the disease centric tetanus : when it | 
resides in some part of the body distant from the spinal cord, he calls the disease i 
eccentric tetanus. These are good and intelligible names ; and I shall take leave to 
adopt them. ' 

Observe now how well this explanation meets the facts of the case. We some- 
times find the spinal cord or its membranes inflamed, when there has been tetanic | 
spasm. We then refer the spasm to the centric irritation. But in a far greater | 
number of cases we can detect no marks whatever of disease in the spinal canal, , 
while we know that an irritating cause has been applied to parts at a distance. j 
Often we have evidence which is visible, that a nerve has been injured, torn across 
perhaps, or half torn, or compressed in some way or other ; just as we might com- 
press a nerve, with a pair of forceps, in a decapitated turtle. That experiment 
shows us that very slight irritation may be enough to produce the spasmodic action ; ! 
and we find that shght injuries, as well as severe, will bring on the disease, when, 
by the operation of certain injurious agencies, the frame has been predisposed, and 
rendered morbidly susceptible. There is no part of the trunk or limbs which is not i 
supplied with nerves from the spinal cord ; and we find that injuries of various parts, I 
or of almost any part, in an individual predisposed to take on the disordered action, 
may produce it. The exciting cause may be a wound irritating a particular nerve ; 
it may be exposure to cold, acting upon the extremities of various nerves that pro- ( 
ceed from the surface : it may be a bundle of worms, irritating the nerves spread ' 
upon the mucous tissue of the alimentary canal ; for I omitted to state before that i 
some writers, especially MM. Laurent and Lombard, have maintained that tetanus i 
is almost always, even when it supervenes after wounds, the result of the presence i 
of worms in the digestive organs. They have founded this opinion upon the fact, i 
that worms have been very frequently indeed discovered in the stomach or intestines j 
of persons dead of this disorder. I think this a point well worth attending to. It is j 
objected that worms infest the human body without causing tetanus : but the very i 
same thing may be said of the operation of cold; and of external injuries. Any of 
these may probably excite the disorder, when the body is pretematurally susceptible 
of it. The real mystery hes in this predisposition. We have reason to suppose 
that a high atmospheric temperature, continued for some time, is one predisposing 
cause ; but how it operates, or what is that state of system in which the increased 
susceptibility consists, these are points concerning which we are really in the dark. 

The disease is common enough in brutes : and it is frequently eccentric in them ; 
brought on by injuries, mostly of the extremities. Locked-jaw is well known in the 
nosology of farriers. It is not uncommon in the horse after castration. I remember 
a mare belonging to my father dying of that disease a few days after foaling. It 
often resuhs, in these animals, from a prick in the foot by a nail in shoeing. Dr. 
Parry noticed eccentric tetanus in lambs. "I have often seen lambs," says he, 
" whose ears, for the purpose of marking them, have been bored with a red-hot iron 
too near the root, so rigid all over with tetanus, alternating with convulsions, that 
their bodies would project in a right line with their hind legs, when one held them 
out horizontally by the hind feet." Dr. Mason Good tells us that parrots also are 



TETANUS. 



353 



frequently affected with trismus : a calamity which, supposing the bird to be within 
ear-shot, it would be difficult to commiserate. 

We are not advancing any wild theory, then, respecting the controverted patho- 
logy of this disease, when we lay down the following propositions : that it is essen- 
tially a disorder of the excito-motory apparatus ; that it results from irritation of a 
peculiar kind, affecting that part of the nervous system ; that the irritating cause 
may be centric, — within the spinal canal itself ; and that it may also be, and often is 
eccentric, — situated at the extremity, or somewhere in the course, of one or more of 
the afferent spinal nerves : and that a certain predisposition of the body is for the 
most part necessary, to render it susceptible of the disease under the operation of 
the exciting irritation. 

At one time it was supposed that the physical cause of the disease was detected, 
in the presence of more or fewer thin scales of bony matter, lying in or upon the 
arachnoid of the cord. I have myself seen these after death preceded by tetanic 
symptoms. But tetanus often happens and proves fatal without them : and they are 
often met with when there has been no tetanus. If, therefore, there be any connec- 
tion between these thin plates of ossification and the occurrence of tetanus (which 
may well be questioned), it must be of this kind ; that the scales of bony matter 
predispose the spinal cord, somehow, to be affected by the exciting causes of the 
disease. 

The doctrines recently propounded by Dr. Marshall Hall, of which the import- 
ance becomes daily more apparent, and by which his name will be enduringly con- 
nected with the physiology of the nervous system, receive a strong^ confirmation from 
the phenomena of tetanus. They furnish a key to many problems which had pre- 
viously perplexed the pathologist ; and they do this simply by distinguishing the 
proper functions of the two distinct nervous centres ; the bsain and the spinal cord. 
But the practical apphcation of these new views is yet in its infancy. 

The treatment of tetanus is a mortifying subject. The disease is and has always 
been a lamentably fatal one. Hippocrates says, £?tc tpco/xa/ti snaG^oi srt^ysvofisvosj 
dat^aoiixop, tetanus supervening on a wound, is mortal : and the aphorism holds true, 
with very few exceptions, in the present day. Almost all the acute and severe trau- 
matic cases are fatal. Hennen declares that he never saw a case of "acute symp- 
tomatic tetanus" recover. "Dr. Dickson found all curative measures followed by 
"unquahfied disappointment." Mr. Morgan uses these words ; "I have never yet 
seen or heard of an instance of recovery from acute tetanus." Another of Hippo- 
crates' aphorisms is oxosot vrto tstcwov al.LGxwto.i sx ^£(^60^6^ rjijLsprj6iv arto'k'K.vv'tcu,, they 

who are seized with tetanus, die within four days ; but he adds, rjv 8s tcwtai Sta^rycooM/ 
ryt£f s ytvouT-at ; if they get over this period they recover. And to this we can only 
add now, that those who survive the first few days, and ultimately get well, recover 
in a variety of different ways, and under various modes of treatment. But as to the 
mode of treatment which is to be preferred, or even as to the real efficacy of any 
mode, there is much room for doubt. Under every plan of management a vast 
majority die. 

Let us briefly pass in review the principal remedies that have been tried, and 
inquire what degree of success has followed their employment. 

One drug from which much benefit has been hoped for, is opium. In some spas- 
modic disorders it is of unquestionable service. Very large doses of it have been 
given and borne in tetanus; and some have recovered under its use, and more have 
died. 

It is well known that pain fortifies the nervous system against the peculiar influ- 
ence of narcotic substances. We need not, therefore, be surprised that opium, admi- 
nistered in enormous quantities, in this painful disease, has had but little effect. I 
was assured by a physician, with whom I formed an acquaintance in Edinburgh 
some years ago, and who is known, I find, to a student now present, that his own 
wife, while labouring under a tetanic affection, swallowed, in twenty successive days, 
upwards of 40,000 drops of laudanum, which is at the rate of more than four ounces 
a day ; in all, more than two imperial quarts. The lady recovered. A case is 
recorded in the second volume of the Medico- Chirurgical Transactions^ in which 
23 2e2 



354 



TETANUS. 



an ounce of &olid opium was taken, in divided doses, every day, for twenty-two 
days. This appears a more astounding instance than the former ; but I am not sure 
that it was so ; for, in this complaint, sohd opium does not always dissolve in the 
stomach. I have heard the late Mr. Abernethy say that he had found enough un- 
dissolved pills of opium in the stomach after death, to poison a dozen healthy per- 
sons. This fact should teach you, if you resolve on trying opium at all, to exhibit 
it in a liquid form ; laudanum, or a solution of the acetate or of the muriate of mor- 
phia. And with the internal administration of opium, it would be well, perhaps, to 
combine its external use ; to apply a broad strip of opiate plaster along the whole 
length of the spinal column. ^ 

It is sometimes a difficult matter to introduce medicine by the mouth, so strong is 
the spasmodic contraction of the muscles that close the jaws. You cannot get the 
mouth open. Some persons sot to work to heave it open, by levers ; and it has been 
proposed, and I believe practised, to break off or extract a tooth or two, to make a 
passage for the introduction of medicine and of nourishment ; but 1 hope you will 
never be guilty of such clumsy barbarity as this. Food, and physic, may be carried 
into the fauces and into the stomach by means of a flexible tube : and this may be 
inserted through the nostril ; or through the mouth, by passing it between the jaws, 
behind the back teeth, where there is always an aperture that will admit a tube suffi- 
ciently large. 

After all, in respect to the cures that have been ascribed to the opiate treatment, 
they have all (so far as I know) occurred in cases of the milder or more chronic 
tetanus ; and mostly in the idiopathic form of the disease ; and this circumstance 
makes it a question whether they were cures at all : whether they were not simply 
recoveries. 

Dr. Wilham Budd (in the paper already referred to) challenges the propriety, on 
physiological principles, of giving any opium in this disease. He says, " It has been 
ascertained that the effect of that drug is to excite, and not to quiet, the motor func- 
tion of the spinal cord : indeed, it is well known that the motor acts of the cord may 
be rendered much more active and powerful, by giving, before decapitation, opium 
to animals that are to be subjects of experiment." He considers "these objections, 
furnished by theory, to be motives sufficient for the future exclusion of opium from 
the treatment of tetanus." 

I had long been avv^are that the effect of opium upon frogs was to produce tetanic 
spasms. But in no case of poisoning by opium in the human subject (and I have 
seen a great many) have I ever witnessed any approach to tetanus : and I much 
question the safety of arguing, in such matters, from what we know to happen in the 
inferior animals, to what we suppose would happen in man. 

The failure, however, of opium in the severer forms of the malady, and its equi- 
vocal utility in any, taken together with these theoretical objections, prevent my 
recommending opium as a remedy for tetanus. 

What is the result of experience in regard to blood-letting in tetanus ? I am afraid 
that as a curative agent, it has very little power over the disease. Yet it may be, 
and probably is, of considerable use, as an auxiliary to other measures. When the 
disorder bears any aspect of inflammation — when, for instance, fever is lighted up, 
and pain is felt along the course of the spine, or when the approach of the spasm is 
marked by the supervention or the increase of pain in the wound — then our chance 
of doing good by venesection is the greatest. Some of the cases that happened in 
the Peninsular war, were decidedly benefited by blood-letting practised under such 
circumstances. I need scarcely say that though the bleeding, when adopted, should 
be early, free, and full, so as to produce some sensible impression upon the system, 
yet we must always use this remedy with caution. The tendency of the disease is 
to exhaust the power of the heart ; and if by one over-bleeding we bring that organ 
to a stand-still, it may refuse to begin again. 

In a complaint which depends so much on irritation, and so often on manifest 
irritation of external parts, we look naturally to the warm bath for help. And it 
^has been fairly tried: and some persons have found it useful; and others have 



TETANUS. 



355 



found it useless, doing neither good nor harm : and some have condemned it as actu- 
ally hurtful. 

The cold bath has been extolled as a much more powerful agent than the warm , 
and so, doubtless, it is. But it is more potent for harm as well as for good. For 
example : a tetanic patient, in St. Thomas's Hospital, was plunged into a cold bath, 
at his own request. "All the symptoms disappeared (says Mr. Morgan) in a moment; 
and he v/as almost immediately taken out of the bath: but he was taken out hfe- 
less." Sir James M'Grigor says that, during the campaign of Spain, "the warm 
bath gave only a momentary relief ; and the cold bath was worse than useless." 

However, the apphcation of cold water to the surface has, in many recorded 
instances, been of at least temporary benefit and comfort : and, in the West Indies, 
where the disease is common, the cold effusion still continues, I believe, to be the 
most favourite expedient. After it, the patient is rubbed dry, put to bed, and has 
laudanum administered. I have again to observe, of this remedy also, that it is 
chiefly serviceable in the idiopathic form of tetanus. It has been tried upon animals. 
Dr. Parry says that it was quite unavailing in the case of certain lambs that had the 
disease. In a note, which I made at the time, of Mr. Abernethy's lecture on teta- 
nus, I find the following statement. " The effect of cold in diminishing excessive 
muscular action was strikingly shown in the case of a horse belonging to Professor 
Coleman, which had tetanus. The animal was slung, and carried out of the stable, 
and laid on thg snow, which was then on the ground : and he Vv^as covered over with 
snow also. A horse affected with tetanus is a curious sight. His legs straddle, and 
become stiff ; his ears are pricked up ; and his tail sticks out. In this case, on the 
application of the snow, his ears sunk, his tail became pliant, and the rigidity of his 
muscles was removed. He was again taken into the stable, and the spasms returned." 
Mr. Abernethy said, that were he himself the subject of tetanus, he would desire to 
have the cold effusion tried. If you are wiUing to assay the same remedy, do not 
plunge your patient into a cold bath, but take him out of his bed on an extended 
sheet, pour cold water over his body, wipe him dry, and place him in another dry 
bed. This will often, for a time at least, diminish the spasmodic action; and the 
patient will sometimes sleep comfortably after it. 

Dr. Todd has suggested to me the application of ice to the spine ; a measure 
which he has found eminently beneficial in convulsions. This mode of employing 
cold as a remedy in tetanus seems well worthy of trial. It would have the advan- 
tage of not inflicting any shock which might excite or disturb the reflex function of 
the cord, through its incident nerves. 



LECTUEE XXXIII. 

Treatment of Tetanus, continued. Wine; Mercury; Purgatives ; Digitalis; 
Tobacco ; Musk ; Prussic Jicid ; Belladonna ; Carbonate of Iron ; Oil of Tur- 
pentine; Strychnia; Surgical Expedients ; General Pules. Hydrophobia. 

In the last lecture we considered the symptoms, the nature, the causes, and to a 
certain extent the treatment, of that terrible malady, tetanus. There is good reason 
for beHeving that it is essentially a disorder of the excito-motory apparatus ; that it 
is caused by irritation of a peculiar kind, affecting that part of the nervous system, 
and producing tonic spasm of the voluntary muscles ; that the irritating cause may 
be centric, situated within the spinal canal, and applied directly to the cord ; or 
«tcentric, situated out of the spinal canal, applied to some part of one or more of its 
afferent nerves directly, and thus influencing indirectly the cord itself, and through 
it the reflex motor nerves : and that a certain ill-understood state of the system is 
necessary, a certain aptitude to take on the disease, before the exciting, cause can. 
be efficient; and that one circumstance which has been ascertained to tend to 



356 



TETANUS. 



the production of such an aptitude, is a long-continued high temperature of the 
atmosphere. 

I mentioned several remedies and plans of treatment which have been fairly tried, ; 
and mostly tried in vain, for the removal of this disease. The severe cases, and 
especially the severe traumatic cases, almost all prove fatal ; the less severe cases, 
those in which the paroxysms are less violent and less frequent, and which run on 
for several days, sometimes terminate in health : whether in consequence of the | 
measures employed, or whether in spite of them, it is not easy to say. The idior 
pathic cases, as they are called, those which appear to be produced by exposure to I 
cold and wet, are usually the least severe, and the more hopeful. The remedies 
that have been tried, and which were mentioned in the last lecture, are opium ; ] 
blood-letting; the warm-bath; the cold-bath. I showed you that, under each of these 
remedies, a great number of patients died, and some recovered ; and that the reco- 
veries had been almost exclusively among those patients in whom the disease ap- 
peared originally in its milder form. So that whether the complaint was actually 
cured in any of these cases, whether, i. e., any single patient recovered, or recovered 
sooner, from using any of these remedies, who would have died, or in whom 
the disease would have been protracted if he had not used them, is a matter of 
uncertainty. 

The celebrated American physician. Dr. Rush, regarding the disease as essentially 
a disease of debility, and looking probably at its common tendency to death by 
asthenia, wrote a paper to recommend the employment of bark, and wine, and 
spirits, in full doses. It is curious enough, but quite in agreement with what has 
been already stated of opium, that how much wine soever may be swallowed by the 
patient, nothing like intoxication is produced by it. The system resists the ordinary 
influence of the alcohol. In one instance related by Dr. Currie, the disease lasted 
six weeks, and in that space of time the patient drank 110 bottles of port wine. The 
same author mentions a remarkable case, in which a horse, which was attacked by 
tetanus, and happened to be a great favourite with its master, was treated with wine, 
and got well, after swallowing more port wine than he was worth. Whenever thi$ 
plan has appeared to do good, it has been in the more chronic variety of the 
complaint. 

Mercury, you may be sure, has not been left untried. It is said that the system 
is slow in submitting to its influence, in this malady. The specific effect of mercury 
upon the gums is not, however, so strongly resisted as that of wine or opium upon 
the nerves. Nor can we be surprised at this, when we consider that in tetanus the i 
functions of organic life are, comparatively, but little involved. It is clear that there | 
is not time for any effectual exhibition of mercury in those severe cases that are early I 
fatal. In its more chronic form the disorder has been known to yield upon the mouth ' 
becoming affected. This happened, if I mistake not, in Mr. Mayo's patient, men- j 
tioned in the last lecture. Tetanus has sometimes, however, commenced while the I 
atient was in a state of salivation. Dr. Wells has recorded three instances of that | 
ind. The experience of the mihtary surgeons who were in Spain, is, upon the 
whole, against the reputed efficacy of mercury. We must take care not to conclude 
too hastily, that because a patient uses a certain remedy and recovers, he recovers i 
through the operation of that remedy: any more than we should conclude, if he ' 
recovered during a general election,' that the election had cured him. Yet this 
absurd and unsafe mode of reasoning is for ever employed in respect to disease, by 
the pubhc ; and too often, I fear, by ourselves. 

Purgatives have been much given in tetanus ; and often with manifest advantage : ■ 
I mean in the less severe cases. But very large doses are commonly required to 
procure evacuations from the bowels. Whether the torpor of the intestines be always 
the effect of the disease, or whether it may not sometimes be, in part at least, a con- 
sequence of the opium that is given, I am not sure. When they do act, very unna- 
tural motions are frequently produced. Mr. Abernethy tells us of a hospital patient 
of his who recovered under the use of purgatives ; the)'- were long before they had 
any effect, and when they did at last operate, such fcetid stuff' came from him that 
no one who could crawl out of the ward would remain in it. He says also that the 



TETANUS. 



357 



nurses, in other cases, have reported the stools to be more like sloughs than feces. 
Enormous quantities of drastic purgatives have been given. You may read an 
instance of this in the second volume of the Medico-Chirurgical Transactions. It 
is related by Mr. Harkness. There is a still more extraordinary case detailed by Dr. 
Briggs, in the fifth volume of the Edinburgh Medical and Surgical Journal. In 
little more than 48 hours, the patient in that case took 210 grains of scammony, 89 
of gamboge, 80 of calomel, an ounce and four scruples of jalap, and 2j pints of 
what we call black dose, the infusion and tincture of senna : and all this without 
either sickness or griping ; but, on the contrary, with the most decided benefit. In 
the first week of his disease, the patient swallowed — of calomel, 280 grains ; scam- 
mony, 260; gamboge, 110; jalap, 3 ounces and 10 grains; infusion of senna, 5f 
pints. And altogether in the first 25 days — of calomel, 320 grains ; scammony, 
340 ; gamboge, 126 ; jalap, 5 ounces and drachms ; infusion of senna, lOf pints; 
besides an ounce and a half and 35 grains of the colocynth pill. I mention all this 
to show what the system will bear, under the bondage of the disease ; not as an en- 
couragement to you to prescribe such doses. 

It is certainly proper and necessary to clear out the bowels, and to endeavour to 
correct unhealthy secretions ; yet numerous evacuations, the act of going to stool 
often repeated, should be avoided. Under such obstinacy of the bowels, the croton 
oil would perhaps be the most ehgible purgative. 

Foxglove and tobacco are two medicines, or rather poisons, which have been 
used ; both, probably, upon the same principle. Their effects, when full doses have 
been given, are much alike : sickness, faintness, feebleness and fluttering of the pulse, 
coldness of the surface, with that slack and passive state of the muscles which 
belongs to syncope. But if we consider that the influence of these substances upon 
the involuntary muscles, especially upon the heart, is more certain and decided than 
upon the muscles of voluntary motion, which are the muscles involved in the tetanic 
spasm, and if we take also into account the strong disposition observable in tetanus 
towards death by asthenia, we shall scarcely be prepared to expect any good, but 
the contrary, from digitahs, or tobacco ; especially in the latter periods, when, so far 
from obviating the tendency to death, they would seem to co-operate with the disease 
in extinguishing life. However, if the result of experience were clearly in their 
favour, we should not be warranted, by mere theoretical vie ws, in withholding these 
drugs. The army surgeons, some of them, have fancied digitalis usef|*il. Sir James 
M'Grigor mentions a case in which it caused a relaxation of the spasms ; but the 
man died afterwards, apparently from the effects of the remedy. And liiis is just 
what I find with digitalis. When given in large doses (and small ones here must 
be useless) it becomes unmanageable. Certainly we have no such accounts of its 
salutary power as would induce me to give it with much expectation of success, or 
to give it at all. 

The tobacco is not given by the mouth, but thrown up into the rectum : either 
the smoke of its burning leaves, or (what is probably as efficacious, and I should 
think more uniform and less unsafe) an infusion of them in water. Mr. Curling, 
afier analyzing a large number of cases of tetanus, thinks tobacco the best remedy 
we at present possess. Mr. Travers is of the same opinion. However, I should 
recommend great caution in the use of this ticklish remedy. You ought to know 
that, when injected in other emergencies, in strangulated hernia, for example, mortal 
syncope has followed such enemata. 

Musk, in large doses, has been strongly recommended by a Frenchman, Fornier- 
Fescay, who has written on this disease. He gave ten or twenty grains, at intervals ; 
so that a drachm, or even two drachms, were taken in the course of the day ; and 
he declares that he found it more efficacious than any thing else that he had tried. 

Prussic acid and belladonna are said, by Dr. Elliotson, to have been freely pre- 
scribed, and to have failed; whether in his own hands, or in those of others, I do 
not know. 

There is another remedy which the same physician has employed : and emplo3^ed 
not without success : the carbonate of iron. Reflecting, he tells us, upon the good 
effect of this medicine in another complaint which has some points of analogy with 



358 



TETANUS. 



tetanus, viz., chorea, of which I shall soon speak, and considering how miserably ;| 
narcotics had failed, he determined to give the carbonate of iron a fair trial upon the | 
first opportunity. He has published some account of its effects in tetanus, in the 
Medico- Chirurgical Transactions. In the first case in which he used it, the tetanus , 
supervened upon a compound dislocation of the great toe. The method in which I 
the remedy was administered was this. The carbonate was made into an electuary 
by mixing it with twice its weight of treacle. The electuary thus made was well j 
stirred in beef-tea just as the patient was about to drink it. He took this every two ' 
hours, as much as he could swallow : and he got well. The next case is described j 
as being a very severe one ; it resulted from a contusion of the thumb. Dr. Eihotson 
says that he never saw a case, which did well, that was more severe. This patient 
also took the carbonate of iron, as much as could be got down ; and that was about 
two pounds a day. He had injections twice daily, to keep the bowels unloaded ; and 
the iron is described as having come away in large red Jumps, in shape like horse 
dung. This man recovered. In a third case, where a chilblain above the heel was 
the exciting cause, the boy died within twenty-hours of the time when the remedy 
was first prescribed. To produce its effects upon the system (Dr. EUiotson observes, 
very truly), iron must be given for a few days : nay, he holds that months some- 
times elapse before it has any effect. So that if it really be useful in tetanus, we I 
cannot expect much good from it in the more acute cases : and these are the cases | 
for which we want a remedy. i 

Oil of turpentine is one of the many substances that have been praised as useful | 
in tetanus. Now, bearing in mind its power (which I shall hereafter describe, 
but which you must at present take for granted) as a worm-killer, and also the 
frequency with which worms are met with in the stomach and bowels after death 
by tetanus, this is one of the drugs which I should employ as a purgative, taking | 
my chance of whatever good might possibly arise from its specific or anthelmintic 
qualities. It may be given in such cases either by the mouth, or in an enema, or at ' 
both ends together : but it must be given in large doses, not less than an ounce at a 
time ; and it may be mixed with an equal quantity of castor oil. The one oil dis- 
solves or becomes incorporated in the other. I 

Strychnia has been suggested as a remedy for severe tetanus ; not in infinitesimal j 
doses, as Hahnemann would, I suppose, prescribe it, but in sufiicient quantity to 
produce a sensible effect. The principle upon which this has been recommended j 
is the same with that on which the nitrate of silver ointment is applied to the in- | 
flamed conjunctiva in purulent ophthalmia. We know that strychnia acts upon the i 
spinal cord, affecting apparently those parts and those functions of the cord which , 
are affected in tetanus : and in so fatal a malady, it would be justifiable, I conceive, i 
to give the strychnia, in the hope that it might occasion a morbid action which would j 
supersede the morbid action of the disease, and yet be less perilous and more | 
manageable "than it. But it would be right to try such a remedy as this in the first 
instnnce, in coiyore vili ^ upon one of the lower animals. This, Avere it successful, ! 
would be a cure, according to the Hahnemannic doctrine — similia similibus curan- ' 
tur — a doctrine much older, however, than Hahnemann. But the opposite maxim, 
contraria contrariis has been suggested. Mr. Morgan proposes to give such poi- j 
sons as are known to cause paralysis, with the view of countervaihng the undue 
action of the muscles in tetanus. He produces artificial tetanus by inserting a 
poison brought from Java, called "chatic," into a wound, and then relieves the 
tetanic symptoms by a North American poison, the ticunas. Professor Sewell of j 
the Veterinary College, has tried this principle in one case at least, where the tetanus j 
was the resuk, not of any poison, but of disease. Not having had an opportunity 
of getting the particulars of this case from Mr. Sewell himself, I give you Mr. : 
Mayo's account of it. " A horse, suffering from a severe attack of tetanus and i 
locked-jaw, the mouth being too firmly closed to admit the introduction of either food. ! 
or medicine, was inoculated on the fleshy part of the shoulder with an arrow-point ; 
coated with wourali poison. In ten minutes apparent death was produced. Arti- f 
ficial respiration was immediately commenced, and kept up about four hours, when ; 
/eanimation took place. The animal rose up, apparently perfectly recovered, and ; 



TETANUS. 



359 



eagerly partook of corn and hay. He was unluckily too abundantly supplied with 
food during the nig-ht. The consequence was over-distension of the stomach, of 
which the animal died the following day, without, however, having the shghtest re- 
currence of tetanic symptoms." I had fancied that the death had resulted from some 
injurious effect upon the lungs, produced by the artificial breathing. But I have 
httle doubt that Mr. Mayo derived his statement from Mr. Sewell himself. The 
experiment deserves to be carefully repeated. 

1 have but httle to say concerning what may be called the surgical treatment of trau- 
matic tetanus. It was a natural thing, the source of the irritation being supposed 
to be the wound, to expect relief from amputation of the limb. But that will not 
arrest the morbid action after it has once been fairly established. Dr. Eliiotson says he 
has searched scores of books, and found only one case in which the hmb and the 
disease were lopped away together. However, Mr. BUzard Curling, in his Essay 
on Tetanus, refers to seven instances of recovery, after the injured part had been 
amputated. Yet he states that " it is almost impossible to ascertain with certainty 
how far the amputation, in these cases, was of service. I believe I cannot offer you 
better advice on this subject than may be gathered from the concluding remarks of 
a very distinguished and philosophical surgeon, in his lectures on this disease. I 
allude to the late Mr. Abernethy, whose pupil I had the good fortune to be. He 
said, " The state of the part injured is not the sole cause of tetanus. In cases of 
tetanus I have often amputated injured fingers ; and though I did not thereby save 
my patients, yet I think that the symptoms were mitigated after such amputations. 
In such cases, then, I would not amputate any considerable member ; nor even a 
small one, unless I thought that, from the injury sustained, it would prove useless to 
its possessor, even though the case should terminate favourably." 

The tourniquet has been applied to the hurt limb ; but not, so far as I know, with 
any good effect. The most promising expedient which surgery offers is the divi- 
sion of the principal nerve proceeding to, or rather from, the seat of the injury. 
This, supposing the nerve to be known and accessible, is less formidable, less severe, 
less hazardous, less maiming, and, if we may judge from past experience, more 
effectual, too, than amputation of the part. Dr. Murray has recorded (in the 
eleventh volume of the Medical Gazette), a very interesting case, in which the 
operation was followed by most decided and instant relief. The patient was a young 
midshipman who, having, trodden on a rusty nail, which pierced the sole of his left 
foot, had kept watch the same night upon deck, the weather being very cold. The 
disease began the next day, and the symptoms ran high. It was a case, therefore, 
of severe or acute tetanus. Without loss of time, the posterior tibial nerve was divided. 
The hmb was previously cold, and, as the patient said, dead, and he had httle power 
of moving it. He could not articulate distinctly, on account of the closed state of 
his jaws. The nerve was cut through by one stroke of the scalpel : and "immedi- 
ately (says Dr. Murray) he opened his mouth with an exclamation ; and on looking 
at his countenance I was astonished at the striking improvement in it. I asked him 
how he fek, and he said he was already much belter, and that his leg had come to 
liff again." Some stiffness of the jaws and neck remained for a day or two ; but 
he soon recovered. Dr. Murray refers to another case, mentioned by Baron Larrey, 
in which division of the nerve had a similar result. 

Probably, to be successful, the operation must be early ; before the morbid con- 
dition peculiar to the disorder has had time to root itself in the nervous system. 

Although, in the present state of our knowledge, there is no one remedy or 
plan on which we can rely for the cure of this fearful malady, we may with 
much confidence lay down certain general rules, the observance of which will secure 
to the patient the best chance of a favourable resuk. 

Since any, the smallest movement, or impression made upon the surface, or upon 
the senses, will bring on the severer degrees of spasm, it is of primary importance 
to protect the patient against these sources of trouble, so sure to aggravate his suf- 
ferings, and so hkely to augment his danger. Hence if blood-leuing should be 
thought advisable, it should be done early, sufficiently, and once for all. There 
should be no repetition of venesection, or of cupping, or of leeches, unless the cir- 



S60 



HYDROPHOBIA. 



cumstances and progress of the case plainly demand them. The same remark 
applies to the frequent use of purgatives. The bowels should be well cleared in the 
outset, and then let alone. The patient should lie in a darkened room ; from which 
noise also should, as much as possible, be excluded. He should not be surrounded 
by a multitude of friends or attendants. He should be enjoined to speak, to move, 
to swallow as seldom as he can. In the severe traumatic cases, the nerve, in my 
judgment, should be promptly divided. And in all cases, there being no special 
indications to the contrary, I should be more inclined to administer wine in large 
doses, and nutriment, than any particular drug. If the tendency to mortal asthenia 
can be staved off, the disturbance of the excito-motory apparatus may, perchance, 
subside or pass away. 

There is a form of this complaint called trismus nascentium. As the name im- 
plies, it occurs in newly-born children. It is very frequent and very fatal in the 
West Indies ; coming on usually in the second week after birth. Hence it has been 
called " the ninth-day disease." Another of its names in the British settlements 
there, is " the jaw-fall ;" from the circumstance that shortly before death the lower 
jaw, which had previously been firmly pressed against the upper, drops on the 
breast. It has been said that a fourth of the infant negroes in Jamaica used to die 
of this disorder. Some persons refer it to the irritation produced by the retention 
of the meconium in the intestines ; others to irritation from the wound made by 
dividing the navel-string. A dose of purgative medicine appears to be the most 
hopeful remedy. The complaint is common, I am told, in ill-ventilated lying-in 
hospitals. Pure air must, therefore^ be desirable as an adjuvant. 

Tetanic symptoms sometimes occur (but I should think very rarely) in ague. Or 
paroxysms of tetanus return at regular intervals, and terminate by profuse perspira- 
tion : the patient being well during the intermissions. When such phenomena 
arise, the treatment proper in severe forms of ague must be adopted : what that treat- 
ment is, I shall in no long time be able, I hope, to lay before you. 

Again, tetanus is occasionally a symptom in hysteria ; and then the treatment 
applicable to hysteria must be had recourse to ; especially enemata of oil of turpen- 
tine, or the same medicine given by the mouth ; and the cold affusion. 

If the disease of which I have been speaking be dangerons, and very often fatal, 
in spite of all remedial measures, that which I propose to bring next under your 
attention is still more appaUing ; for I believe that hitherto it has been uniformly 
mortal. I know not that any one has eyer been rescued by art, or saved by the 
efforts of nature, from Hydrophobia, after that frightful disease has once declared 
itself by its characteristic symptoms. The nature of those symptoms, and the 
absence of all definite or constant traces of organic change in the dead body, suffi- 
ciently mark the disease as belonging essentially to the nervous system, and as being 
essentially a spasmodic disease also. 

What are the symptoms stated in broad outhne ? These. Excessive nervous 
irritability and apprehension ; spasmodic contractions of the muscles of the fauces, 
excited by various external influences, and especially by the sight or sound of liquids, 
and by attempts to swallow them; and extreme difficulty, amounting sometimes to 
impossibility, of drinking. 

This is one of the diseases which are produced by animal poisons ; and its course 
will be most conveniently traced if we include in our description of it the very first 
step towards its production, — the apphcation of the specific poison to the body. A 
man is bitten by a dog. After a time the symptoms proper to hydrophobia come 
on. After another interval the man is dead. Before w^e advert to the many very 
interesting points of inquiry which arise out of the contemplation of this malady, let 
us follow the tragedy from its commencement to its closing scene. 

A person is bitten, then, by a mad dog. Does the existence of rabies in the ani- 
mal modify in any way the injury thus inflicted ? No ; the wound that is made 
behaves just the same, to all appearance, as it would have behaved if the dog had 
not been rabid ; and it gradually heals. After an uncertain interval — which lies, 
for the most part, between six weeks and eighteen months, and which has been 



HYDROPHOBIA. 



361 



called the period of incubation — the following symptoms begin to be noticeable. 
The patient experiences pain, or some uneasy or unnatural sensation, in the situa- 
tion of the bite. If it has healed up, the cicatrix tingles, or aches, or feels cold, or 
stiff, or numb : sometimes it becomes visibly red, swelled, or livid ; on one occasion 
a papular eruption took place around it; sometimes it opens afresh, and discharges 
a peculiar ichor. The pain or uneasiness extends from the sore or scar towards the 
central parts of the body : i. e., if the bite has been inflicted on a limb, the morbid 
sensations extend towards the trunk. All this gives fearful notice of what is about 
to happen. This period is called the period of recrudescence. I believe it seldom 
fails to occur, although it sometimes is not noticed ; the attention of the patient, and 
of his medical advisers, being absorbed by the horrible sequel. Very soon after this 
renewal of local irritation — within a few hours, perhaps, but certainly within a very 
few days, during which the patient feels uncomfortable and ill — the specific consti- 
tutional symptoms begin : he is hurried and irritable ; speaks of pain and stiffness, 
perhaps, about his neck and throat : unexpectedly he finds himself unable to swal- 
low fluids, and every attempt to do so brings on a paroxysm of choking and sobbing, 
of a very distressful kind to behold ; and this continues for two or three days, till the 
patient dies exhausted, in the way of asthenia. 

I have seen only two examples of this terrific malady ; one in St. Bartholomew's 
Hospital, in the year 1826 ; one much more recently in the Middlesex Hospital. 
As they constitute the whole of my personal experience in the matter, I shall relate 
these cases. 

The first occurred in a coachman, the back of whose right hand had been struck, 
ten weeks previously, by the teeth of a terrier dog ; but, as both the patient and his 
fellow-servants declared, there was no wound made, no blood drawn, no breach or 
lifting of the skin ; but merely an indentation, showing where the animal's teeth had 
pressed. He was brought to the hospital on a Tuesday. On the preceding Thurs- 
day his hand had become painful, and swelled a little. On Friday the pain ex- 
tended into the arm, and became more severe. His wife stated that he had been in 
the habit of sponging his head and body every morning with cold water, but that, 
on this morning, he refrained from doing so, on account of some feeling of spasm 
about the throat. His own remark on this was, that " he could not think how he 
could be so silly." 

On Saturday the extent and the severity of the pain had still further increased. 
On this and the preceding night he got no sleep. He felt ill and drowsy on the 
Sunday, but drove the carriage to Kensington Gardens : he was, however, obliged 
to hold both whip and reins in his left hand. The pain extended to the shoulder. 
He was then bled. A slop-basin full of blood was taken, with much rehef to the 
pain ; and purgative medicine was given, which operated well. 

The next day he complained of " feeling very ill all over," and he told his medi- 
cal attendant that he could not take his draughts, because of the spasm in his throat. 
That gentleman (Mr. Macdonald), concealing his own suspicions as to the true 
nature of the disease, said, " Oh, you don't ■ hke the taste of your physic ! drink 
some water." But he declared he had the same difficulty with water. The next 
day he came to the hospital. When there, water was brought and placed before 
him in a basin, for the alleged purpose of allowing him to wash his hands. It did 
not seem to disturb him, nor to excite any particular attention. Water was then 
offered him to drink, which he took, and carried to his mouth, but drew his head 
from it with a convulsive shudder. After this, on the same morning, he was much 
questioned by several persons about the supposed cause of his illness ; and water 
was again brought him, which agitated him, and he became exceedingly distressed 
and unquiet, complaining of the air which blew upon him. 

I first s^iw him myself soon after this. He was then, to all outward appearance, 
well; lymg on his back, without spasm, without anxiety; his face somewhat 
flushed. He said he had a little headache, but no pain in the arm. His pulse 
was 132, full, and strong; his tongue moist, and shghtly furred. He appeared to 
be a very quiet, good-tempered man ; and smiled generally when he was spoken to. 

I was naturally much interested by this case, and at nine in the evening I visited 

2f 



362 



HYDROPHOBIA. 



the patient again. He was composed and tranquil. Gruel was mentioned, and 
then he sighed two or three times deeply ; then sat up, and, after a moment's look 
of serious terror, took half a spoonful of the gruel in a hurried gasping manner ; 
and said he would not take more at a time, lest the sensation should come on. He 
was desired to drink the last portion of the gruel from the basin. He accordingly- 
seized it with a hurry, carried it to his mouth with an air of determination, and 
then a violent choking spasm of the muscles about the throat ensued, the sterno- 
mastoidei starting strongly forwards. Most of the gruel was spilled over his chin ; 
and he observed that he had been too much in a hurry, or he should have managed it. 

The treatment consisted in full doses of opium, repeated at frequent intervals. On 
this visit to him I noticed, that while attempting to take some of the gruel with a 
spoon, he seemed inclined to doze as he sat. Otherwise there were no signs of his 
being overwhelmed, or even sensibly affected by the opium, unless indeed his gene- 
ral quietness was the consequence of it. He was quite rational and calm, except 
when attempting to take fluids. , 

On the Wednesday, at noon, he was in nearly the same state, but' said he was 
better. In the course of the night some morsels of ice had been given him : with 
considerable effort he swallowed two or three of these ; the third or fourth caused 
so much spasm, however, that he was obliged to throw it out of his mouth : but so 
great was his resolution that he seized it again, and, by a strong exertion, succeeded 
in swallowing it. He complained now that his mouth was and had been clammy ; 
and he champed much, and spat out a good deal of tough mucus. At his own 
request, and (as he said) that he might injure no one, a strait-waistcoat was brought, 
which he assisted in putting on. But he was perfectly tranquil then. 

I now had an opportunity of seeing him take some arrow-root. He sat up in bed. 
to eat it ; and before attempting to do so, he made hurried inspirations, and sobbings 
precisely resembling those which occur when one wades gradually into cold water. 
He swallowed small quantities of arrow-root eight or nine times, with hurry and 
ditBcuky, and with sighs that succeeded each other rapidly. He said that he felt 
the upper part of his throat narrower than it should be. He continued to take 
laudanum mixed with sugar and bread into a kind of pulp. 

By the evening of that day the disease had not made much further progress. He 
again sat up and tried to eat some thinnish gruel. While taking the basin into his 
hand, he drew back his head to a distance from it, apparently involuntarily. Fie 
took one half-spoonful with effort and distress, then sighed deeply and rapidly, or 
rather his breathing consisted of a succession of sighs at short intervals : he gave up 
the basin, and sank back on his pillow still sighing. In the course of that night he 
ceased to take the laudanum ; he could no longer attempt it. The next day he was 
still composed, though more easily irritated ; and it was found that he had .lost the 
power of moving the left arm. His pulse was 140, and much weaker than before, 
and his mental powers were failing. He gradually sank, and died in the evening, 
having repeated the Lord's Prayer an hour previously. During the last hours of 
life he had been moaning, and tossing from side to side : his bowels were purged ; 
fluid stools ran from him, and distressed him greatly. His lower extremities first 
became cold, and the coldness extended by degrees up to his chest. He hawked up 
in the course of the day a considerable quantity of ropy mucus, and much frothy 
saliva came from his mouth towards the close. As his wife was wiping this away, 
his teeth, whether by convulsive accident or otherwise, came in contact with her 
finger, and drew blood. The part was cut out; and no bad consequence followed 
that I know of. 

The examination of his body threw no satisfactory light upon the essential nature 
of the disease. Blood and serous fluid escaped on the removal of the calvarium. 
The vessels of the membranes were full, and the brain itself was motded .somewhat 
by its vascularity. There were a few spots of ecchymosis on the heart. The back 
part of the tongue was very vascular. The stomach presented the most notable 
appearance. There was a quantity of brownish-coloured mucus on its inner surface, 
and the mucous membrane had disappeared from a space about four inchfis in 
diameter at its left and larger end. That space alone was diaphanous ; its edges 



HYDROPHOBIA. 



383 



sloped inwards ; and a segment of this thin place looked exactly like a piece of china. 
On a white ground, there were inosculating vessels, some of them blue, and some 
of them of a coffee-coloured brown. I conclude that this appearance was produced 
by the action of the gastric juice after death. 

This was in some respects a remarkable case. It was remarkable for its duration. 
Dr. Bardsley, in the article on Hydrophobia in the Cyclopaedia of Practical Medicine, 
states that the patients " invariably go on from bad to worse, and finally die before 
the sixth day." Now if we reckon that stage of the complaint here referred to by 
Dr. Bardsley to have begun on the morning of Friday, when he was obliged to omit 
his sponging because of the spasm about his throat, this patient did not die till the 
middle of the seventh day. In fact it was a very protracted case, and the symp- 
toms were less violent than usual. Whether this was owing to the opium he took 
or not, it would be difficuk to determine. 

In the second of the two cases which it has been my lot to witness, the charac- 
teristic symptoms of hydrophobia were more faintly pronounced than is usual. 

On my arrival at the Middlesex Hospital, on Thursday, the 5th of October, 1837, 
I was told that a patient had been admitted (under one of my colleagues) labouring 
probably under hydrophobia. He had applied at the hospital in the middle of the 
night ; but was then sent away, after receiving some aperient pills, with assurances 
that he was only feverish and nervous. On his reapphcation in the morning, he had 
been admitted. 

I found him in the ward : a man twenty-five years old, of dark complexion and 
hair. He expressed his conviction that he was afflicted v^^ith hydrophobia ; and said 
he was prepared for his fate. I observed that every now and then he suddenly 
sighed in a very pecuhar manner ; just as I had seen the former patient sigh. This 
would happen sometimes in the middle of a sentence, while he was speaking. He 
told us that he had been bitten by a dog in the latter end of July ; the dog was swim- 
ming, and like to drown, in a canal, and upon his reaching over to lift him out of the 
water, the animal seized upon his hand. After dragging the dog out, he beat him 
for his ingratitude ; and then the dog ran off", and was pursued by a m.ob of boys, 
who had previously been pelting him as a mad dog. There was a scar on the 
middle finger of the right hand; the nail of that finger had (he said) been torn 
through, and each of the two adjacent fingers had been more slightly bitten. His 
pulse was 84 ; but varied in frequency at short intervals. 

He acknowledged that after receiving the bite he was uneasy as to its possible 
effects, and read books about hydrophobia at the time : but he affirmed that he had 
afterwards ceased entirely to think about it. He had persuaded himself that the 
dog could not be mad, from its being in the water. On Tuesday, if not earlier, he 
had been uncomfortable and restless ; and on Wednesday he found he could not 
swallow hquids. On one of these days he experienced a slight pricking sensation, 
without any redness or tenderness, in the site of the scar ; his right arm and leg 
seemed to himself hotter than the opposite limbs ; and the arm, though not tender, 
felt raw, and he could not bear the light contact of his clothes upon it. He became 
feverish also. From time to time a slight expression of terror passed across his 
features, and then he made a sudden, deep, sighing inspiration : at other times his 
breathing and appearance were perfectly natural. It was said that when some 
water was brought him he drew himself back from it with horror. He talked a 
good deal. 

I saw him eat rice, made pulpy with milk. He took it without looking at the 
spoon, from which he averted his eyes, and ate several mouthfuls, in a gulping man- 
ner, and with evident effort. His bowels had been purged by the pills, and he 
declared that the noise of the water in the water-closet had distressed him. The 
sound of some water poured from one vessel into another by the patient in the next 
bed, had also agitated him. So did the contact of my cold hand on his arm ; and 
currents of air, even the breath of any one speaking to him ; so that he insisted on 
conversing with the apothecary in such a position that the chin of each was upon 
the other's shoulder. But there was no actual or apparent spasm. 

At this time he affirmed that the presence of company cheered him, and did hinx 



I 



364 HYDROPHOBIA. ^ 

good ; and begged that he might not be removed into a separate room. And he | 
wished for some amusing book that he might read. 

In the evening I again went to see him. He did not seem worse, though he 
said " his symptoms were increasing." He had taken a dose of musk and some 
morphia. 

The next day I found the hospital in some confusion. Between eleven and twelve 
o'clock in the preceding night some of the olEiicers of the hospital had gone to his 
bed, while he was apparently asleep, and certainly very quiet. They asked him if 
he would like some water. This seems to have greatly excited him ; and imme- 
diately after their departure he rushed out of bed, (terrified he said,) became furious 
and unmanageable, and was never again tranquil till he died, about the same time j 
next night. He was now put into a room by himself; and, taking advantage of the 
momentary absence of the nurse, he boked himself in alone : and he declared he 
would admit no person but her. The door was at length forced, and a strait- 
waistcoat was put upon him. He then became quieter in his manner ; begged that 
no unnecessary violence might be used ; asked to be poisoned ; spat at some of the 
bystanders, and reproached them, talking rapidly and wildly like an insane person ; ' 
yet loudly and angrily imposing silence on every one who addressed him. He said i 
he could not bear to hear any one speak ; that he did not like my bass voice. Then I 
he would sneer at the students, and say they showed bravery enough now he was | 
confined: " Was it right for young gentlemen of education to stand there gazing f 
wkh. curiosity on a dying man ?" asked for bread soaked in water, and when it was | 
held towards him, snatched it in his mouth in a savage manner ; spoke of his " poi- ; 
soned tooth," and talked perpetually. He took a fancy to one of the students, and > 
begged that he might remain with him. 

About this time he vomited some yellow fluid, and thought he felt the better for j 
it, and asked for an emetic ; and some tartarized antimony was exhibited. He was : 
now pale, and his lips were livid ; but none of the distinctive spasmodic attacks | 
occurred : indeed water was not at this time suffered to be brought near him. This 
circumstance it was, this absence of the peculiar spasmodic paroxysms which char- | 
acterize hydrophobia, that induced several medical men of much sagacity and expe- i 
rience to doubt, and even with some positiveness to deny, that the patient was suffering ' 
under that disease at all. They supposed him to be hysterical, half-crazy, or on the | 
brink of dehrium tremens. But though shghtly expressed, the symptoms were j 
unlike anything I had ever witnessed, except in the previous instance. And the j 
closing scene was quite distinctive. i 

It appeared, and he spoke of it as a thing which distressed him, that when he was 
most excited, his urine passed involuntary. 

In the evening I found his father with him. He had recognized him, and kissed | 
his mother-in-law; but soon began to rave, and to be apparently occupied with , 
absent persons. He was pale and weak, and lay with his head over the side of the I 
bed, spitting continually upon the floor, which was thus made quite wet. He wished 
to have his hands at hberty that he might " clear his mouth." He was soliloquizing 
when I went into the room in this way : " Monsters — monsters — see that monster, 
Susan — take her away." (It appeared that he was now speaking of a young woman i 
who had had a child by him.) "I thought they would do much for science, but | 
never supposed they would inflict such agony as this ;" and so on. ; 

A little later Mr. Arnott visited him. He had then no pulse at the wrist. The 
waistcoat was removed. He sat up, and used some water, brought to wash his 
hands, without apparent distress. Soon after he sank back exhausted ; and expired, , 

His father corroborated what the patient had said of the dog ; and told us his son 
was clever, and better educated than many of his rank (he was a tailor), but always 
exceedingly nervous. 

The body was examined the next day. Its posterior and undermost surface was 
very livid. The blood everywhere quite fluid. , The veins of the spinal cord, on its 
posterior part, were turgid ; not at all so on the anterior. The substance of the cord 
was quite natural. There was some fluid in the theca. The brain appeared to me 
in every part, quite sound and healthy. 1 



HYDROPHOBIA. 



365 



The head and face, which had been hanging: over the table while the spinal canal 
was opened from behind, -were deeply purple as though universally bruised. This 
colour diminished rapidly after the corpse was placed supine, and the head raised 
somewhat above the level of the body. The papillae at the back part of the tongue 
were greatly exaggerated, and looked like large vesicles. The cartilage of the 
epiglottis, at its lower part, was red. At about the middle portion of the oesophagus 
there was an appearance as if the cuticle was abraded. The mucous membrane of 
the stomach was soft, and red here and there, with a dotted injection resembling 
ecchymosis, especially on its rugae. The air-passages were apparently healthy. 

Generally, the disease, when it has once set in, and shown the peculiar hydro- 
phobic symptoms, runs a short and fierce course. The nervous irritability becomes 
extreme. The peculiar paroxysms of choking spasm, and sobbing, are excited, not 
only by attempts to swallow Hquids, but by the very sight or sound of them. Dr. 
Elliotson mentions a boy who was thrown into a state of violent agitation by hearing 
a dresser who sat up with him make water. The passage of a gust of wind across 
his face, the waving of a polished surface, as of a mirror, before his eyes, the crawl- 
ing of an insect over his skin, is often sufficient to excite great irritation, and the 
peculiar strangling sensation about the fauces, in a hydrophobic patient. These 
circumstances were but little observable in the men whose cases I have related. The 
first of them indeed was remarkably calm and tranquil under the disease. In general 
the patient is dreadfully irritable, and apprehensive and suspicious ; and in most 
cases there is a degree of mania or delirium mixed up with the irritability ; the suf- 
ferer is very garrulous and excited. In this respect there is a marked difference 
between hydrophobia and tetanus. In the latter disorder the mental faculties are 
clear, and the patients serene, and what is called heart-whole, to the last. The two 
diseases differ in another striking particular: the spasm in the one case is tonic, in 
the other clonic. In tetanus, again, there is no thirst, and seldom any accumulation 
of tough and stringy mucus in the fauces and about the angles of the mouth ; in 
hydrophobia both these symptoms are always, I believe, present. So probably is 
vomiting; but vomiting in tetanus is rare. The nervous irritability in hydrophobia 
is doubtless a part of the disease, and is very seldom absent even now-a-days. Some- 
time ago it might perhaps have been plausibly attributed to the treatment adopted. 
I allude to that period in which it was believed that these miserable persons had both 
the power, and the inclination, to impart the disease to others by biting them ; and 
when, under pretence of shortening his sufferings, but really, I am afraid, with the 
cowardly view of protecting themselves, his friends were accustomed to smother the 
unhappy patient between two feather-beds, or to open a vein, and to leave him to 
bleed to death. Any person suspecting what was the matter, and foreseeing such a 
termination to his disease, might well be nervous and irritable. But now that this 
barbarous practice has been exploded, and the dread of being smothered does not 
occur to the mind of the patient, he is still found to be exquisitoiy irritable and timo- 
rous. The foam and sticky mucus that gather in the throat and mouth, these patients 
make great efforts, by spitting and blowing, to get rid of ; and the sounds they thus 
produce have been exaggerated by ignorance and credulity into the barking and 
foaming of a dog. In the same way the paraplegia which sometimes takes place, 
rendering the patient unable to stand upright, has been misconstrued into a desire on 
his part to go on all fours like a dog. The pulse, though it may be strong and hard 
at the outset, becomes, in a short time, frequent and feeble, and the general strength 
declines with great rapidity. Death occasionally takes place within twenty-four 
hours after the commencement of the specific symptoms. Most commonly of all it 
happens on the second or third day ; now and then it is postponed to the fifth day ; 
and in still rarer instances, of which my first case was one, death does not occur till 
the seventh, or eighth, or ninth day. In most cases the paroxysms becoming more 
violent and frequent, exhaust the patient ; but in a few instances the symptoms un- 
dergo a marked alteration before death. The paroxysms cease, the nervous irritabi- 
lity disappears, the patient is able to eat and drink, and converse with ease ; those 
eights and sounds which so annoyed and distressed hira before, no longer cause him 

2f2 



366 



HYDROPHOBIA. 



any disquiet. In this state he often sinks into a sleep, and suddenly wakes from it 
to die : sometimes his existence is put an end to by a sudden and violent convulsion. 

It is needless for me to go into a minute account of the morbid appearances that 
have been met with in persons dead of hydrophobia. They are various, uncertain, 
unsatisfactory. In some bodies the most careful examination has discovered nothing 
amiss. In others, vascularity of the brain, or of the spinal cord, has been noticed. 
And in not a few instances the mucous membrane of the fauces, oesophagus, and 
stomach — or of the larynx and trachea — or of both these tracts — has been found red, 
and covered with adhesive mucus. But we must take care not to attribute undue 
importance to these last appearances — not to conclude that they have been the cause 
of the symptoms, when, in truth, they may have been the effect of the disease. That 
we should find the parts in the throat red and congested is what we might naturally 
expect, when we consider the violent straining spasmodic action of these parts for 
some time before death. The morbid anatomy of this disease throws but little hght 
upon its nature, or upon its proper treatment. 

There are many very interesting questions, connected with hydrophobia. I will 
state the principal of these as shortly as I can. 

1. You will be surprised when I tell you that some persons have made it a ques- 
tion whether there is any such disease at all. I have known such. The late Sir 
Isaac Pennington, who was Regius Professor of Physic at Cambridge, had never 
seen a case of hydrophobia, and nothing could persuade him that any one else had 
seen any thing more than a nervous complaint produced by the alarmed imagination 
of the patient, who, having been bitten by a dog reputed to be mad, and having the 
fear of feather beds before his eyes, was frightened into a belief that he had hydro- 
phobia, and ultimately scared out of his very existence. Now if you meet with such 
incredulous persons, and think it worth your while to argue the point with them, you 
may object to their unbehef, the improbability that so many persons who have been 
bitten by mad dogs should have suffered so precisely the same train of symptoms, 
and at last have died, from the mere force of a morbid imagination. You may urge 
them with the fact that many of these persons have been under no apprehension at 
all until the disease has seized upon them ; that many also have been men of na- 
turally strong and firm minds, not at all likely to be frightened into beheving that 
they were seriously ill unless they really were so, and still less likely to be terrified 
into their graves. And if this has no weight with such reasoners, you may bring 
forward the conclusive facts that the disease has befallen infants and idiots, who had 
never heard or understood a word about mad dogs or hydrophobia, and in whom the 
imagination could have had no power in calling forth the complaint. And if they 
are proof against this, you must give them up : I can suggest nothing more. 

2. Allow that the disease exists as a real, and not merely imaginary disease, and 
also that it is caused by the bite of a rabid animal : this important question arises— 
has it any other cause ? 

Setting aside that quibbling application of the term hydrophobia, which some 
writers have chosen to make, to diseases in which, from some painful affection of 
the throat, the patients have been unwilhng to attempt to swallow fluids, there are 
cases recorded, exactly resembhng hydrophobia in their sj^mptoms, and occurring 
in persons who were never known to have been bitten by, or even to have been in 
the presence of, a rabid animal. The celebrated and accurate Pinel has given the 
history of such a case. There is another by Savirotte, in the Journal des Savans 
(August, 1757). Now it is just possible that this disease may sometimes develop 
itself in the human body without any contagion having been applied : and it is also 
possible, and much more probable, in my judgment, that the poison may have been 
apphed without the person's being aware of it. We shall see, by and by, some very 
possible ways in which that might happen. All that we need concern ourselves with 
practically, is this — that in 999 cases out of 1000 the disease in the human body is 
derived from a rabid animal. If it ever be spontaneous, we cannot reckon upon 
meeting with such a case : indeed, many medical men pass through hfe without 
witnessing the disorder at all. 



HYDROPHOBIA. 



367 



3. Granting, then, that the disease in man is the result of an animal poison, the 
next question is, from what animals may he receive the infection ? 

We are sure that the disease, by the inoculation of which hydrophobia may be 
produced in man, is common in the dog^ and that it has been communicated to the 
human animal by the fox also, the wolf, the jackal, and the cat. Mr. Youatt says 
that the sahva of the badger, the horse, the human being, has undoubtedly produced 
rabies, and some affirm that it has been propagated even by the hen and the duck. 
The same author mentions a case in which a groom became affected with hydro- 
phobia through a scratch which he received from the tooth of a horse that was 
labouring under the disease. All animals, even fowls, are susceptible of the disorder 
when bitten by the rabid dog. Of course it is an important question to have resolved, 
whether the saliva of all these is capable of conveying the malady. The case just 
now mentioned on Mr. Youatt's authority would seem to settle the question as 
respects the horse ; but as horses, cows, turkeys, &c., do not generally bite, we have 
not many opportunities of supplying a positive answer to the general question : there 
can be no doubt about the cat,, the fox^ the wolf, and the jackal. 

The late Duke of Richmond died abroad of hydrophobia, communicated, it was 
thought, by a tame fox. In the 13th volume of the Medico-Chirurgical Transac- 
tions, an account is given by Mr. Hewitt, of several cases of fatal hydrophobia from 
the bite of a wild and rabid jackal. Many examples are on record of the produc- 
tion of the disease by the bites of mad cats and wolves. 

The first case which I have spoken of, as having been seen by myself, would seem 
to prove, if all the facts were correctly stated at the time, that the saliva of the dog 
may be sufficient to produce the disease, when it is merely applied to the unbroken 
skin. It was affirmed by various persons that the teeth of the terrier did not break 
the cuticle. But we must take care not to draw a hasty general inference from a 
single case. Mr. Youatt, who has seen more of the disease probably both in man 
and in other animals, than any person alive, does not think that the saliva of a rabid 
animal can communicate the disorder through the unbroken cuticle : he believes that 
there must be some abrasion or breach of surface. He holds, however, that it may 
be communicated by mere contact with the mucous membranes. 

Of its harmlessness on the sound integument he offers this presumption — that his 
own hands have many times, with perfect impunity, been covered with the saliva 
of the mad dog. He mentions some singular instances in which the disease had 
been transmitted by contact of the saliva with the mucous membranes. " A man 
had endeavoured to untie with his teeth a knot that had been firmly drawn in a 
cord. Eight weeks afterwards he perished, undeniably rabid. It was then recol- 
lected that with this cord a mad dog had been confined. A woman was attacked 
by a rabid dog, and escaped with the laceration of her gown. In the act of mend- 
ing it she thoughtlessly pressed down the seam with her teeth. She died." If 
these cases be authentic, they are conclusive of this question ; unless, indeed, the 
hps of those who perished happened to have been chapped or abraded. But Mr. 
Youatt's own opinion is, that the virus cannot be received on a mucous surface 
without imminent danger. 

The disease is said to have been caused by the scratch of a cat. But as we know 
that cats as well as dogs frequently apply their paws to their mouths, especially 
when the latter part is uneasy, (as it clearly is in mad dogs,) this fact, of the produc- 
tion of the disease by a scratch, if thoroughly made out, would not prove that the 
disease can be introduced into the system in any other way than by means of the 
slaver. 



368 



HYDROPHOBIA. 



LECTURE XXXIV. 

Hydrophobia^ concluded. Various Questions considered respecting the Disease as 
it appears in the Human Subject, and respecting Rabies in the Bog. Pathology 
of the Disorder. Treatment. Preventive Measures. 

After giving you some account of the phenomena of hydrophobia, or rabies 
canina, I began to notice, in the last lecture, the chief of the interesting questions 
which naturally present themselves to the minds of most men, and especially of 
medical men, in respect to that shocking disorder. 

In the first place, there is such a disorder. It appears, too, secondly, from state- 
ments made upon credible authority, that the same group and succession of symp- 
toms as characterize the disease when it is produced by the bite of a rabid animal, 
have been observed to occur in persons who were never known to have been bitten. 
In my own opinion it is more probable that these persons had been exposed to the 
virus without being aware of it, than that the disease was spontaneously engendered 
in their bodies. I would make the same remark with regard to an instance which 
is said to have happened of hydrophobia in a lad w^ho had been bitten five weeks 
before by a healthy dog : the dog remaining well at the time of his seizure and 
death. Mr. Youalt holds, indeed, that however the disease originated, it never 
occurs now, not even in the dog, except as a consequence of the application of the 
specific contagion. It is certain, in the third place, that (besides the dog) the wolf, 
the fox, the jackal, and the cat, have communicated the disorder to the human ani- 
mal. Mr. Youatt affirms, that the saliva of the badger, of the horse, and of the human 
being, has caused rabies ; and I mentioned, on his authority, a case in which a groom 
contracted the disease through a scratch which he received while administering a 
ball to a rabid horse. But I feel much less certain about these latter animals. Re- 
specting the dog, the fox, the wolf, the jackal, the cat, there can be no question. 
The result of certain experiments made at the Veterinary School, at Alfort, is opposed 
to Mr. Youatt's statement. Professor Dupuy made wounds in cows and sheep, and 
rubbed upon these wounds sponges which had been chewed by rabid animals of the 
same species : yet he never succeeded in communicating the disorder in this way ; 
but when he used a sponge that had been mumbled by a mad dog, then the disease 
occurred in the sheep and cows. 

It is still more interesting to inquire, whether the saliva of a human being, labour- 
ing under hydrophobia, is capable of inoculating another human being with the same 
complaint? Mr. Youatt , says yes : that the disease has undoubtedly been so pro- 
duced. If this be so, the fact will teach us — not to desert or neglect these unhappy 
patients, still less to murder them by smothering — but to minister to their wants with 
certain precautions : so as not to suffer their saliva to come in contact with any sore 
or abraded surface ; nor, if it can be avoided, with any mucous surface. On the 
other hand, all carefulness of that kind will be unnecessary, if the disease cannot be 
propagated by the human saliva. Certainly many experimenters have tried in vain 
to inoculate dogs with the spittle of a hydrophobic man ; but there is one authentic 
experiment on record, which makes it too probable that the disease, though it may 
not be communicatee? often, or easily, is yet communicable. The experiment is said 
to have been made by MM. Magendie and Breschet, at the Hotel-Dieu, and to have 
been witnessed by a great number of medical men and students. Two healthy dogs 
were inoculated, on the 18th of June, 1813, with the sahva of a patient, named Surlu, 
who died of hydrophobia the same day in that hospital. One of these dogs became 
mad on the 27th of the following month. They caused this dog to bite others, 
which, in their turn, became rabid also : and in this way they propagated the mala- 
dy, among dogs, during the whole summer. Now this is a very striking fact, yet it 
ought not to be considered conclusive : for it is possible that the dog might have 
gone mad at that time, whether he had been so inoculated, or not. It may have 
been a mere coincidence. We want repetitions of such experiments to settle the 



HYDROPHOBIA. 



369 



point : nevertheless, we have enough in this one experiment to make us use all 
necessary caution when engaged in attending upon a hydrophobic patient. 

I just touched upon the question, whether the saliva of a rabid dog could produce 
the disease if it fell upon the sound skin? The first of the two cases which I related 
as having been witnessed by myself, would appear to give an affirmative answer to 
this question. Mr. Youatt thinks the disease would not follow such an application 
^ of the virus ; but that it cannot be received upon even the unbroken surface of a 
mucous membrane without the greatest danger. Horses are said to have died mad 
after eating straw upon which rabid pigs had died. Portal was assured that two 
dogs, which had licked the mouth of another dog that was rabid, were attacked with 
rabies seven or eight days afterwards. Mr. Oilman, of Highgate, in a little pam- 
phlet on Hydrophobia, quotes an instance from Dr. Perceval, in which a mad dog 
licked the face of a sleeping man, near his mouth, and the man died of hydrophobia, 
although the strictest search failed to discover the smallest scratch or abrasion on 
any part of his skin. 

At the very close of the lecture I observed, that even should it be clearly proved 
that hydrophobia has ever resulted from the scratch of a rabid animal's claws — the 
claws of a cat, for example — we are not to set it down as a sure thing that the dis- 
ease can be introduced into the system independently of the saliva of the diseased 
animal. As we know that dogs and cats are in the habit of putting their paws to 
their mouths when they feel uneasy there, we may readily understand how the poi- 
sonous sahva may be introduced by a mere scratch with the creature's nails. Mr. 
Youatt believes that the saliva only is capable of conveying the disease. 

4. Supposing the virus to have been inserted into the part bitten, what becomes 
of it ? Is it immediately taken into the system, and does it, like the poison of small- 
pox, in some mysterious way, mukiply and diffuse itself in the body, until the dis- 
ease explodes ? Or does it remain imprisoned in the wound, or in the cicatrix, for 
a time ? This is an important practical question. For if the poison lurks for some 
weeks in the place where it was originally deposited, we might successfully remove 
it at any time between the infliction of the bite and the period of recrudescence. 
Now, the facts that at this period of recrudescence the wound or scar is re-inflamed 
often, and almost always becomes the seat of some fresh morbid phenomena, pain, 
swelling, numbness and the like, spreading towards the trunk — and that, soon after 
this, the peculiar paroxysmal symptoms begin — these facts are strong in favour of 
the belief that the poison does lie inert in the place of the original hurt, for some 
time. Dr. Bardsley states that the recrudescent pains seem always to follow the 
course of the nerves, and do certainly never inflame or irritate the lymphatic glands 
in the vicinity, though passing in a parallel course towards the trunk. He affirms 
the entire absence of any fact contrary to this observation in the works of the nume- 
rous authors who have written on the subject. I mention this statement because it 
certainly is not correct. Mr. Mayo says, " in one case which I witnessed and exa- 
mined after death, the inner part of the cicatrix was bloodshot ; and a gland in the 
axilla had swelled at the coming on of the hydrophobic symptoms." And I fi;n,d 
among my notes of Mr. Abernethy's lectures, another striking case, still more to the 
point. " A very intelhgent boy had been bitten by a dog in the finger : he was 
brought into St. Bartholomew"* s Hospital. Caustic had been liberally used, affecting 
the sinewy parts, and producing a terrible sore : yet the boy was recovering him- 
self, and the sore was healing. One day as Mr. Abernethy was going round the 
hospital, he saw and spoke to the boy, who said he thought himself getting well, 
but that he had that day an odd sensation in his fingers, stretching upwards inta his 
hand and arm. Going up the arm, Mr. Abernethy saw two red lines, like inflamed 
absorbents : they doubtless were so. He affected to make light of the matter, ordered 
a poultice, and recommended the boy to take some medicine. Early the next morn- 
ing Mr. Abernethy visited the ward, pretending he had some other patient there 
whom he wished particularly to see : and when going out again, he asked the boy, 
in a careless tone, how he was. He said that he had lost the pain, but that he was 
very unwell, and had not slept all night. Mr. Abernethy felt his pulse, told him he 
was a little feverish, as might be expected, and asked him if he were not thirsty, 



370 



HYDROPHOBIA. 



and would like some toast and water. The boy said he was thirsty, and that he 
should like some drink ; when, however, the cup was brought, he pushed it from 
him : he could not drink. In forty-eight hours he was dead." 

Facts, such as these, would lead to the conclusion that, in cases in which ex- 
cision had not been performed in the first instance, the scar or the sore might be cut 
out with propriety at any time before the period of recrudescence : and if the case 
happened to be my own, I would have done this even at that period, the moment 
any new sensation manifested itself in the seat of the injury. Mr. Mayo, on the 
same grounds, advocates the removal of the cicatrix, even although the hydrophobic 
symptoms may have appeared. I do not mean to say that the facts now referred to, 
show with any certainty that the poison remains in the place where it was first de- 
posited, until the phenomena of recrudescence take place : but they afford some 
presumption in favour of that notion ; and in such a disease as hydrophobia, we are 
bound to act upon the very lowest presumption that affords a chance for our patient's 
hfe. The poison may be absorbed into the general system at the period of recru- 
descence, although no affection of the absorbing vessels or glands should be mani 
fest : through the veins, namely. 

Considering the matter philosophically, we might be inclined to suppose that the 
poison was silently maturing its force in the general system during the period of in- 
cubation, just as the poisons of small-pox and of measles are presumed to do. But 
looking at it practically, I should recommend, under the circumstances already 
stated, the excision of the cicatrix. 

5. Another important question is this. Is a man who has been bitten by a mad 
dog, and in whose case no precautions have been taken, a doomed man ? will he be 
sure to have the disease, and therefore to die of it ? By no means. But few, upori 
the whole, of those which are so bitten, become affected with the hydrophobia. 

It is curious that different species of animals appear to be susceptible of hydro- 
phobia in different degrees. Thus, according to Mr. Youatt, two dogs out of three, 
bitten by one that is rabid, become rabid. The majority of horses inoculated with 
the virus, perish. Cattle have a better chance : perhaps because in them the skia 
is looser and less easily penetrated. A full half (he thinks) of those that were 
seized by a mad dog, would escape. With sheep the bite is still less dangerous. 
He reckons that not more than one in three would be affected. The tooth, perhaps, 
has been wiped clean in its passage through the wool. The human being is least of 
all in danger. John Hunter states that he knew an instance in which, of twenty- 
one persons bitten, one alone fell a victim to hydrophobia. Dr. Hamilton estimates 
the proportion to be one in twenty-five. But I fear these computations are much 
too low. In 1780, a mad dog, in the neighbourhood of Senhs, took his course 
within a small circle, and bit fifteen persons before he was killed : three of these 
died of hydrophobia. The slaver of a rabid wolf would seem to be highly virulent 
and effective. These beasts fly always, I believe, at a naked part. Hence, probably, 
the fatality of their bites. The following statement applies exclusively to the wolf. 
In December, 1774, twenty persons were bitten in the neighbourhood of Troyes ; 
nine of them died. Of seventeen persons similarly bitten in 1784, near Brive, ten 
died rabid. In May, 1817, twenty-three persons were bitten and fourteen perished. 
Four died out of eleven that were bitten near Dijon : and eighteen of twenty-four 
bitten near Rochelle. At Bar-sur-Ornain, nineteen were bitten, of whom twelve 
died of hydrophobia within tv*^o months. Here we have one hundred and fourteen, 
persons bitten by rabid wolves, and among them no less than sixty-seven victims ; 
considerably more than one-half. There is no doubt, however, that the majority of 
persons who are bitten by a mad dog escape the disease. This may partly be 
owing to an inherent inaptitude for accepting it. We see some persons who, though 
often in the way of it, do not contract syphilis ; there are others upon whom the 
contagion of small-pox has no influence. This difference exists, apparently, even 
among dogs. There was once a dog, at Charenton, that did not become rabid after 
being bitten by a rabid dog ; and it was so managed that, at different times, he was 
bitten by thirty different mad dogs ; but he outhved it all. Much will depend also 
upon the circumstances and manner in which the bite is inflicted. If it be made 



HYDROPHOBIA. 



371 



through clothes, and especially through thick woollen garments, or through leather, 
the saliva may be wiped clean away from the tooth before it reaches the flesh. In 
the fifth volume of the Edinburgh Medical and Surgical Journal, there is a case 
described by Mr. Oldknow, of Nottingham, in which a man was bitten in three dif- 
ferent places by the same dog ; viz., in the scrotum, the thigh, and the left hand ; 
the bite on the hand was the last. Now it seems not improbable that but for this 
last bite, on a naked part, he might have escaped. At least it was a remarkable 
circumstance that the phenomena of recrudescence occurred only in the hand and 
arm. The dog is supposed to have closed his mouth after inflicting the first two 
bites ; and thus to have charged his teeth afresh with the poisonous saliva. 

It is this frequent immunity from the disease in persons who have been bitten, 
that has tended to confer reputation upon so many vaunted methods of prevention. 
Ignorant persons, and knavish persons, have not failed to take advantage of this. 
They announce that they are in possession of some secret remedy which will prevent 
the virus from operating: they persuade the friends of those who die that the 
remedy was not rightly employed, or not resorted to sufliciently early : and they 
persuade those who escape that they escape by virtue of the preventive remedy. 
If the plunder they reap from the foolish and the frightened was aU, this would 
be of less consequence : but unfortunately the hope of security without under- 
going a painful operation, leads many to neglect the only sure mode of obtaining 
safety. 

Mr. Youatt is of opinion that the power of the virus ceases with the life of the 
animal. He states, that in many dissections of the dog, the saliva, in spite of all 
care, must have come in abundant contact with his hands, and they were not always 
sound. I should strongly recommend you not to act upon this opinion : but to use 
the same precautions, in dissecting a rabid animal, as you would use if you were 
persuaded that the disease might be communicated with equal certainty before and 
after the death of the animal. 

6. A still more anxious inquiry next arises. Whoever has been bitten by a 
rabid or a suspected animal, must be considered, and will generally consider himself 
as being in more or less danger of hydrophobia. This dread is not entirely removed, 
even by the adoption of the best means of prevention. Now, how long does this 
state of hazard continue ? When is the peril fairly over ? After what period may 
the person who has received the injury lay aside all apprehension of the disease ? 
To this inquiry no satisfactory reply can be given. In a vast majority of instances, 
indeed, the disorder has broken out ivithin two months from the infliction of the bite. 
But the exceptions to this rule are too numerous to permit us to put firm trust in 
the immunity afforded by that interval. Cases are recorded in which five, six, 
eleven, nineteen months have intervened, between the insertion of the poison and 
the eruption of the consequent malady. Nay, in one instance, three years are said 
to have elapsed, and in another the enormous period of twelve years. In these 
cases one cannot help supposing that some unsuspected re-inoculation, some fresh 
application of the peculiar virus, must have taken place. If not, then we must con- 
clude that the poison really lies imprisoned in the part ; and only becomes destructive, 
when, under certain obscure conditions, and at indefinite periods, it is set afloat in the 
circulating blood. 

It is interesting to know that the same uncertainty of access has been noticed 
among infected dogs. On the night of the 8th of June, 1791, the man in charge of 
Lord Fitzwilliam's kennel was much disturbed by the hounds fighting; and got up 
several times to quiet them. On each occasion he found the same dog quarrelling ; 
at last, therefore, he shut that dog up by himself, and then there was no further dis- 
turbance. On the third day afterwards, the quarrelsome hound became unequivocally 
rabid ; and on the fifth day he died. The whole pack were thereupon separately 
confined and watched. Six of the dogs became subsequently mad ; and at the 
following widely different intervals from the 8th of June, viz., 23 days, 56, 67, 88, 
155, and 183 days. 

There are some considerations respecting this disease which relate both to the 
biter and the bitten ; the canine and the human being. And there are some which 



372 



HYDROPHOBIA. 



relate exclusively to the dog, yet concerning which, we, as medical philosophers, 
ought not to be ignorant. I shall advert to a few of these. 

One question I have already glanced at, viz., whether the disease may be pro- 
duced by a healthy, though angry dog or cat. I referred to one instance in which 
this was supposed to have been the case ; and I repeat that I should be more inclined 
to think, unless we had other examples of the same kind, that the person had been 
inoculated in some way that he was not aware of. But I have heard Mr. Youatt 
describe cases in which there had been no symptoms of rabies observed in the dog 
at the time the injury was inflicted, though soon afterwards the animal became 
decidedly rabid. It is much to be regretted that the dog is so often destroyed. When 
a person has been bitten by a dog or cat suspected to be rabid, the beast ought by 
no means to be killed, but to be secured, and kept under surveillance, and suffered, 
if it shall so happen, to die of the disease. If he does not die, in other words, if he 
is really not rabid, that will soon appear; and the mind of the patient will then be 
relieved from a very painful state of suspense and uncertainty, which might other- 
wise have haunted him for months or years. If the dog dies mad, the injured person 
will be no worse off than if the animal had been killed in the first instance : nay, 
in one respect, he will be better off, inasmuch as certainty of evil is preferable to 
perpetual and uneasy doubt. " Give a dog a bad name (says the proverb), and hang 
him :" and it is Hterally so with the imputation of madness. A poor wretch of a 
dog is perhaps ill, or weary, or cross, or he may have been worried already by mis- 
chievous boys : the cry of mad dog is raised ; and then he can expect no mercy. 
There are gross errors prevalent with regard to the signs of madness in the dog. 
If a dog be seen in a fit in the street, some person charitably offers a conjecture that 
perhaps he may be mad ; the next person has no doubt of it ; and then, woe to that 
dog ! But Mr. Youatt assnrps us that the rabid dog never has fits : that the exist- 
ence of epilepsy is a clear proof that there is no rabies. Again, it is a very common 
belief that a rabid dog, like a hydrophobic man, will shun water; and if he takes 
to a river, that is thought to be conclusive evidence that he is not mad. But the 
truth is, that the disease, in the quadruped, cannot be called hydrophobia : there is 
no dread of water, but an unquenchable thirst ; no spasm attending the effort to 
swallow, but sometimes in dogs an inability to swallow, from paralysis of the muscles 
about the jaws and throat. They will stand and lap, lapping, without getting any 
of the liquid down. They fly eagerly to the water ; and Mr. Youatt states that all 
other quadrupeds, with, perhaps, an occasional exception in the horse, drink with 
ease, and with an increased avidity. This erroneus impression is not confined to the 
vulgar. In the case which I have more than once alluded to, and which is men- 
tioned in Hufeland's Journal, of a lad who died of hydrophobia after having been 
bitten by a dog that had not been, and was not then, mad, one circumstance stated in 
evidence of the animal's freedom from rabies is, that he drank without difficulty a 
large quantity of water. 

There is another superstitious opinion not at all uncommon, viz., that healthy dogs 
recognize one that is mad, and fear him, and run away from his presence, in conse- 
quence of some mysterious and wonderful instinct, warning them of danger. This 
is quite unfounded. Equally mistaken are the notions that the mad dog exhales a 
peculiar and offensive smell, and that he may be known by his running with his tail 
between his legs ; except, as Mr. Youatt says, when, weary and exhausted, he is 
seeking his home. 

It will not be out of place to state what are the Symptoms of rabies as observed in 
the dog, and as described by Mr. Youatt. 

The earliest symptoms of madness in the dog (he says), are suUenness, fidgeti- 
ness, continual shifting of posture, a steadfast gaze expressive of suspicion, an ear- 
nest Hcking of some part, on which a scar may generally be found. If the ear be 
the affected part, the dog is incessantly and violently scratching it. If it be the foot, 
he gnaws it till the integuments are destroyed. 

Occasional vomiting and a depraved appetite are very early noticeable. The dog 
will pick up and swallow bits of thread or silk from the carpet, hair, or straw, even 
dung : and frequently he will lap his own urine, and devour his own excrement. 



HYDROPHOBIA. 



373 



Then the animal becomes irascible ; flies fiercely at strangers ; is impatient of cor- 
rection ; seizes the whip or stick ; quarrels with his own companions ; eagerly hunts 
and worries the cats ; demolishes his bed ; and if chained up, makes violent efforts 
to escape, tearing his kenne] to pieces with his teeth. If he be at large he usually 
attacks only those dogs that come in his way ; but if he be naturally ferocious he 
will diligently and perseveringly seek his enemy. According to Mr. Youatt, the 
disease is principally propagated by the fighting dog in towns ; and by the cur or 
lurcher in the country : by those dogs, therefore, which minister to the vices of the 
lower classes in town and country respectively. He maintains that if a well- 
enforced quarantine could be established, and every dog in the kingdom confined 
separately for seven months, the disease might be extirpated. This opinion is founded 
of course upon the belief that rabies never originates at present, any more than 
small-pox does, spontaneously ; but is always propagated by the specific virus. And 
it is corroborated by the fact that rabies and hydrophobia are unknown in some 
countries. I fancy that South America is, or was, a stranger to it. It appears to 
have been imported into Jamacia, after that island had enjoyed an immunity from 
the disease for at least fifty years previously ; and Dr. Heineken states that curs of 
the most wretched description abound in the island of Madeira ; that they are 
afflicted with almost every disease, tormented by flies, and heat, and thirst, and 
famine, yet no rabid dog was ever seen there. On the contrary, 1666 deaths from 
hydrophobia in the human subject, are stated to have occurred in Prussia in the 
space of ten years. 

Very early in the disease, as it appears in the dog, the expression of countenance 
is remarkably changed ; the eyes glisten, and there is slight strabismus. Twitch- 
ings of the face come on. About the second day a considerable discharge of saliva 
commences ; but this does not continue more than ten or twelve hours, and is suc- 
ceeded by insatiable thirst: the dog is incessantly drinking, or attempting to drink: 
he plunges his muzzle into the water. When the flow of saliva has ceased he ap- 
pears to be annoyed by some viscid matter in his fauces ; and in the most eager and 
extraordinary manner he works with his paws at the corners of his mouth, to get rid 
of it : and while thus emplpyed he frequently loses his balance and rolls over. 

A loss of power over the voluntary muscles is next observed. It begins with the 
lower jaw, which hangs down, and the mouth is partially open ; but by a sudden 
effort the dog can sometimes close it, though occasionally the paralysis is complete. 
The tongue is affected in a less degree. The dog is able to use it in the act of lap- 
ping : but the mouth is not sufficiently closed to retain the water. Therefore, while 
he hangs over the fluid, eagerly lapping for several minutes, it is very little or not 
at all diminished. The paralysis often attacks the loins and extremities also. The 
animal staggers about, and frequently falls. Previously to this he is in almost inces- 
sant action. Mr. Youatt fancies that the dog is subject to w^hat we call spectral illu- 
sions. He says he starts up and gaze^^ eagerly at some real or imaginary object. 
He appears to be tracing the path of something floating around him, or he fixes his 
eye intently upon some spot in the wall, and suddenly plunges at it; then his eyes 
close, and his head droops. 

Frequently, with his head erect, the dog utters a short and very peculiar howl; 
or if he barks, it is in a hoarse inward sound, altogether dissimilar from his usual 
tone, and generally terminating with this characteristic howl. Respiration is always 
affected : often the breathing is very laborious ; and the inspiration is attended with 
a very singular grating, choking noise. On the fourth, fifth, or sixth day of the dis- 
ease, he dies : occasionally in slight convulsions, but oftener without a struggle. 

Mr. Youatt gives a detailed account of the appearances met with after death in. 
the carcases of these rabid dogs. They are not very constant or distinctive. The 
most curious and uniform consist in the presence of unnatural ingesta in the stomach ; 
straw, hay, hair, horse-dung, earth. Sometimes the stomach is perfectly distended 
with these substances ; and when it contains none of them, there is a fluid of the 
deepest chocolate colour mixed with olive ; or still darker, like coffee : and when 
neither the unnatural ingesta nor the dark fluid appear, it will be found, Mr. Youatt 

2g 



374 



HYDROPHOBIA. 



says, upon careful inquiry, that the dog has vomited much hair, hay, straw, or the 
like. 

In 1837, a few days after the case of hydrophobia occurred in the Middlesex Hos- 
pital, I saw the carcass of a dog, that had died rabid, examined by Mr. Ainslie at his 
and Mr. Youatt's Infirmary. The most remarkable morbid appearances were in the 
stomach, which contained some bits of straw and stick, and a considerable quantity 
of a dark fluid like thin treacle. In various parts of the stomach there were spots 
almost black, of a considerable size ; apparently produced by dark blood partly extra- 
vasated beneath, and partly incorporated with, the mucous membrane. 

I believe that Mr. Youatt's opinion, already mentioned, of the cause of rabies ir. 
dogs, and in all creatures — viz., that it always results from the introduction of a spe 
cific virus into the system — I beheve this opinion is not commonly entertained. 
Most people think that the disease is generated, de novo, in the dog at least ; and 
causes have been assigned for it which certainly are not the true or the sole causes. 
Thus hydrophobia in the dog has been ascribed to extreme heat of the weather. It 
is thought by many to be particularly likely to occur in the dog-days ; and to be, as 
Mr. Mayo observes, " a sort of dog-lunacy, having the same relation to Sirius that 
insanity has to the moon : which, indeed, in another sense, is probably true." Many 
cautions are annually put forth, about that period, for muzzling dogs, and so on : 
very good and proper advice, but, if those who have noted the statistics of the dis- 
ease may be depended upon, it would be as appropriate at one period of the year as 
at another. Rabies occurs nearly as often in the spring, in the autumn, and even in 
winter, as it does in summer. M. TroUiet, who has written an interesting essay on 
rabies, states that January, which is the coldest, and August, which is the hottest 
month in the year, are the very months which furnish the fewest examples of the 
disease. The disorder has often been ascribed to want of water in hot weather, and 
sometimes to want of food. But MM. Dupuytren, Breschet, and Magendie, have 
caused both dogs and cats to perish with hunger and thirst, without producing the 
smallest approach to a state of rabies. At the Veterinary School at Alfort, three 
dogs were subjected to some very cruel but decisive experiments. It was during 
the heat of summer, and they were all chained in the full blaze of the sun. To one 
salted meat was given ; to the second water only ; and to the third neither food nor 
drink. They all died; but none of them became rabid. Nor does the supposition 
that the disorder has some connection with the period of sexual heat in these ani- 
mals appear to have any better foundation. 

If you are desirous of knowing what my own opinion on this matter is, I must 
say that I think Mr. Youatt's doctrine by far the most probable one ; that rabies 
never occurs except from inoculation of the specific virus. It has never been proved, 
and indeed it would scarcely be susceptible of proof, that the disease ever breaks out 
spontaneously ; large tracts of country are totally free from it ; and in nineteen cases 
out of twenty, perhaps, we trace the bite,^or the fray in which the inoculation has 
been effected. 

If I were asked to define the seat of this terrible disease, I should place it, without 
hesitation, in that division of the nervous system which comprises the excito-motory 
apparatus ; the true spinal marrow, with its appendages of afferent and efferent 
nerves. Nay, I should go further, and sa)^ that it is the upper part of this appara- 
tus, of which the functions are primarily and chiefly deranged: that the poison acts 
mainly upon the nervous arcs which pertain to the throat, and with which the eighth 
pair of nerves in particular is connected. There is nothing singular in this locahza- 
tion of the influence of a specific poison. The ergot of rye affects principally those 
arcs which belong to the uterus; cantharides, those which govern the muscular 
fibres of the bladder. It is true that the mental functions are remarkably modified, 
and that paralysis of the lower extremities occurs, in most instances of the disease. 
But neither of these phenomena is constant ; and they simply illustrate, when they 
do happen, the facility with which any morbid state of the spinal cord may propa- 
gate its influence in either direction. Whether, in hydrophobia, the essential change 
be centric or eccentric, cannot be determined with any thing like certainty : but it 
seems to me to be most probable that the sensibility of the afferent nerves of the 



HYDROPHOBIA. 



375 



fauces, of the skin, and of the air-passages, is altered or morbidly exalted ; whence, 
upon the application of the exciting stimulus, the peculiar sighing dyspnoea, and the 
strangling dysphagia, are produced by a reflected influence through the central axis 
upon the muscles concerned in these actions. But, as I said before, the pathology 
of the excito-motory apparatus is as yet in its new birth. 

What can I say of the treatment in hydrophobia, or in rabies 1 There is no well- 
authenticated case on record, that I am aware of, in which a hydrophobic person has 
recovered. As it has been, so it is still, larpo? iatai davatoi. The physician that cures 
is death. There can be no ground therefore for the recommendation of any espe- 
cial drug, or form of medicine, nor even for any general plan of treatment, after the 
peculiar symptoms of the disease have once set in. 

Of course those powerful remedial agencies that are in common use among medi- 
cal men, have been fairly tried ; copious blood-letting, mercury, opium, arsenic, 
sugar of lead, oil of turpentine, the cold afllision even : and not only those, but the 
strong poisons that are sometimes, but not so generally, employed for other diseases : 
belladonna, stramonium, prussic acid, white hellebore, strychnia, cantharides, the 
nitrous oxide gas : and no end of less gigantic remedies ; such as alkalies, and espe- 
cially ammonia, carbonate of iron, electricity and galvanism, tobacco-juice and the 
guaco (which was introduced into this country a few years ago with high encomi- 
ums for its power over the disease), the mineral acids, violent exercise : and if we 
take into account the substances administered to the brute also, we may increase 
this list by the alisma plantago, Scutellaria, box, and rue, all of which, at one time 
or another, have been vaunted as successful remedies, veratrum sabadilla, and ticu- 
nas poison. 

The difficulty of swallowing fluids, and in some cases of swallowing at all, is a 
serious obstacle to the fair trial of almost every form of internal remedy. It has 
been proposed to introduce powerful medicines into the rectum, in clysters ; but to 
this also the patients have been found to make great resistance. The injection of 
medicines into the veins has been tried. Magendie hoped that he had discovered a 
cure, in first largely bleeding the patient, and then injecting his veins with a corres- 
ponding quantity of warm water : but it has always happened with this, and with 
other promising experiments, that just as the patient seemed to be about to recover, 
he has died. The nervous irritability has in one instance or two been much calmed 
by the injection of a solution of a salt of morphia into the veins. In a case treated 
by Professor Todd the symptoms appeared to be greatly mitigated for a time, by 
applying ice to the cervical portion of the spine, and to the fauces. 

Mr. Mayo has suggested bronchotomy : upon this ground (to use his own words), 
*' that the principal character of the disease, and the rapid exhaustion which attends 
it, appear to depend in great part upon the fits of spasm and closure of the glottis, 
brought on, not merely by the attempt, or the idea of drinking, but by any sudden 
impression upon the senses. Now it is clear (he adds) that as far as the distressing 
feehngs in the throat consist in a sense of suffocation, they would be put an end to 
or relieved by the establishment of a free opening in the windpipe." Dr. Marshall 
Hall would use, in combination with tracheotomy, the hydrocyanic acid. Now I 
should be sorry to say any thing to damp your reasonable hope of benefit from any 
experiment ; but I am bound to confess to you that I should not expect the smallest 
advantage from tracheotomy in this disease. The mode of death offers no encour- 
agement to its use. There may be spasm of the glottis, but I doubt it. At any rate 
the patients do not die of sufibcation. The death is not death by apncea, but by 
asthenia. We see persons labouring grievously for their breath for hours together, 
who yet survive, and are presently themselves again ; persons, for instance, who are 
affected with severe spasmodic asthma. I have seen a man sitting up in bed a whole 
night long, inspiring with such difficulty that, if I had not been aware of his having, 
scores of times, been as bad before, I should not have thought he could exist five 
minutes longer. Now we have nothing of this dyspnoea in hydrophobia : and, as I 
Eaid already, I am sorry, and diffident too, when 1 differ from great authorities on 
practical points, but I see no hope of cure, nor even of sufficient benefit to counter- 
balance the inconvenience and hazard of the operation from the performance of 



376 



HYDROPHOBIA. 



bronchotomy. The principle is that of suffering the parts gradually to recover 
themselves, and of allowing the patient in the meanwhile to breathe through another 
channel. The principle is excellent (as I shall show you by and by), where there is 
a permanent obstacle to the admission of air to the lungs through the larynx ; but in 
hydrophobia there is no such permanent obstacle to surmount. Though your patient 
in laryngitis should be at the point of death, yet open his wind-pipe, and he breathes 
ag-ain and is safe ; but it is not at all uncommon for a hydrophobic patient to lose his 
spasms, to swallow well, and to breathe easily, yet he does not recover. This amend- 
ment is the prelude of death, the last flicker of the expiring lamp. Since I lectured 
upon this subject last year. Dr. Latham has told me the following circumstance 
respecting a patient whom he treated for hydrophobia, in the Middlesex Hospital. 
He went one day to the ward, fully expecting to hear that the patient was dead. But 
he found him sitting up in his bed, quite calm, and free from spasm : and he had 
just drunk a large jug of porter. "Lawk, sir (said a nurse who sat by), what a 
wonderful cure !" The man himself seemed surprised at the change. But he had 
no pulse ; his surface was cold as marble. In half an hour, he sank back, and 
expired. Furthermore the experiment in question has been tried, and it has been 
tried by its proposer, Mr. Mayo, upon- the dog, without affording, as Mr. Youatt 
assures us, the shghtest rehef. In the matter of cure, surgery, I fear, is as impotent 
as physic. 

Not so, however, in the matter of prevention : this is the most important part of 
the practice. The early and complete excision of the bitten part is the only measure 
in which we can put any confidence : and even here we are met with a source of 
fallacy. In the majority of cases no hydrophobia would ensue, though nothing at 
all were done to the wound. How can we know, then, that the disease is ever pre- 
vented by its excision ? No doubt many persons go through the pain of the operation 
needlessly. But in no given case can we be sure of this. They get at any rate relief 
from the most harassing suspense, with which they would probably have been tortured 
for months. And if a large number of bitten persons, who had suffered the wound 
to heal as it would, could be compared with an equal number who had had the bitten 
part cut out, hydrophobia would be found a frequent consequence of the bite in the 
first class — a very rare consequence of it in the second. Mr. Youatt, who trusts to 
caustic, and who has himself been bitten seven times, and is yet ahve and well, tells 
us that he has operated, with the caustic, on more than four hundred persons, all 
bitten by dogs, respecting the nature of whose disease there could be no question ; 
and that he has not lost a case. One man died of fright, but not one of hydrophobia. 
Moreover, a surgeon of St. George's Hospital told him that ten times that number 
had undergone the operation of excision there, after being bitten by dogs (all of 
w^hich might not, however, have been rabid), and that it was not known that any one 
had been lost. Mr. Youatt, I say, trusts to caustic ; and the caustic he uses is the 
nitrate of silver. But I advise you to trust to nothing but the knife, if the situation 
of the bite will allow you to employ it effectually. If the injury be so deep or 
extensive, or so situated, that you cannot remove the whole surface of the wound, 
cut away what you can ; then wash the wound thoroughly, and for some hours 
together, by means of a stream of warm water, which may be poured from a tea- 
kettle ; place an exhausted cupping-glass from time to time over the exposed wound ; 
and finally apply to every point of it a pencil of lunar caustic. If you cannot get 
the solid caustic in contact with every part, you had better make use of some hquid 
escharotic : the nitric acid, for example. In my own case — and what I should choose 
for myself I should advise for another — if I had received a bite from a decidedly 
rabid animal upon my arm or leg, and the bite was of such a kind that the whole 
wound could not be excised, my reason would teach me to desire, and I hope I 
should have fortitude enough to endure, amputation of the hmb, above the place of 
the injury. 

But if the wound is of such a size, and in such a part, that it can be excised, what 
is the proper way of cutting it out? Were I to give you any opinion, as from 
myself, upon that point, you might think, perhaps, that I was stepping beyond my 
proper province. 1 shall, therefore, again retail to you the advice of my old master, 



HYDROPHOBIA. 



377 



Mr. Abernethy. " The cell (he says) into which a penetrating tooth has gone, must 
be cut out. Let a skewer be shaped, as nearly as may be, into the form of the tooth, 
and then be placed in the cavity formed by the tooth ; and next let the skewer, and 
the whole cell containing it, be removed by an elliptical incision. We may examine 
the removed cell, to see if every portion with which the tooth might have con)e in 
contact has been taken away : the cell may even be filled with quicksilver, to see if a 
globule will escape. The efficient performance of the excision does not depend upon 
the extent, but upon the accuracy, of the operation." Mr. Abernethy was of opinion 
that when once the poison had been imbibed into the system, nothing ever bad done 
good, and nothing, probably, ever would. I should be sorry to be so absolutely 
despairing in respect to a disorder from which dissection after death discloses no 
reason why the patient might not recover. He used to add, that as bleeding had 
been much extolled, had he hydrophobia he would allow a surgeon to bleed him, 
even to death. Like Seneca he would be willing to have his veins opened, though 
his disease might not permit him to indulge at the same time, like Seneca, in the 
luxury of a warm bath. 

I say early excision is the only sure preventive ; but let me repeat that it will, in 
all suspicious cases, be advisable, if, for any reason, the operation has been omitted 
in the first instance, to cut out the wound, or the cicatrix, within the first two monihs, 
or at any time before the symptoms of recrudescence have appeared. One would 
do it, though with less hope, as soon as possible after they had appeared ; but i do 
not expect to hear of excision being successful then in stopping the disease. Dr. 
Bright has recorded a case in which the arm was amputated upon the supervention 
of tingling, and other symptoms, in the hand, in which the patient had been bitten 
some time before ; but the amputation did not save him. 

It has been proposed to fill the wound with ink, and then to wash it until every 
trace of the ink is gone ; in this way, it is conceived, the complete ablution of the 
poison also will be ensured. With a timid or an obstinate patient, who would not 
submit to the knife or the caustic, some such expedient ought to be diligently tried ; 
but it would be better to try it after the excision, or after the appHcation of the escha- 
rotic substance. It is impossible to take superfluous pains to obviate so fearful a 
disease as hydrophobia. 

It has been recommended, after the wound has been excised or cauterized, that it 
should be prevented from healing, and made to discharge for a long time, by means 
of irritating applications. This may be advisable when thorough excision, or com- 
plete cauterization, cannot be effected ; but I should think it quite useless as auxihary 
to those expedients, and only likely to keep up, or to produce, a hurtful irritability 
of the system. 

I should perhaps have rrientioned before, a theor}'-, and a plan of preventive treat- 
ment, which made a great figure in all the journals, foreign and domestic, a few years 
ago. It was pretended by a Russian physician. Dr. Marochetti, that some time be- 
tween the third and the ninth day after a person has been inoculated with the hydro- 
phobic poison, by the bite of a rabid dog, small pustules appear on or about the 
fraenum of the tongue, containing a small quantity of sanious fluid, of a yellow or 
greenish colour. Pustules of the same kind were declared to exist also under the 
tongues of the mad dogs themselves. Now Dr. Marochetti pretended further, that 
if, from the very time of the bite, you gave the patient large doses of the decoction 
of broom tops, and looked out for the eruption of these pustules, which seldom lasted 
more than twenty-four hours, you might infalhbly prevent the disease by opening 
and emptying the pustules, and then cauterizing them with a red-hot iron ; and after- 
wards causing the patient to gargle his mouth with that same decoction of broom. 
He held that the poison was deposited there for a short time, and then re-absorbed 
into the system ; and he proposed to prevent such re-absorption. This was a very 
pretty theory ; and took mightily in the medical world. But it has turned out d: sort 
of hoax. I do not mean a wilful hoax on the part of Dr. Marochetti ; for I have no 
doubt that he contrived to hoax himself. These pustules have been looked for again 
and again ; but they have never been discovered in Englishmen affected with hydro- 
phobia ; nor in Enghsh mad dogs. The truth seems to be that the mucous follicles 

2g2 



378 HYDROPHOBIA. 

of the mouth, generally, and those at the base of the tongue, and those beneath the 
tongue, in particular, are commonly enlarged and exaggerated in the dog, and in the 
human animal, labouring under the disease ; and these enlarged and altered follicles 
were regarded by the Russian physician as a specific eruption, which furnished the 
virus and pabulum of the complaint. 

As almost every drug that has ever been included in any Pharmacopoeia has been 
administered with the hope of checking the disease, so a great number of medicines 
and measures have been praised as preventives. Some people have great faith in 
sea bathing ; and they go to the coast to be ducked and half drowned every day for 
six weeks : and if they escape hydrophobia they conclude that the immersion in the 
salt water has saved them. Some of the specifics, as you may suppose, are great 
secrets ; and they who possess them — whether they beheve in them or not is another 
matter — sell them at no cheap rate to those who, having been bitten by the dog, are 
weak enough to be bitten again by the quack. The composition of several of them 
has transpired ; and they are found to consist either of ingredients the most insigni-! 
ficant and worthless, or of poisons of which the inefficacy had already. been ascer^ 
tained. The celebrated pulvis antilyssus, which was introduced by no less a person 
than Dr. Mead, into the London Pharmacoposia, was a mixture of ash-coloured 
liverwort and black pepper. The Ormskirk medicine, long famous, and scarcely 
obsolete yet in the north of England, was made up of bole armeniac, alum, chalk, 
elecampane, and oil of aniseed. The Tonquin medicine was composed of cinnabar 
and musk : and the Tanjore pills were a combination of mercury and arsenic. Even 
now scarce a year elapses but some correspondent of the newspapers, whose philan- 
thropy is more conspicuous than his judgment or his knowledge, recommends a new 
and infallible preventive. I confess to you that 1 have not the shghtest faith in any 
one of them ; but as I have a great respect for Mr. Youatt, and as he is not quite so 
sceptical as I am on this point, and as patients or their friends will insist upon the 
adoption of protective measures sometimes, when the local means of prevention 
have been omitted or imperfect, I will tell you what he (Mr. youatt) has done in 
respect to these prophylactic drugs. 

In the first place he never succeeded in curing the disease in the dog with any 
thing that he had ever tried. 

In the way of prophylaxis, he experimented with a great number of substances. 
He thought that the box-wood, which is the basis of some celebrated preventive 
drinks in Hertfordshire and Kent, had some efl^ect. He tried the alisma plantago, the 
boasted efficacy of which had been strictly inquired into by the magistracy of Toula, 
and the receipt purchased by the Russian government at an immense price. But 
he had no success with it. He then put the belladonna to the test, beginning with 
two grains, and increasing the dose to a scruple twice every day, and continuing this 
for six weeks : and he says he is confident that he saved several dogs ; but he lost 
almost as many. They all became debihtated and most rapidly emaciated. 

Then, in the year 1820, his attention was directed to the Scutellaria lateriflora, 
which Dr. Spalding, an American physician, had found highly successful as a pre- 
ventive of rabies: and upon trial of it, he soon was brought to regard it as really 
valuable : and (not to tire you with a detail of his proceedings in the interim) he at 
length combined it with belladonna: "and the resuU" (I here quote his own' lan- 
guage) "has been a medicine which I cannot, dare not, call a specific; for it has 
failed : but the use of which, in the cases of doubt and fear to which I have alluded, 
I would most earnestly recommend." He relates two experiments, which seem to 
have made a great impression upon his mind. They are as follows : — 

" Three pieces of tape were thoroua:hly moistened with the saliva of a rabid dog, 
and inserted as rowels in the polls of three other dogs. To two the Scutellaria and 
belladonna were given : the third, a fox-hound bitch, was abandoned to her fate. On 
the 29th day after the inoculation she became rabid." The others, at the time this 
was written, i. e., some months afterwards, were living and well. 

He afterwards took the same two dogs, and a third. He moistened two pieces of 
tape with the sahva of a rabid dog, and inserted them in the polls of one of the old 
dogs, and of the third dog. Another piece of tape, dragged repeatedly through the 



EPILEPSY* 



379 



mouth of the same rabid dog twenty-four hours after its death, was inserted in the 
poll of the second of the old dogs. This dog and the new one were suffered to take 
cheir chance. To the other old dog the ntiedicine was given. In the fourth week 
the new dog died undeniably rabid. The other two survived. 

I repeat that I have no faith in these preventives. But sometimes some of them 
must be tried ; and I would prefer those which are thus sanctioned by Mr. Youatt's 
good opinion to any others. 

And with respect to the established disease, I think that if I were the unhappy 
subject of it, I should wish to be put into a hot air bath, and thoroughly sweated, 
and to take opiates ; not so much in the hope of recovering as with a view to the 
euthanasia. But with all respect to those gentlemen who advocate that practice, no 
one, if I could help it, should make a hole in my wind-pipe. 



LECTURE XXXV. 

Epilepsy. Its symptoms and varieties; duration and recurrence of the parox- 
ysms; periods of life at which they commence ; warnings. Effects of the 
paroxysms, immediate and ultimate. Pathology. Anatomical characters. 
Causes. ^ 

The great functions of which the brain is the material instrument, are sensation, 
thought, and voluntary motion. The influence of the will is a cerebral influence : 
it reaches and acts upon the muscles through the interposition of the spinal cord. 
Motions that are involuntary belong more exclusively to the system of the true 
spinal marrow. Yet cerebral changes, morbid states of the brain, may excite 
them. 

I have shown you that all these functions are hable, under disease, to be sepa- 
rately affected, and each in various ways and degrees. The number of combina- 
tions capable of arising out of disordered conditions of two, or three, or all of thfse 
functions, is very great. Yet the symptoms proper to the nervous system do arrange 
themselves into groups su^ciently definite and constant to allow of our giving them 
distinctive names, and making them separate objects of inquiry. 

-At the same time, as might indeed be expected, these several groups have strong 
resemblances to each other. They are obviously of the same family: "facies non 
omnibus una, nec diversa tamen ; qualis debet esse sororum." Occasionally the 
features are so near alike, that we find it somewhat puzzling to determine with 
which of the sisters we are conversing ; but usually there is some mark or other by 
which the individual may be identified. * 

Of these essentially nervous diseases, there are several in which the most promi- 
nent and obvious of the phenomena relate to the muscular system ; irregular, violent, 
and involuntary contractions occurring of muscles which, in the healthy state of the 
body, are subject to the control of the will. I have spoken of two very frightful dis- 
orders belonging to this head : — of tetanus, namely, in which the muscles of volun- 
tary motion present the most striking changes, being affected with tonic spasm ; 
while the sensibility undergoes no other alteration than what is a consequence of 
that spasm, pain I mean in the muscles themselves ; and the intellectual functions 
continue undisturbed : — and of hydrophobia, in which the natural sensibility suffers 
much, and the mental functions some derangement ; yet still the characteristic fea- 
tures of the malady depend upon the irregular and uncontrollable action of muscles 
usually obedient to volition. 

The disease which I am next to consider is scarcely less terrible to witness, when 
It occurs in its severer forms, than tetanus or hydrophobia; but it is not attended 
with the same urgent and immediate peril to fife. Yet it is, upon the whole, pro- 
ductive of even more distress and misery ; and is liable to terminate in worse than 
death. You will understand that I am alluding to Epilepsy: a disease not painful 



380 



EPILEPSY. 



probably in itself ; seldom immediately fatal ; often recovered from altogether : yet 
apt, in many cases, to end in fatuity or insanity ; and carrying perpetual anxiety 
and dismay into those families which it has once visited. 

The leading symptoms of epilepsy are, a temporary suspension of consciousness, 
with clonic spasm ; recurring at intervals. 

It is impossible to frame a perfect definition of epilepsy ; nay, so various are its 
forms, so numerous its modifications, that no general description even of it can be 
given. It will be necessary for me therefore here (as it has been stated before) to 
describe first the most ordinary type of the disease, as a standard ; and then 
to note the several variations from that standard which are known to occur in 
practice. 

A man, then, in the apparent enjoyment of perfect health, shall suddenly utter a 
loud cry, and fall instantly to the ground, senseless and convulsed, fie strains 
and struggles violently. His breathing is embarrassed or suspended ; his face 
turgid and livid : he foams at the mouth ; a choking sound is heard in his wind- 
pipe; he appears to be at the point of death by apnoea. But presently, and by 
degrees, these alarming phenomena diminish, and at length cease ; the patient is 
left exhausted, heavy, stupid, comatose : but his life is no longer threatened. And 
in a short time he is once more, to all appearance, perfectly well. The same train 
of morbid phenomena recur, however, again and again, at different, and mostly 
at irregular intervals. — This is a brief description of the most ordinary form of 
epilepsy. 

The suddenness of the attack is remarkable : in an instant, when it is least ex- 
pected by himself or by those around him, in the middle of a sentence, or of a ges- 
ture, the change takes place ; and the miserable sufferer is stretched foaming, strug- 
gling, and insensible upon the earth. This fearful suddenness is expressed in the 
name of the disease, tTiCKri-i^ia., a seizure, an abrupt invasion. The ancients, among 
whom the complaint was well known, superstitiously ascribed it to the malice of 
demons, or to the anger of their offended deities. If a person was seized with epi- 
lepsy in the forum, it was considered an ill omen, and the meeting was at once 
di^olved, and all public business suspended for that day. Hence the disease was 
called morbus comitialis. Morbus qui sputatur was another of its names, because 
those present were accustomed to spit upon the epileptic man, or into their own 
bosoms ; either to express their abomination, or to avert the evil omen from them- 
selves. In this country its common designation is the falling sickness : or, more | 
vaguely fts. The cry which is frequently, though by no means always, uttered, is i 
enerally a piercing and terrifying scream. Women have often been thrown into | 
ysterics upon hearing it. It is said to have caused pregnant females to miscarry. ^ 
Even the lower animals appear to be sometimes startled and alarmed by a note so [ 
harsh and unnatural. Dr. Cheyne informs us that, upon one occasion, " a parrot, j 
himself no mean performer in discords, dropt from his perch seemingly frightened 
to death by the appalling sound." The muscular convulsions are strong, irregular, , 
and often universal. In most of the fits of which I have happened to see the com- i 
mencement, the first efl^ect of the spasm has been a twisting of the neck, the chin | 
being raised, and brought round by a succession of jerks, towards one shoulder :' and i 
one side of the body is, usually, more strongly agitated than the other. The 
features are always greatly distorted. The brows are knit; the eyes sometimes | 
quiver and roll about, sometimes are fixed and staring, sometimes are turned up 
beneath the fids, so that the cornea cannot be seen, and the white sclerotica alone is 
visible ; the mouth is twisted awry ; the tongue thrust between the teeth, and caught i 
by the violent closure of the jaws, is bitten, often severely ; and the foam which j 
issues from the mouth is reddened by blood. The hands are firmly clenched, and i 
the thumbs bent inwards upon the palms : the arms are thrown about, striking the ! 
chest of the patient with great force, or bruising themselves against surrounding 
objects, or inflicting hard knocks upon the friends and neighbours who have has- j 
tened to the patient's assistance. It frequently happens that the urine and excre- i 
ment are expelled during the violence of the spasm : and seminal emission some- 
times takes place. The spasmodic contraction of the muscles is occasionally so ' 



EPILEPSY. 



381 



powerful as to dislocate the bones to which they are attached : the joints of the 
jaw, and of the shoulder, have been thus put out; and the teeth are sometimes frac- 
tured. 

When the convulsive paroxysm is over, the patient falls into a deep sleep. You 
might imagine that he slept from exhaustion, hke a man worn out by great fatigue ; 
but^ there is something more than this ; the patient passes into a state of incomplete 
coma, or rather the insensibility continues after the convulsions have ceased. When 
he w^akes he is often confused and incoherent for a time ; by degrees, however, he 
resumes his ordinary appearance and condition : but he remembers nothing of what 
passed during the fit. 

You may suppose that so much irregular contraction of the muscles of voluntary 
motion is not likely to occur without some derangement or modification of the func- 
tions of the circulation. The breathing is irregular, gasping, or arrested. The heart 
palpitates violently against the ribs during the paroxysm ; the pulse becomes fre- 
quent and feeble ; and sometimes it ceases to be tangible at the wrist during the 
height of the fit, and begins to be felt again as the spasms subside. The turgescence 
of the face indicates obstruction of the venous circulation ; the cheeks and lips 
become purplish and livid, and. the veins of the neck and forehead are visibly dis- 
tended. 

This, then, is one form, the most severe and the most common as well as the best 
marked form, in which an epileptic attack occurs. 

But there is a large class cf cases, in which the symptoms are much more mild. 
There is very slight and transient, or even no convulsion at all ; no turgescence of 
the face ; no foaming at the mouth ; no cry ; but a sudden suspension of conscious- 
ness, a short period of insensibility, a fixed gaze, a totter perhaps, a look of confu- 
sion ; but the patient does not fall. This is momentary ; consciousness presently 
returns ; the patient resumes the action in which he had been previously engaged, 
and is not always aware that it has been interrupted. Sometimes, with this tempo- 
rary abeyance of the mental functions, there is some slight evidence of convulsion or 
involuntary action ; the fingers of one hand, or less commonly of both, are moved 
irregularly, and without any object ; or the eyes roll or are turned upwards : or the 
muscles of the face are twitched. Sometimes the patient is himself aware of what 
has been his condition, but shows some cunning in endeavouring to conceal it. 

This shghter attack is called by the French, petit mal ; while the severer form is 
named grand mal. The former is spoken of also as epileptic vertigo, and distin- 
guished by that appellation from the epileptic Jit. 

Of affections so different in degree, and in some respects so dissimilar in kind, 
you may be disposed to ask whether they really constitute the same disease. That 
they are essentially of the same stamp, we have this evidence ; that both forms of 
attack occur in the same individuals. Sometimes a patient will suffer many recur- 
Tences of the epileptic vertigo, and at length will become affected with violent epi- 
leptic fits. Or the two forms will intermingle, sometimes the milder happening, 
sometimes the severer. In such cases we cannot doubt that the attacks are the same 
in nature, though different in form and degree. And when (as sometimes happens) 
we meet with the slighter disease alone, we cannot refuse to assign to it the charac- 
ter and the name of epilepsy. 

Between the two extremes there are many links of gradation. Sometimes the 
sufferer sinks or slides down quietly, and without noise ; is pale, is not convulsed at 
all, but insensible ; much like one in a state of syncope. After recovering, he 
remains sick, languid and confused, during the remainder of the day. 

You will perceive, from what I have now said, the difficulty of giving any single 
description of epilepsy, which will include all its varieties. It is of course still more 
difficult to offer a strict definition of the disease. Cullen defines it to be "musculo- 
rum convulsio, cum sopore." Dr. Copland furnishes a larger and more compre- 
hensive definition : " Sudden loss of sensation and consciousness, with spasmodic 
contraction of the voluntary muscles, quickly passing into violent convulsive distor- 
tions, attended and followed by sopor, recurring in paroxysms often more or less 
regular." 



382 



EPILEPSY. 



But almost every one of these circumstances may, in its turn, be wanting. There- 
may be no convulsion ; there may even be very slight and transient interruption of 
consciousness ; there may be no subsequent coma or sopor ; there may be no recur- 
rence of the attack. 

Yet I trust that you now have obtained some general notion of what is meant by 
an epileptic seizure. And I go on to inquire into several most important points con- 
nected with the paroxysms. 

In the first place they vary considerably in duration. Sometimes, as T have 
already stated, the seizure is slight, and does not occupy more than a moment or 
two of time. But even the severer attacks are often over in a few minutes. They 
seldom continue longer than half an hour, and probably the average duration may 
safely be laid at between five and ten minutes. Attacks that are spread over three 
or four or more hours, generally consist of a succession of paroxysms, with indistinct 
intervals of comatose exhaustion. In the long-continued fits, or in the protracted suc- 
cession of fits, the patient often dies. 

The periods at which the paroxysms return are also extremely variable. Occa- 
sionally the patient dies in the first paroxysm ; occasionally, though he recovers 
from it, he never has another. Both of these occurrences are rare. Rather more 
frequently the fits recur at very long intervals ; at the distance, I mean, of many 
years. Most commonly of all, they revisit the sufferer at irregular periods of a few 
months or weeks : sometimes they are repeated at intervals of a few days : some- 
times every day or every night : and not very unfrequently they take place many 
times in the twenty-four hours. This extreme frequency of repetition belongs prin- 
cipally to the slighter imperfect seizure, the petit mal. Sometimes the fits observe 
a strictly regular period of return ; but, for the most part, they are quite uncertain 
and irregular. 

The time of life at which the fits commence, and the circumstances attending 
their commencement, are deserving of notice. They not uncommonly begin in 
infancy. Those fits of convulsion to which young children are subject during the 
first dentition, and which sometimes appear to depend upon the irritation of teeth- 
ing, and sometimes upon manifest disorder of stomach and bowels — these fits are 
not distinguishable in their phenomena from genuine epilepsy ; and we must reckon 
them as instances of epilepsy. It has been remarked by some one, that if you can 
trace the early history of an adult epileptic, you will almost always find that he or 
she suffered infantile convulsions. 

[This is true. Epileptics, it will very generally be found, were affected with repeated 
attacks of convulsions during the period of infancy. In many subjects, however, we have 
known the disease to commence immediately subsequent to puberty, or even late in life. 
In the majority of these latter cases the disease appeared to be the result of a life of inteni- 
perance. — C] 

To what extent this is true I do not know, but I recommend it to you as a point 
worth attending to in your future opportunities of observation. 

. The epileptic attack may come on, for the first time, at any age. According to 
Dr. Bright (whose account of the disease, though short, is particularly perspicuous), 
the most common periods are about the age of seven or eight years, probably about 
the time of the second dentition ; and from fourteen to sixteen, shortly before the age of 
puberty. And the disease (he says) is very apt to occur for a few years subsequently 
to this. But sometimes the first fit has taken place between the ages of thirty and 
forty ; in not a few cases after sixty ; and occasionally quite in the decline of life. 

Dr. Bright offers a httle piece of theory in respect to the periods at which epi- 
lepsy is apt to begin. It is a reasonable piece of theory, and serves to tie the alleged 
facts to one's memory, even if it be not yet proved to be true. Doubtless in many 
cases the circumstances that determine the first attack are quite accidental. But 
setting aside these casualties, he says " there are leading periods in the evolution of 
the frame, and pecuhar circumstances connected with certain periods, which may 
well be considered as influential in the production of the disease. In infancy the 
nervous system is delicate, and easily acted upon by various causes of irritation. 
Then follows the trying period of teething. In a few years the second dentitioa 



EPILEPSY. 



38a 



occurs. In a few years later, all the great changes connected with the age of pu- 
berty. To this follow the excesses and exposures of manhood ; and after the lapse 
of years, the vigour of the system fails, and many causes act to derange the nice 
balance of the constitution ; the bowels often become sluggish ; changes more or 
less serious take place in the structure of the arterial and venous system ; and many 
causes, organic or functional, which had before been unable to exert an influence on 
the vigorous frame, acquire power from its relative weakness." 

The first accession of the disease takes place more commonly before than after 
puberty. Of sixty-six epileptic women, in whom the outset of that disease and the 
first period of menstruation were carefully noted, thirty-eight had epileptic fits before, 
and twenty-eight 'not till after that period. 

The attacks are very apt to come on during the night ; in the commencement of 
the disease, they frequently are confined to the night. They are said chiefly to 
occur at the moment when the patient is sinking into sleep, or awaking from sleep. 
How far this is true T cannot tell. When the disease is yielding, the fits often 
happen in the night only ; so that after they have, for a certain period, taken place 
in the day-time, or during the day and night, indiscriminately, it is reckoned a good 
prognostic sign if they begin to restrict themselves to the night. Some patients, 
under these circumstances, suppose that the physician has particular remedies that 
will make the fits happen in the night rather than in the day ; and they ask for these 
remedies. 

Sometimes each paroxysm arrives unannounced and unexpected ; sometimes dis- 
tinct warnings of its approach are given. The latter is less frequent than the former. 
Georget affirms that the premonitory symptoms do not occur more than four or five 
times in a hundred cases. I am sure that this is much understated. When warning 
symptoms do happen, they are sometimes spread over a considerable period ; several 
hours, or a whole day ; sometimes they last just long enough to enable the patient to 
remove from a situation in which a fall would be attended with unusual danger: to 
dismount from horseback, to lie down in a boat, to get away from the fireplace, from 
the edge of a precipice, from the vicinity of water, to assume the horizontal position 
of his own free will and in his own manner, or to give notice to those about him of 
what is going to befall him. In some cases the warning is too short and sudden even 
for this. The kind of notice that he receives is very variable indeed. Often it 
consists in some unnatural state of the mind, the feeHngs, the temper ; the patient is 
fidgety, irritable, low-spirited, timid, sullen ; or, on the other hand, he feels unusually 
strong, and hearty, and cheerful. Sometimes there is a notable change in some one 
or more of the natural functions, or of the bodily sensations ; the patient loses his 
appetite, or his appetite becomes voracious ; a great flow of urine takes place ; he 
smells an ill smell, is aware of a strange taste, hears extraordinary noises, or sees 
spectral illusions ; not mere specks floating before him — muscse volitantes — but dis- 
tinct forms of persons and things. This is not very common, but it certainly happens. 
The late Dr. Gregory, of Edinburgh, was assured by a patient of undoubted veracity, 
that always, when he had a fit of epilepsy approaching, he fancied that he saw a 
httle old woman in a red cloak, who came up to him, and struck him a blow on the 
head, and then he immediately lost all recollection, and fell down. 

Headache, giddiness, dim or dazzled vision, are all of them common symptoms 
among those which have been observed to be precursory of epilepsy. Sometimes 
there are circumstances which are obvious to a bystander : a flushing of the face, 
or lividity : difficult articulation ; vomiting. Of twenty-one epileptics treated in the 
hospital at Wilna, by Joseph Frank, vomiting announced the paroxysm in seven. 
Some of the uneasy feelings are apt to come on and continue even for several days 
previously to the attack ; restlessness in particular, disturbed sleep, distressful 
dreams, a peculiar and sudden coldness of the extremities. An internal working 
is a phrase often used by such persons to express a sensation which is probably in- 
describable. 

But the most curious precursory symptom of all, if we except the spectral illu- 
sions, is what is called the epileptic aura. This is a sensation which is likened by 
different patients to diflferent things ; to a stream of water or cold air, to the trickling 



EPILEPSY. 



of water, to the creeping of a spider. The sensation proceeds commonly from some 
distant part of the bod3% — from one of the extremities, from a thumb or finger, or 
to some spot on the trunk, — and runs along the skin towards the head: occasion- 
ally it gets no further than the pit of the stomach : as soon as it reaches the head, 
or stops at the epigastrium, or elsewhere, the patient's consciousness forsakes him, 
and the paroxysm declares itself. 

There seems to be some analogy between this epileptic aura and the well-known 
sensation, to be spoken of hereafter, of a ball rising from the stomach to the throat, 
and constituting the globus hystericus ; except that in cases of epilepsy the sensation 
commonly begins in an extremity, and not in the stomach : and the fit comes on 
when it reaches the head and not the throat. Sometimes, I think, these two sensa- 
tions are blended. 

In some instances, spasms of the muscles of the part whence the aura proceeds 
are observed to take place prior to the more general state of spasm. 

This aura is certainly a very curious phenomenon. It has been thought to depend 
upon some change propagated along the nerve upwards to the brain, and to be some- 
times connected with some injury done to, or some morbid impression made upon, 
an afferent nerve. I think that this explanation may apply to some cases. 

Dr. John Thomson, of Edinburgh, used to state in his lectures, that he had known 
epilepsy to begin with an aura proceeding from an old cicatrix in the side. In a 
patient of my own, who was subject to epilepsy, the warning sensation commenced 
in one of his thumbs, which presently after began to be twisted inwards ; but by 
tying his handkerchief tightly round the thumb, he could prevent the fit. Dr. Sey- 
mour mentions the case of an epileptic boy, who had learned to protect himself 
against a threatened paroxysm, by biting his tongue. 

In other cases the aura probably originates in some change within the head, and. 
is analogous to the numbness or tingling that is often felt in some part of the body or 
extremities immediately before an attack of palsy or apoplexy. There is no real 
inconsistency in this twofold explanation : the source of the aura may be centric or 
eccentric ; so also may the exciting cause of the paroxysm ; as, in due time, I shall 
explain to you. 

A knowledge of these warning circumstances is clearly of importance, always as 
far as respects the comparative security of the patient during the attack ; sometimes 
as affording us the opportunity of staving off the fit altogether. And it is necessary 
to remark, that they sometimes give, as it were, a false alarm ; they occur, and yet, 
although no measures of prevention are taken, no paroxysm follows. 

The phenomena that succeed the paroxysm are also of great interest and moment. 

I have already apprised you that the convulsions generally terminate before the 
insensibihty is over : the patient draws, perhaps, two or three deep sighs, and ceases 
to struggle. Some few persons are quite themselves again in a few moments ; some 
appear to recover consciousness, and then fall into a deep and prolonged slumber ; 
but many do not regain their consciousness at all upon the cessation of the convul- 
sions, remaining in a state of profound stupor, from which, however, they can gene- 
rally be roused for a time. This state of coma (for it is nothing else) has been 
known to last a week. After the patient emerges from it, he is sometimes merely 
languid and inert : sometimes he is like a person stunned, or in a state approaching 
to idiocy, which gradually clears up ; sometimes he is furiously dehrious for a short 
time : not unfrequently there is a degree of partial paralysis, which also usually 
soon goes off, though it occasionally is permanent ; the eyes are fixed, or he squints, 
or the pupils are dilated, or he drags a leg, or he falters in speech. Most commonly 
he speaks of headache, or discomfort of some kind. 

It is very seldom that the patients have any recollection whatever of what has 
passed during the fit. Many of them are not aware that they have had a fit : and 
those who do know it, discover the fact by finding themselves wet or dirty ; by the 
injuries they have received during the convulsions; by the soreness of the bitten 
tongue ; by the bruises of their limbs ; or by the confused or painful sensations 
which they subsequently experience, and which they have learned to associate with 
the conviction that a fit has happened, by having been informed on previous occasions, 



EPILEPSY. 



383 



when they felt the same sensations, that they had suffered a paroxysm of insensi- • 
bihty and convulsions. 

Upon the whole, it is seldom that any permanent ill effect can be noticed as 
having been left behind it by any one single fit ; but, alas ! this cannot often be said 
of their repetition. 

Doubtless a single paroxysm does often leave the patient in a worse condition than 
that in which it found him ; but this does not become perceptible to an ordinary ob- 
server, until after the alteration has been rendered apparent by repeated fits, and 
repeated small additions to the permanent injury. The friends of the patient 
remark that his memory is enfeebled in proportion to the number of his attacks ; 
that his mental power and intelligence decline. His features even assume, by 
degrees, a pecuhar character ; and too often he sinks into hopeless fatuity, or con- 
firmed imbecihty or insanity. It is this tendency which renders epilepsy so sad 
and fearful a disease. 

Foville affirms, that the intellectual degeneration is more constant, and comes on 
more early, in persons who are principally afflicted with the epileptic vertigo, the 
petit mal, the imperfect seizure, than in persons in whom the grand mal, the vio- 
lent and decided paroxysm, takes place. Dr. Copland, on the other hand, is of 
opinion, that " the more severe the fits, the more is that result to be dreaded. This 
is a point which can only be settled by statistical facts. And as we all have the 
opportunity of collecting some such facts, and of adding them to the general stock, 
I mention this, and some other points that are still uncertain or disputed, as worth 
bearing in mind. More, probably, depends upon the repetition of the fits, than 
upon their precise nature or severity. Cases do occur in which epileptic persons 
preserve their faculties to a good old age ; but those who are early epileptic do 
not often attain old age ; and whenever the disease comes on, if it repeats itself 
frequently, it is much more often than not followed by impairment of the mind, 
or by some apoplectic or paralytic affection, which imphes and accompanies the 
mental change. You will sometimes hear the cases of Julius Caesar, of Ma- 
homet, and of Bonaparte quoted, as examples of high intellectual power, existing 
and remaining in spite of epilepsy : — and it is allowable, perhaps, to make use of 
such cases for comforting the friends of epileptic persons : or for giving the 
advantage of sustained hope to the patient himself. But, in truth, these cases * 
are not worth much. Napoleon is said, I know not upon what authority how- 
ever, to have suffered something hke epilepsy during sexual intercourse. This is 
not very uncommon in persons subject to that disease. And, with respect to Juhus 
Caesar, we learn from Suetonius, that it was only in the latter part of his Hfe that 
he laboured under epilepsy ; and that he had two attacks while engaged in business. 

Having now described the phenomena of epilepsy ; the periods of hfe at which 
it is most apt to commence ; its varieties ; and its tendency and termination : let 
us next inquire what is known respecting the real seat and nature of this strange and 
melancholy complaint. 

The functions that are affected are clearly the functions of the brain. Sensation, 
thought, and motion regulated by the will, are the natural functions of that organ. 
The temporary abeyance of sensibihty, thought, and volition, and violent and ir- 
regular action of the muscles which are thus withdrawn from the empire of the 
will, constitute a paroxysm of epilepsy. We have, in this malady, another illus- 
tration of the fact, that when the controlling influence of the sensorium is suspended, 
the peculiar functions of the spinal marrow are exercised, not only in a disorderly, 
but also in an unusually energetic manner. That the brain and the spinal marrow, - 
though physiologically distinct, are yet intimately connected with, and dependent 
upon, each other, a thousand famiUar facts assure us : and there are good reasons 
for beheving that the change, whatever it is, which is the immediate precursor and 
cause of the epileptic fit, may sometimes originate in the spinal cord, and thence 
extend to the brain ; and sometimes originate in the brain, and communicate itself 
to the spinal cord. Dr. Marshall Hall's doctrine, that all convulsive diseases are 
diseases of the spinal marrow, cannot be properly apphed to this convulsive disease 
25 2h 



ft 



386 



EPILEPSY. 



of epilepsy. It is true that the spinal cord is concerned whenever there is convul- 
sion ; but it is concerned in every voluntary movement also, through the instru- 
mentahty of the brain itself; and it may be, and often is, irregularly influenced by 
a disordered and unnatural state of the brain. Tetanus may fairly be regarded as 
a disease of the cord and its proper appendages. The spasms arise and reach their 
height, while the powers of thought and sensation are undisturbed, and while vo- 
lition remains, although the morbid condition of the cord renders it ineffectual. In 
epilepsy, these cerebral functions are always implicated. There is always a loss of 
consciousness : and in epileptic vertigo, the petit mal, there is frequently a suspen- 
sion of consciousness only, without any convulsion at all. The brain, therefore, 
we must consider to be essentially concerned in this disorder. 

What the precise state of the nervous matter may be, which determines the loss 
of consciousness and the spasms, we can only conjecture. A derangement in the 
relation between the arterial and venous circulation within the head ; a temporary 
pressure somehow arising ; a determination of blood towards the head ; a diminu- 
tion of the natural quantity of blood sent thither from the heart ; all these have 
been assigned as possible causes of the paroxysms. Plausible reasons might be 
given in favour of the operation of each of them; but the speculation is more 
curious than useful. We have not yet penetrated the mystery of these remarkable 
phenomena, and it will be more profitable to turn to another question, which 
admits of a somewhat more definite answer, viz. : what is the morbid anatomy of 
epilepsy ? 

Suppose that a person who has had epileptic fits, but in whom they have not been 
followed by any durable affection of the intellectual or locomotive functions, dies of 
some other malady ; and you may have the opportunity of minutely examining the 
condition of the nervous system. Often you will find nothing at all which can throw 
any light upon the occurrence of the epileptic paroxysms ; no appreciable alteration 
whatever in any part either of the brain or of the spinal cord. In other cases you 
may discover some organic disease within the head : a scrofulous tubercle, a spicu- 
lum of bone projecting from the skull. Have you then detected the cause of the 
disease ? All that can be said is, that the piece of bone or the tubercle was 
probably a predisposing cause of that derangement of the nervous substance which 
* determined the paroxj^sms ; the derangement itself, if, indeed, it was of such a 
nature as to be cognizable by our senses, has gone, with the symptoms ; the tuber- 
cle or bone having in the meantime remained, without any sign which could betray 
its presence. 

M. Foville, whose testimony in this matter is entitled to much weight, affirms 
that in persons who have been subject to epilepsy, uncomplicated as yet with any 
permanent disorder of the intellect, or of the faculty of voluntary motion, and who 
have died in the Jit, constant alterations are observable within the head; viz., a 
strong injection of the vessels of the encephalon. The membranes, the brain, and 
the cerebellum, are gorged, he asserts, with hvid blood. But he goes on to say that 
this is to be ascribed to the mode of death : that we see the same appearances in 
persons who have died by hanging, or any form of apncea ; that they are not pecu- 
liar to epilepsy, and do not explain the attack, but only point out the way in which 
it has been fatal. 

It is, I fancy, a very common notion, both that such congestion does take place, 
and that it is the cause of the paroxysm : and it may be worth while shortly to state 
the reasons which are opposed to the conclusion, that the congestion (granting for 
the moment that it does happen) is a sufficient explanation o-f the attack. 

In the first place it is not easy to conceive that the congestion could so suddenly 
arise and subside again, as it must sometimes do, if it be the immediate determining 
cause of the fit : within the space of a single minute, for example. 

And in the second place, the signs of external congestion and plethora, by which 
signs we measure the amount of the internal, are most marked just when the symp- 
toms of the paroxysm begin to subside and disappear. So that we cannot, I think, 
]ook upon the congestion as the cause of the convulsive symptoms. 

Let us go a step further, and inquire into the state of the encephalon in those 



EPILEPSY. 



387 



persons who, having suffered epilepsy, had, before death arrived, been affected 
with some permanent impairment of the mental functions, or (what often goes 
along with such impairment) with some degree or other of muscular paralysis or 
debility. 

The most common alterations met with in the brain in such cases are the 
following. 

Induration of the white matter of the brain, which presents a dull appearance ; 
sometimes, besides the hardening, a general injection of the white matter ; and in 
the majority of cases a marked dilatation of the blood-vessels. In some instances the 
consistence of the white matter is diminished ; it is soft and flabby ; but there is the 
same dilatation of the blood-vessels. These changes pervade the whole of the white 
matter in every part of the brain. At the same time the gray matter is found irre- 
gular on its surface, marbled or of a rosy colour in its substance, and sometimes 
altered in consistence. And in many cases the membranes are found to be adherent 
in some parts to the convolutions with which they he in contact. 

Such are the results of the experience of careful observers in respect to the 
morbid anatomy of epilepsy ; of Morgagni, of Foville, and of MM. Bouchet and 
Casauvielh. The changes last described are such as are produced by chronic inflam- 
mation of the brain and its membranes. They are the consequences (I imagine) of 
repeated paroxysms of epilepsy ; they are the very same as are frequently met 
with in cases of insanity complicated with paralysis, and they elucidate, therefore, 
the connection of these affections ; but they certainly teach us little or nothing of 
that actual condition of the nervous mass upon which the epileptic paroxysms de- 
pend. And, in truth, to expect to find in the brain the traces of convulsions that 
have passed away, would be as unreasonable as to expect to find the traces of former 
voluntary movements. 

Of those organic changes which may be regarded as strong predisposing causes 
of the paroxysms, my own experience accords with that of Dr. Bright ; who states, 
that they are more frequently such as affect the surface, than the deeper-seated parts 
of the brain : tumours external to the cerebral matter ; alterations in the bones of 
the skull ; or in the membranes that envelop the organ. Various altered states of 
the spinal marrow have also been recorded. 

But besides the morbid appearances that are sometimes only visible in the nervous 
centres themselves, there are others, which it is of great importance to attend to, situ- 
ated in other parts of the body, and at a distance from those centres : diseased states 
of the hver ; biliary concretion ; granular kidneys ; renal calculi ; stones in the 
bladder ; worms in the alimentary canal ; diseases of the uterus ; and of various 
other parts. And these morbid conditions have often, no doubt, an intimate connec- 
tion with the epileptic paroxysms. Accordingly, some authors make almost as many 
varieties of epilepsy as there are organs of the body ; they specify the cerebral, the 
spinal, the cardiac, hepatic, gastric, intestinal, nephritic, genital, uterine, and so on. 
It will be sufficient, however, to consider two species only ; that, namely, in which 
the disease originates in the nervous centres themselves, and especially in the brain; 
and that in which it originates in some other part. Most persons who have written 
on epilepsy make this distinction, although they employ different terms to express it. 
Cerebral and occasional ; primary and secondary ; idiopathic and sympathetic ; cen- 
tric and eccentric. The last two terms are the best. But let us clearly understand 
them. The disease may, in one sense, be considered eccentric, even when it is situ- 
ated in the brain ; eccentric, i. e., in respect to the true spinal marrow. But I apply 
the epithet centric to epilepsy when its cause lies in either of the two great nervous 
centres; the brain, or the cranio-spinal axis. The distinction itself we shall find to 
be an important one, both as regards the prognosis and the treatment. But I must 
first say a few words respecting the causes and the diagnosis of epilepsy.- 

There is no doubt that a tendency to epileptic disease is frequently Jtereditary. 
It may be derived from parent to child ; or it may skip over a generation or two, and 
appear in the grandchild or great-grandchild; or it may be traceable only in the col- 
lateral branches of the ancestors. This is just what takes place in other hereditary 



388 



EPILEPSY. 



maladies. You may often notice also that other forms of nervous disorder prevail in 
the same families. 

MM. Bouchet and Casauvielh found that among 110 instances of epilepsy, 31 
were hereditary. Of 321 persons afflicted with epileptic insanity, and seen by 
Esquirol, 105 were descended from insane or epileptic parents. 

Again, a tendency to epilepsy is very often found to go along with an unnatural 
form of the head, which is pinched up like a sugar-loaf; or misshapen and unsym • 
metrical, one-half being unUke the other ; or oddly configurated in some way oj 
other. Epilepsy is no uncommon attendant of chronic hydrocephalus. 

And thirdly, the scrofulous diathesis is a strong predisposing cause of epilepsy 
Dr. Cheyne even holds that epilepsy is as certain a manifestation of the strumous 
disposition, as tubercular consumption, or psoas abscess. Now of the two predis- 
posing circumstances last mentioned, it may be observed, that they commonly 
merge in that which preceded them : the strumous diathesis, and a particular con- 
formation of the head, are both very likely to descend from parents to their progeny. 

Whether the sex has any influence in determining a predisposition to epilepsy, is 
a question that remains to be settled. Fov.il le thinks it is most common in females ; 
Dr. Elliotson in males. I have certainly seen more epileptic boys and men, than 
girls and women. But the casual experience of a single observer is not enough to 
determine the point. We want numerical statements on a large scale. At the close 
of the year 1813 there were 162 male epileptics in the Bicetre ; 289 female cases in 
the Salpetriere. Jos. Frank observed that of 75 patients, 40 were females. 



LECTURE XXXVI. 

Epilepsy, continued. Recapitulation. Exciting causes. Simulated epilepsy. 
Diagnosis. Prognosis, Treatment : during the Jit ; during the intervals ; 
during the warnings. 

At our last meeting I began to speak of epilepsy. Let me rapidly retrace the 
ground we then passed over. 

An epileptic seizure may be very severe ; or very slight. The very severe attacks 
are characterized by a sudden cry, immediate loss of consciousness, general and vio- 
lent convulsions, and subsequent coma or heavy sleep. The very slight attacks * 
consist in a momentary abeyance of the mental faculties, sometimes with and some- 
times without sHght and partial convulsion. The extreme forms of epilepsy we 
judge to differ only in degree, inasmuch as they both attack the same persons at 
different times ; or the one form conducts to the other. Between these the gradations 
are innumerable. We call the extremes the epileptic fit, and the epileptic vertigo } 
the French name them the grand mal and the petit mal. 

These fits may last from a few seconds to half an hour. Paroxysms apparently 
longer than this commonly consist of a succession of fits. The average duration is 
from five to ten minutes. 

The fits recur at variable intervals ; which are sometimes periodic, mostly irregular. 
There may be many in a single day : there may be only one for many years. They 
are commonly more severe in proportion as they are less frequent. 

The epileptic seizures sometimes begin in early infancy : another period at which 
they often commence is about the age of seven or eight : another period at fourteen 
or sixteen, or for some few years after that age. They more frequently begin before 
puberty than after it. Sometimes the first fit lakes place in the middle period of 
life : sometimes even in dechning age. They often occur in the night, espe- 
cially in the outset and the dechne of the disease ; usually when the patient is. 
between asleep and awake ; i. e., at the commencement or the termination of his 
slumber. 

In the majority, perhaps, of cases, the fit is unexpected, and preceded by no 



EPILEPSY. 



389 



warning. But in other instances there is some alteration perceptible by the patient 
himself, or by his friends, giving notice of its approach ; some change in the temper, 
feelings, appearance ; some disturbance of the senses ; ocular spectra ; or what is 
called the epileptic aura, a creeping sensation arising in some part of the surface, 
generally of the extremities, and gliding towards the head. Some of these warnings 
precede the paroxysm by a day or two, or by a few hours ; some by two or three 
seconds only. Sometimes the blow is threatened by their appearance, but it does 
not fall. 

The fit is almost always, in its severer forms, attended and followed by coma ; 
sometimes, after the coma, by temporary confusion of mind ; deafness ; slight para- 
jysis ; dehrium ; inarticulate speech. There is seldom any appreciable permanent 
damage effected by a single fit. 

A repetition of the fits leads, in a large majority of instances, first, to a defect of 
the memory, and of the general intelhgence ; and at length to a peculiar expression 
of countenance, to decided imbecihty of mind, to complete fatuity ; and with this 
there is often associated some paralysis or muscular debility. 

The convulsions take place, necessarily, through the medium of the spinal cord 
and nerves — just as voluntary movements do; but the suspension of sensation, 
thought, and volition (which suspension is seldom absent, while the irregular mus- 
cular action often is wanting) shows that the brain is essentially involved in the 
disease. 

Accidental organic lesions are sometimes (and sometimes only) found in the ence- 
phalon, or in the spinal cord, of persons who have suffered epilepsy uncomplicated 
with any permanent mental or paralytic affection ; tubercles, for example, or bony 
growths from the interior of the skull : but as these are constant, while the paroxysms 
are occasional, and as in the intervals they give no signal of their presence, we can 
only regard them as being probably predisposing causes of the seizures. 

When the epilepsy has been complicated with permanent alienation of mind, or 
with some degree of paralysis, evidence of chronic inflammation of the brain and 
its membranes is generally discovered. This has been the consequence of the 
repetition of the paroxysms. This explains the frequent connection of fatuity and 
palsy with epilepsy of long standing. 

The diseased condition which excites the paroxysms may be situated in the nervous 
centres themselves, or in some other part of the body. In the one case we call the 
disorder centric, or idiopathic ; in the other, eccentric, or sympathetic. We cannot 
always be sure with which species of the disease, the centric, or the eccentric, we 
have to deal : but the distinction, when it can be made, is of considerable importance, 
in respect to the prognosis, and in respect to the management of the case. 

The predisposition to this fearful complaint is often hereditary. Malformation, or 
defect of symmetry in the two sides of the head, is a frequent predisposing cause. 
So, pre-eminently, is the scrofulous diathesis. And these two, viz., the scrofulous 
diathesis, and a peculiar conformation of the head, are both liable and hkely to be 
propagated from parents to children. But the predisposition is found to be here- 
ditary, even when the shape and structure of the body is, to all appearance, quite 
perfect and natural; and when no outward indication of the strumous diathesis is 
perceptible. 

[The following statistics are presented by M. Leuret, in an interesting paper on Epilepsy 
in the Archive^ Gmerales for May, 1843. Among 106 epileptics, in 24, or nearly one-fourth, 
the disease commenced between the tenth and fourteenth years of their age ; in 18, or nearly 
one-sixth, between the fifteenth and nineteenth years, and in 16, between the fourteenth and 
twenty-fourth years. Thus 58 patients, or more than one-half, were first attacked between 
their fourteenth and twenty-fourth years. Of the whole number of cases, in six only was it 
ascertained that the disease existed in one or other parent, and in but eight was it found that 
one of the parents had died of any disease of the brain, namely, three of insanity, two of 
apoplexy, one of paralysis, one of suicide, and one of meningo-cephalitis. Of the 106 patients, 
thirty had been drunkards, twenty-four masturbaters, and fifteen addicted to women. In 
fifteen cases, the actual or presumed cause of the first attack of epilepsy was ascribed to 
terror ; in twelve to onanism ; in six to drunkenness ; in two to anger ; in two to distress ; in 
two £0 falls ; in one to libertinage, Sfc. Thirty cf the patients had an attack very regularly 



390 



EPILEPSY. 



once a fortnight; 17 suffered attacks once a month ; 13 once a week ; 9 every three or four 
days ; 4 almos': every day ; 2 every day ; 1 every two months ; 3 every three months ; and 
24 at very irregular intervals. In 35, the attacks took place in the night especially ; in 29, 
they were as frequent in the day as in the night ; in 12, they frequently occurred in the day ; 
in 8, -they occurred during the day only ; in 8, during the night only ; in 3, in the morning 
only; in 3 others generally in the morning; and in 4, in the evening only. — C] 

At the very close of the lecture I informed you that it is an unsettled question 
— and it is not a question of very great importance — whether the disease is more 
common in females or males : whether the sex has any thing to do with the pre- 
disposition. 

There are certain vices w^hich are justly considered as influential in aggravating 
and even in creating a disposition to epilepsy ; debauchery of all kinds ; the ha- 
bitual indulgence in intoxicating liquors ; and, above all, the most powerful 'predis- 
posing cause of any, not congenital, is masturbation — a vice which it is painful and 
difficult even, to allude to in this manner, and still more difficult to make the subject 
of inquiry with a patient. But there is too much reason to be certain that many 
cases of epilepsy owe their origin to this wretched and degrading habit : and more 
than one or two patients have voluntarily confessed to me their conviction that they 
had thus brought upon themselves epileptic paroxysms for which they sought my 
advice. 

Among the exciting causes of epilepsy, fright is conspicuous. And any strong 
mental emotion is apt to produce the fit in a person who is already subject to the 
disease. This fact alone would be enough, I conceive, to forbid our ascribing the 
paroxysms exclusively to an affection of the spinal cord. Bodily pain ; manifest and 
great disturbance of almost any of the principal functions of the body, may |ict also 
as exciting causes. Sometimes the cause is obvious ; sometimes it is quite inscru- 
table. If the attack occurs every night, Dr. Bright thinks it may be attributed to 
the " congestion " of sleep : if it takes place at monthly intervals in women, we may 
*' often trace it to nervous irritation in sympathy with the uterus : and when long 
periods have intervened we may usually trace each distant paroxysm to the repe- 
tition of some excess, or to a neglected state of the bowels." In these latter cases 
the epilepsy is of the sympathetic or eccentric kind ; the irritation being seated in 
some part at a distance from the nervous masses in the stomach, or intestines, oi 
"Uterus. Now I would suggest the expediency of observing what muscles or sets 
of muscles are Jirsf affected by the spasm in such cases, and in what part the 
warning aura (if there be any) arises : because by accurately noting these parti- 
culars, we may, perhaps, be led to a knowledge of the part or organ in which the 
irritation operates ; and if we know the seat of the irritation, we shall be more likely 
to know its nature and its cure. 

[M. Lamonthe relates, in the Journ. de Med. de Bourdeaux, a case in which the epilepsy 
was caused by a foreign body in the ear, and ceased upon its removal. The patient was a 
man thirty years of age, in whose external meatus a pebble had been accidentally introduced. 
He at first experienced only a slight diminution of hearing ; afterwards suppuration 
ocGurred. and finally epileptic attacks supervened ; from which he had suffered for two years 
before he consulted M. Lamothe. This gentleman, being informed of the probable existence 
of a foreign body in the ear, made an examination, and detecting it, by proper means, sue 
ceeded in removing from the meatus a rough pebble of nearly a triangular shape, and from 
that period the patient had no more attacks of epilepsy. In the same Journal, another case 
of the same kind is related by M. Roussilhe. — C] 

Among the exciting causes of epileptic fits are also enumerated — and I beheve, 
from what I have myself noticed, with great justice — the repulsion of eruptions, and 
especially of eruptions about the head, when proper artificial evacuations are not 
obtained at the same time ; the cessation of habitual discharges ; and, on the other 
hand, profuse and unusual discharges. Hemorrhage certainly will often bring on 
convulsions and a state of insensibility exactly like certain forms of epilepsy. Per- 
sons who are bled till they actually faint, are often at the same time convulsed. 
And animals that are killed by loss of blood are always affected with convulsions 
before they expire. 

There is yet another very singular occasional cause of epilepsy that deserves to 



EPILEPSY. 



391 



be mentioned, viz., the sight of a person in a fit of that disease. This has boen 
noticed over and over again. Not only will a patient who has already suffered such 
attacks, often fall into one upon seeing another so affected ; but people will even 
sometimes do so who have never before shown any symptom of epilepsy. In this 
way the disease will now and then run through a boarding-school : or through a 
ward in an hospital. There is a very good example of this recorded in the 1 1th 
volume of the Medical Gazette^ by Dr. Hardy, of Bath. A strong, healthy young 
man was hired to take care of an older patient, who suffered frequent and exceed- 
ingly violent paroxysms of epilepsy. He remained with the patient night and day ; 
and at the end of seven weeks became himself epileptic in a very high degree. An 
acquaintance of his, of equally robust make, but some years older, occasionally 
visited the parties. In a fortnight from his first visit he also was seized with simi- 
larly violent attacks. Dr. Hardy quotes the following short case, also, from Baglivi : 
— " Vidimus, anno 1690, in Dalmatia juvenum gravissimis correptum convulsionibus, 
propterea quod inspexerat solummodo ahum juvenem dum epilepsia humi contor- 
quebatur." 

[M. Meyer has recently given an account of a number of the pupils in a female school that 
were attacked with epilepsy, in consequence of seeing one of their number under the influ- 
ence of the disease. Most of the subjects were approaching the period of puberty ; whilst 
they were all of a highly excitable temperament, — C] 

Dr. Cullen, who, as well as many others, had noticed the same things, starts the 
question whether this mode of propagation of the disease be imputable to dread and 
horror ; or the mere force of imitation, which is often so strong, in health as well as 
in disease : and he decides in favour of the force of imitation. In fact there are 
many other signs equally horrifying with that of a person in convulsions ; yet there 
is no spectacle of horror so efficacious in producing a fit of epilepsy in others, as that 
of a person suffering under epilepsy. 

This principle of imitation holds good in many of the spasmodic diseases : and 
in some of them, especially in hysteria, its influence is more remarkably seen than 
in epilepsy : I shall therefore have to recur to it again. There is one very curious 
fact, however, which relates to epilepsy in particular. You are aware that this 
disease is often feigned, by impostors. Now I believe it is ascertained, be3^ond the 
possibility of doubt, that fits and actions which were at first, in these pretenders, 
strictly voluntary, have at length become involuntary and uncontrollable, and have 
passed into paroxysms of real epilepsy. The rogue is caught in his own trap. 

And the mention of these impostors leads me to consider the diagnosis of epilepsy. 
First, how are we to distinguish the feigned disease from the true ? Secondly, are 
there any other real diseases which may be mistaken for epilepsy, or for which 
epilepsy may be mistaken ? 

In the number of feigned diseases epilepsy is one of the most common. Soldiers 
and sailors .pretend to have epileptic fits, in the hope of obtaining their discharge 
from the service. Cases of simulated epilepsy occur also continually in our streets 
among mendicants and impostors, who think to excite the compassion and pecuniary 
charity of the credulous ; and are even sometimes actuated I beheve by a desire to 
obtain admission into hospitals, where they five tolerably well, and quite idly. It is 
easy enough, they think, to throw their legs and arms about, and to grin ; and many 
of them get up a capital show of foaming at the mouth, by placing a bit of soap 
between the gums and cheek. The means of detecting these vagabonds are of 
some importance to us all; and it is more particularly necessary that they should 
be well known to those who are likely to join the medical department of our fleets 
or armies. 

It is of course desirable, in questionable case&, to witness a fit. But pretenders 
are not very willing to perform when they know that a medical man is looking on. 
You may sometimes convict them, in the absence of the fits ; as cross-examination. 
A cheat will seldom be consistent in the account which he gives of his fits ; as to 
whether they are regular or irregular; and as to the times and places in which he 
has suffered them. An impostor chooses such situations for his exhibition as are 
most suitable to his own purposes ; a crowded street, or a well-frequented public 



392 



EPILEPSY. 



walk. True epileptics almost always select retired places to take exercise in ; espe- 
cially if they have any warning or expectation of the approach of a paroxysm. You 
will find also that the impostor is not attacked at his own home ; but always fixes 
upon some spot in which he is not only sure to be seen by others, but in which he 
is not hkely to sustain any injury by tumbling down. True epileptics are often 
seriously hurt by their falls ; feigned ones generally come off without much bodily 
damage. However, if the fits are alleged to be frequent, and if also they are regular, 
you may soon expect one, and mv^t make a point of being present : and then you 
will seldom fail to remove or to verify your suspicions. In the first place the mus- 
cular power of epileptics is far beyond what is natural. It will sometimes take four 
or five stout men to hold a weak emaciated lad, in a fit of epilepsy. Of course no 
impostor can command more than his natural strength. In the second place a real 
epileptic fit, if it lasts long, is seldom violent ; whereas impostors, for obvious reasons, 
make their fits both long and violent. You may often get much information from 
the state of the eyes, which usually in true epilepsy are partly open, with the eye- 
ball visibly rolling and distorted. In feigned epilepsy the actor almost always prefers 
to shut his eyes completely. Sometimes, if he be closely watched, and no suspicion 
is expressed, he wnll be seen to open his eyes occasionally, to ascertain the effect of 
his exhibition upon the bystanders. In real epilepsy, too, the pupils are often con- 
siderably dilated, and do not contract when stimulated by light. This is a very sure 
criterion ; for no impostor can prevent his iris from acting on exposure to vivid light. 
The pulse, in true epilepsy, is not only frequent but often irregular also ; a circum- 
stance which can never be imitated. The skin of an epileptic, during the fit, is 
commonly cold ; but that of an exhibitor is hot, and covered with sweat, obviously 
the consequence of his violent and voluntary exertions. In this respect, also, it is 
scarcely possible for him to deceive us. Again, an impostor will not bite his tongue, 
as epileptics often do; nor very willingly void (like them) his excrements and urine 
during the fit ; indeed, it would not be very easy for him to do so, and at the same 
time to carry on the necessary pretence of convulsions. Besides, epileptics, during 
a fit, are quite insensible to external impressions ; and hence the vulgar modes of 
detection, though harsh and not to be recommended, are often effectual ones ; such 
as dropping meUed sealing-wax upon the patient; putting some gin into his eyes; 
burning him with a hot poker ; or (what I beheve is more fashionable among beadles 
and poKce constables, when they have to administer to such patients), the pressing 
your thumb nail violently under that of the supposed impostor. This causes exqui- 
site pain, yet inflicts no lasting or serious injury ; and I beheve that few pretenders 
stand out against this expedient. It is astonishing, however, how much torture some 
of them will bear before they can be brought to confess their imposition. If we 
speak of having recourse to some of these painful tests in the hearing of the pre- 
tender, we shall find that the fit will soon come to an end. Dr. Cheyne mentions an 
instance in which one table was placed upon another, and a soldier, who was sup- 
posed to be shamming, was laid upon the upper one, while his paroxysm was on 
him ; and the fear of falhng from such a height soon stopped the convulsions. Mr. 
Hutchinson relates the case of a sailor who was suspected to be a cheat, in whom 
the convulsions were instantly removed^by blowing some fine Scotch snuff up his 
nostrils through a quill. This brought on another kind of fit, viz., a fit of sneezing, 
which lasted nearly half an hour ; and there was no return of the epilepsy so long 
as Mr. Hutchinson remained in that ship. He tried the same expedient in cases of 
real epilepsy, but never could produce any similar effects, although the patients were 
not snuff-takers. There was a beggar in Paris, who often fell into epileptic fits in 
the streets ; one day some compassionate spectators, fearing that he might injure 
himself in his struggles, got a truss of straw and placed him upon it : but when he 
was in the height of his paroxysm, and performing remarkably well, they sat fire to 
the straw ; and he presently took to his heels. 

There is another ingenious plan, very likely, I should think, to detect an impostor, 
nnd yet not calculated, like the one last mentioned, to injure a real sufferer : which 
is to propose gravely, in his hearing, to pour boiling watey uporj ius legs, and then 
to proceed actually to pour cold water upon them* . 



EPILEPSY. 



393 



Of the real diseases which are apt to be confounded with epilepsy, hysteria is the 
chief. The question whether a given case be one of epilepsy or of hysteria, very 
often arises. By a careful attention to several circumstances, the discrimination is 
generally to be made. In the first place the total suspension of consciousness, which 
is so constant an accompaniment of the epileptic paroxysm, does not take place in 
the hysterical : in epilepsy there is no globus hystericus, no alternations of laughter 
and tears ; the solitary cry which ushers in the epileptic attack so frequently, and 
which is so characteristic, is not heard in hysteria ; not that hysterical girls do not 
scream, for they often do; but then it is repeatedly and continuously. The heavy 
comatose sleep that succeeds epilepsy is not common in hysteria. Hysterical patients 
contrive also to avoid hurting themselves by their contortions : they do not bite 
their tongues, nor foam at the mouth. Dr. M. Hall tells us that, in epilepsy, there 
is a forcible closure of the larynx, and expiratory efforts which suffuse the counte- 
nance, and probably congest the brain with veflous blood. In hysteria the respira- 
tion, on the contrary, is rapid and sobbing. 

Observe that I have been speaking, all along, of what has been sometimes called 
habitual epilepsy. It is not every attack of convulsions with insensibility which 
ought to be so named. Such attacks are apt to follow sudden injuries done to the 
brain ; stunning blows on the head, fractures of the skull, the eruption of blood in 
sanguineous apoplexy, and even overwhelming emotions of the mind. The reten- 
tion of urea in the unpurified blood, occurring in connection with a peculiar renal 
disease to be hereafter described, appears to be a frequent cause of similar seizures. 
With these casual occurrences of epileptiform convulsion I do not here meddle. 

Epilepsy is one of those complaints concerning the probable issue of which the 
patient, and still more the patient's friends, are sure to make repeated and anxious 
inquiries. It is seildom that we can pronounce with any confidence a favourable 
prognosis ; but there are some cases in which the prospect is much worse than in 
others. 

If we have reason to believe that the disease is centric, and connected with any 
organic derangement of the nervous centres themselves, the prognosis must be bad. 
Cseteris paribus it is rendered worse by the coexistence of any sign of scrofulous 
disease, or of the well-known bodily characteristics of the scrofulous diathesis : it is 
rendered worse, also, when the disease has happened in the parents or among the 
more immediate ancestors of the patient ; whenever, in short, there is reason to think 
the disposition to it is inherited. The prognosis is bad when the complaint occurs 
in persons who have slanting foreheads and misshapen skulls : and when the epi- 
leptic physiognomy has become established. The prognosis is always the more 
unfavourable the longer the disorder has lasted ; the oftener the fits have been 
repeated ; and the more habitual they have become. And when the memory is 
permanently enfeebled, or fatuity has come on, or the disease is complicated with 
any form or degree of paralysis, the case is hopeless ; so far, at least, as a perfect 
cure is concerned. 

On the other hand, the prognosis is better when the disease is eccentric: i. e., 
when there is any obvious exciting cause of the paroxysms, manifest in structural 
or functional disorder of some part of the body other than the nervous matter. And 
when this eccentric cause is removable — a stone in the bladder, for instance, worms 
in the intestines — then the prognosis still further improves. On this account th-e 
prognosis is better in children than in older persons, for the exciting cause is often 
clearly eccentric, and hkely to be transitory ; the irritation of teething, for example : 
and besides this, it is stated by many practical writers jjiat even repeated and habitual 
attacks of epilepsy in children often go off as the patients grow older; and especially 
at the age of puberty. The experience of Heberden, however, was against this. 
He says that he had known several persons become epileptic at that time ; but that 
he had never met with one who had then got rid of the disease. He had seen a 
few who had recovered before, and some after, the age of puberty. Dr. Elliotson 
mentions a case in which a girl had epilepsy prior to the first period of menstrua- 
tion : then the fits stopped ; and she remained free from them until in advanced life 
the catamenia ceased to recur ; and then the epilepsy returned. In all those cases 



394 



EPILEPSY. 



in which we can assign some evident cause for the fit — such as the use of improper 
food, uterine irritation, mental emotion, and so on— -the prognosis is somewhat better 
than usual. 

[In the predisposed, one of the most frequent causes by which the paroxysm is brought 
on, is errors in diet, either in regard to the quality or quantity of the food taken. We have 
known cases in which the patients remained free from an attack so long as they abstained, 
from a particular article of food, but invariably experienced one on partakings of it. — C] 

" The eccentric epilepsy (says Dr. Hall) is to he viewed as curable, however 
difficult of cure." And however unfavourable the prognosis may be, there is nothing 
that can excuse any apathy or neglect on the part of the practitioner. Though few 
cases of habitual epilepsy admit of a cure under any treatment, yet there are few 
which may not be relieved by treatment, so far as regards the frequency or the vio- 
lence of the fits, or both. 

The treatment of epilepsy resolved itself into the measures to be adopted during 
the fit ; and the measures to be adopted during the intervals between the fits. 

In the paroxysm itself we have to provide against the risk of injury from the 
struggles and contortions of the patient ; and if possible, to mitigate the violence, and 
to shorten the duration of the fit. The patient should be placed in the centre of a 
large bed ; his neckcloth, and any ligatures about his person, should be loosened ; 
his head should be somewhat elevated. When the risk of his hurting himself can- 
not be avoided in any other way, his limbs should be restrained by the bystanders, 
or secured in a waistcoat. Some persons have advised that a piece of cork or soft 
wood should be placed between his teeth, to prevent him from biting his tongue, or 
breaking his teeth. But it is not easy to manage this expedient cleverly. If the 
head be visibly congested, and hot, cold wet cloths may be applied to it with pro- 
priety ; and if, at the same time, the extremities be cold, means of restoring warmth 
to them should be adopted. 

I do not know whether art can abbreviate the paroxysm. Some years ago the 
late Barry O'Meara sent a letter to one of the newspapers, saying that he fancied he 
had seen a popular remedy useful in such cases ; that, namely, of cramming salt 
into the patient's mouth : he thought he had succeeded in bringing the patient about 
by that expedient. In the epileptic patients that come into hospitals, the physician, 
not being always on the spot, does not see all, nor even many of the paroxysms ; but 
after reading that letter, I desired the nurses to treat all my patients who might be 
seized with epilepsy in the wards upon that plan : and on comparing the length of 
the paroxysms when the salt was used, with their ordinary duration as reported by 
the friends of the patient, or as previously observed in the hospital during some of 
the earlier fits, it certainly did seem to curtail the convulsions. Probably it is more 
calculated to reheve an hysterical than an epileptic fit. In the epileptic fits of chil- 
dren much benefit often results from immersing them in warm water : particularly 
if there be any coldness of the extremities. 

It is very much the fashion to bleed persons who are seen in a fit, of whatever 
kind ; and to bleed them largely. I have already sfiven you my opinion respecting 
the indiscriminate use of this decided measure in apoplectic attacks. If it be clear, 
from the phenomena, or from the known history of the patient, that the case is one 
of epilepsy, bleeding, during the fit, will seldom be necessary or proper ; unless, 
indeed, the evidence of cerebral plethora is very strongly marked : and even then I 
would advise you not to do more than take a moderate quantity of blood, by cup- 
ping, from the neck or temples. The convulsions and the sopor may be expected 
soon to pass off; as soon, probably, and as completely without, as with, any abstrac- 
tion of blood. Whereas the difference of the alternative is not trifling, in respect to 
the condition in which the patient will be left when the fit is over. The injurious 
eflfect of excessive blood-letting upon the system at large, is manifest, sometimes, for 
months afterwards. 

During the intervals between the attacks we seek to prevent their recurrence ; 
and this end is to be attained, when it is attainable at all, by getting rid of the pre- 
disposition to the disease on the one hand, and by protecting the patient against its 
exciting causes on the other. Now there are certain kinds and causes of predispo- 



EPILEPSY. 



395 



Sition which we cannot get rid of; such are the tendency that is inherited; the 
strumous diathesis ; malformation of the head ; the presence of some organic lesion 
in the brain or spinal cord. Vicious and dissolute habits are also difficult, but not 
impossible to eradicate. It will be our duty, when such are discovered, to set strongly 
before the unhappy patient the dreadful end towards which he is hastening ; the 
certain loss of reason to which, when once the disease has shown itself, the continu- 
ance of his baneful indulgences will drive him ; and to urge upon him the necessity 
for a short and sudden turn on his part, if he would expect any aid from medicine. 
Where no physical cause of the prochvity exists, or can be detected, it is of much 
importance to ascertain whether there be any deviation from the standard condition 
of health ; towards general plethora in the one direction, or towards emptiness and 
asthenia in the other. The first of these unnatural states may be redressed by regi- 
men and exercise, by abstinence from stimulating food and drink ; by a slender diet 
also ; and, if need be, by direct depletion. The second, which, perhaps, is the most 
common of the two, and which often leads (as I have explained before) to local ple- 
thora, may be removed or lessened by a tonic treatment. The object in both cases 
is to give stability and firmness to the nervous system; to diminish that mobility, or 
readiness to be impressed, which is so strong a characteristic^ of the" class of patients 
affected with epilepsy, although it may not be very apparent in some few individuals 
among them. It is upon tTiis principle that mineral tonics sometimes do good in 
epilepsy, and not by any specific virtue which they possess in restraining the fits. 

It is owing, perhaps, to a neglect of these two somewhat opposite conditions of 
general plethora and general debility, or to the difficulty which sometimes is met 
with in distinguishing them, that such a variety of opinions have been expressed 
concerning the proper treatment of habitual epilepsy. Plethora is to be reduced 
without causing hurtful debility: tone is to be given without inducing dangerous 
fullness. It requires some nicety to carry the balance even ; to attain the hoped-for 
good, and at the same time to avoid the evil that is apt to wait upon it. In very 
many cases the requisite extent and measure of the tonic plan on the one hand, or 
of the lowering system on the other, can only be learned by careful trials. But 
sometimes the indications of treatment are more plain. When the patient is young 
and strong, and full of blood, and not of a particularly movable temperament ; when 
he has a hard pulse, or any degree of feverishness ; when the disorder has super- 
vened upon the suspension of some customary discharge, so that there is an obvious 
cause of plethora ; and when the disease is in its early stage, and the recurrence of 
the fits has not yet been estabhshed by habit ; in any or all of these circumstances it 
will often be proper to abstract blood from the patient, and it will always be right to 
purge him actively, and to insist upon an abstinent regimen. When former pa- 
roxysms have been preceded by signs of fullness of the vessels of the head — by 
headache, for instance, throbbing of the temporal arteries, distension of the superfi- 
cial veins, a flushed or loaded countenance — you may sometimes, by a timely use 
of the lancet or the cupping-glass, avert an attack that was apparently impending. 

On the other hand, if the patient is pale and weak ; or unduly susceptible ; or if 
his malady has been fastened upon him through many repetitions of the fit ; you 
will generally find that any form of active depletion is injurious, and learn to place 
your best hope in measures which are calculated to invigorate the frame. 

One of the most useful of the particular remedies employed for strengthening the 
body, is the cold shower-bath. This tends more, perhaps, than any single measure, 
to give permanent firmness and steadiness to the system. The best test, in all cases, 
of the tonic and bracing effect of this remedy is the occurrence of a pleasant and 
general glow after each application of it. It is the only safe mode in which the cold 
bath can be used by an epileptic person. 

You will find, in books, a great many tonic medicines recommended for this dis- 
ease, which medicines you w^ill have opportunity and ample time for trying. Of the 
mineral tonics, the salts of silver, zinc, copper, and iron, have been chiefly praised. 
The nitrate of silver used to be highly thought of ; but there is one very serious 
objection to it which must never be forgotten : viz., that it is apt to produce a perma- 
nent discoloration of the skin, a frightful lead-colour. There is a footman in a house 



396 



EPILEPSY. 



near Cavendish Square who has been thus blackened : and there is a gentleman of 
property resident at Brighton in the same predicament ; his face looks as if it had 
been thoroughly and carefully pencilled over with plumbago. A barrister, a hieuL 
of my own, had a narrow escape from a similar misfortune : in fact his skin has 
acquired a just perceptible tinge of gray. Now if the remedy were sure to cure the 
disease, I am not certain that every one would accept of a curQ on such terms. It 
would be proper, even on that supposition, to tell the patient that though he (or, a 
fortiori, she) would get rid of the epilepsy, there was a likelihood that this unamia- 
ble complexion might ensue. But the truth is, that in giving this nitrate of silver 
we run a great risk of obtaining its disfiguring elfect, for the sake of a very small 
chance of curing the epilepsy. I have been assured, by one of his friends, that the 
Brighton gentleman has carried a dark outside for a quarter of a century at least ; 
and that he is as subject to epileptic fits now as ever he was. If the lunar caustic is 
to do good, it must be given for some time together, and the probability is that it 
will not do good even then ; and if it be given for some time together, there is great 
danger of its changing the colour of the skin. For these reasons I never give it 
myself, and therefore I cannot recommend it to you. If you wish to try it, or if you 
have a patient who insists on trying it, as some will, you may begin with half a 
grain in a pill three times a day ; and the dose has sometimes been carried as high 
as fifteen grains. And it is worth observing that in the larger doses this drug proves 
purgative. It is possible that its good effect, when it has any, may be attributable 
to its operation in that way. 

There is no danger of spoiling the beauty of your patient by administering the 
oxide or the sulphate of zinc ; or the cuprum ammoniatum. The hquor arsenicalis 
has been thought useful ; but it requires to be exhibited with great caution. Of all 
the metallic remedies I should prefer some preparation of iron. I think I have 
seen much good done by the vinum ferri ; not by any specific agency, however, but 
by its giving what is called tone to the nervous system, and rendering it less prone 
to be affected by the slighter exciting causes of the disease. I cannot pretend to 
weigh the merits of the long list of substances which have been lauded as efficacious 
in keeping off and curing the disease ; and which, when they have been useful at 
all, have operated, I conclude, in diminishing the disposition to epilepsy by corro- 
borating the nervous system. The most renowned of them are valerian, assafetida, 
wormwood, the misletoe of the oak, the cardamine pratensis, rue, the sedum acre, 
indigo ; narcotic vegetable preparations, stramonium, belladonna, hemlock, lettuce ; 
animal substances, musk, castor, ox-gall; and the number might be many times 
multipHed : and this long array of drugs, all of which have been known, or sup- 
posed, to accomplish a cure, affords, in truth, one of the strongest evidences of the 
intractability of the disease under any plan of treatment. There is a shrewd remark 
of Esquirol's which I believe to be quite true, however difficult it may be to account 
for the fact, which is, that epileptics are apt to improve for a time under every new 
plan of treatment. 

Whatever drug you may see reason to prefer (and the patients will have drugs, 
and you must be prepared to ring the changes upon them), there are certain other 
points in the management of the disease which are of considerable importance. The 
patient who is subject to epilepsy should hvebyrule, and be temperate in all things. 
His diet should be simple, nutritious, but not stimulating : he should renounce all 
strong liquor, and become, in the new-fangled and vulgar phrase, a tee-totaller. He 
should rise early, and take regular exercise in the open air ; keeping his head cool^ 
and his extremities warm. He should avoid all mental excitement, and the fatiguing 
pursuit of what is called pleasure: all probable sources of sudden anger, surprise, 
alarm, or deep emotion of any kind ; all striving and contention of the intellect. The 
student, of whatever age and sort, in whom epilepsy has declared itself, should shut 
his books : the man of business abandon or abridge his professional toil : at least 
they must be instructed to abstain habitually in their respective callings, from such 
applications as would task and strain their powers, whether mental or bodily : and 
endeavours should be made to engage their thoughts and to interest their minds in 
less engrossing objects of attention. No minute rules can be laid down on these 



EPILEPSY. 



397 



points, but, keeping the general indication in view, it will seldom be difficult to follow 
it up in practice. 

When the fits appear to have been brought on by a species of moral contagion, or 
by imitation of the same disease seen in others, care should be taken to exclude as 
much as possible those objects or trains of thought which produce the mental emotion 
or the morbid propensity. In these cases, and, indeed, 1 may say in almost all cases, 
it is more rational to expect benefit from such measures as tend to calm the mind 
and to fortify the nerves, than from this or that substance thrown at random into the 
stomach. 

There is cause for suspecting that epileptic fits sometimes depend upon a syphi- 
litic affection of the bones of the skull ; I am much mistaken if I have not seen such 
cases. When that suspicion arises, it will be proper to give mercury a full and fair 
trial. Such a plan has been followed by success. I should always premise, how- « 
ever, in such cases, the iodide of potassium; the efficacy of which in dispersing 
syphilitic nodes is no longer doubtful. I am accustomed to recommend a gentle and 
long-continued course of mercury whenever organic disease of the brain is sus- 
pected ; the influence of that remedy being carefully watched. It will be right and 
proper also to try the effect of counter-irritation ; of blisters, a seton in the neck, or 
the tartar-emetic ointment. But I must confess to you that, often as this, expedient 
is employed, I have seldom witnessed any such result from it as would encourage 
me to expect benefit from repeating it in another case. There is one form of counter- 
irritation which I have never seen put to the test, but which has of late been strongly 
recommended by a very able and observing physician. Dr. Pritchard ; and of which 
I have heard very good accounts from a gentleman who had seen it extensively 
employed in Bristol ; I mean the making a long issue in the head itself, dividing 
the integuments down to the bone by means of a scalpel in the direction of the 
sagittal suture, and keeping the incision open and discharging for some time, by 
means of issue peas. The formation of the issue is said to be not so painful as one 
might suppose. 

Dr. Gluain, in his edition of Martinets Pathology, relates the following case : 
" Some years ago I saw a boy who was epileptic from infancy, and who, in one of 
his usual fits, fell over the chff by the sea-side, and received a very severe lacerated 
wound of the scalp, which healed slowly and with a copious suppuration. While 
the discharge continued he was free from any epileptic attack ; but as soon as the 
wound healed, the fits returned as before." 

Twice I have seen similar good effects from the insertion of a seton in the neck. 
Twenty times that measure has disappointed my hopes. 

When the disease is ascertained or believed to be of the eccentric kind, we must 
search diligently to find the seat of the distant irritation, in some disturbance of 
function ; and apply our remedies accordingly. The irritation may be found, as I 
have already intimated, in almost any organ of the body. Painful or irregular 
dentition is perhaps one of the commonest of the eccentric sources of epilepsy. 
Sometimes the attacks are attended with symptoms of disease in the liver ; slight 
yellowness of the skin, uneasiness and tenderness of the right hypochondrium, and 
iowness of spirits. In such a case we must rectify that state of the fiver, by such 
means as I shall have to specify hereafter. If the disorder depends on a stone in 
the bladder, the cure must be committed to the surgeon. I have a patient at present 
under my occasional inspection, who from time to time has slight fits of epilepsy ; 
on most occasions he passes about the same time a small calculus by the urethra. 
I make no doubt that in his case the exciting cause of the epilepsy fies in the 
kidney. 

You will find that most persons, in respect to such diseases as that which we are 
now considering, have some favourite or usual mode of treatment ; and if I were 
called upon to name any single drug, from which, in ordinary cases of epilepsy, I 
should most hope for relief, I should say it was the oil of turpentine. And I find 
that other physicians have come to the same conclusion. Dr. Latham the elder was, 
I believe, the first person who made known its efficacy in this disorder. Foville 
states that he has seen excellent effects from it. It is highly spoken of by Dr. Pel 



398 



EPILEPSY. 



cival, in the Dublin Hospital Reports. It is not to be given in large doses, but in 
smaller ones, frequently repeated ; from half a drachm to a drachm every six hours. 
You are aware that it sometimes produces strangury, and therefore the patient must 
be forewarned of this, or carefully watched. Occasionally turpentine has done good 
in virtue of its anthelmintic properties. I know that a physician of my acquaint- 
ance cured a case of epilepsy in this way, somewhat to his own surprise. Without 
having in his mind any notion of worms, he thought it might be well to purge his 
patient, who had laboured under epilepsy for some time, with the oleum terebinthinas. 
The patient, who is the brother of a person holding at present a high office in this 
country, was residing two or three miles out of town. In the middle of the night the 
doctor was summoned to him in a great hurry ; the messenger said he was supposed 
to be dying. He was only intoxicated, however, by the free dose of turpentine he 

• had swallowed : the next morning he voided into the close stool a large tape-worm ; 
and he has never had epilepsy since. A nobleman residing in Cambridgeshire was 
long epileptic ; and he too got rid of his epilepsy and of a worm at the same time. I 
believe that the cure was effected by turpentine in his case also ; but I am not certain 
of that. Such cases are remarkably interesting : they show that irritation of the 
stomach or intestines may be sufficient to cause the fits ; they illustrate excellently 
well the eccentric form of the disease ; and they deserve to be always borne in mind 
when we are asked to prescribe for an epileptic patient. A cure from so dreadful a 
complaint, by such simple means — the cause of his malady, and the certainty of his 
having got rid of that cause, being both so obvious and intelligible to the patient — 

■ may be enough, sometimes, to make a practitioner's fortune. But I think you will 
sometimes find the oil of turpentine very useful, even though it expels no worm, and 
when there is no worm to expel. If the bowels should be costive, the oil of turpen- 
tine and castor oil, in equal proportions, go exceedingly well together. 

When the patient has a distinct warning of an approaching paroxysm, can any- 
thing be done to ward it off? Why, in some cases, by interrupting the precursory 
symptoms, it certainly may be prevented. A pupil of the class informs me that a 
brother of his, twelve or thirteen years old, has been subject to epileptic fits for two 
years. They occur in the night, especially if he is waked, even though the awaken- 
ing cause has no tendency to startle him. He often is dull and drowsy the evening 
before, and if he is roused from this lethargic state by conversation or amusements, 
the attack expected that night sometimes does not happen. Another student knows 
a young girl, in whom the occurrence of very high spirits is always precursory of 
the paroxysm ; when this extreme vivacity is moderated by those about her, the 
threatened fit is sometimes averted. I mentioned before an instance in which the 
aura, proceeding from one of the thumbs, was frequently checked by tying a hgature 
tightly round the thumb. Other examples of exactly the same kind are on record. 
Mr. Wardrop cured a case beginning with an aura in one finger, by amputating a 
joint of the finger. Dr. M. Hall states that the immediate accession of the parox- 
ysm may sometimes be prevented by dashing cold water on the face, or by exciting 
the nostrils by snuff. In this manner the disposition to closure of the larynx, and to 
expiratory efforts, is exchanged for sudden acts of inspiration. Another patient of 
my own, an old coUege friend, indeed, who is afflicted w^th epilepsy, feels convinced 
that he sometimes staves off a fit by applying smelhng salts to his nose : and he 
always carries a bottle about with him for that purpose : but unfortunately the warn- 
ing (which consists chiefly in giddiness) is generally so short that he has not time to 
have recourse to his preventive before he falls down. It is a question whether the 
fit may not be obviated by a strong mental effort in some cases. I make no doubt 
that it may, especially in the imitative form of the disease, which originates in and 
depends upon mental and moral causes. 

It is scarcely necessary that I should do more than advert generally to those pre- 
cautions which every one who is subject to epilepsy ought to observe, and which 
it is the business of his medical adviser to enforce, both upon the patient himself, 
and upon his friends. His bed should be large ; or if not large, it should be enclosed 
\vith some netting or other defence against his falling out of it. If he sleeps in a 
room by himself, care should be taken th^t in the winter a proper temperature is 



CHOREA. 



399 



kept up, for if in his attacks he gets out of bed and on the floor he may be seriously- 
injured by the cold. He should not, however, be left alone if it can be helped. 
Guards should be placed over every grate near which the patient may come. He 
should avoid ascending and descending stairs as much as he can. He should not 
ride on horseback ; nor on the outside of a coach ; nor even in a gig ; nor go about 
especially in solitary places, without an attendant. A patient of Dr. Cheyne's, a 
young man of twenty, was drowned in his own garden by falling into a little runnel 
of water, which was not four inches deep. Neither, on the other hand, will it be 
proper or safe for him to frequent crowded or hot rooms ; or the streets of a popu- 
lous town, in which the multiphcity and distraction of objects are apt to produce, 
even in a healthy person who is not accustomed to them, a degree of vertigo and 
confusion. Dr. Cheyne advises that when the patient's circumstances will admit of 
his having a constant attendant with him, the latter should be provided with some 
diffusible stimulus ; a potion, for example, composed of camphor mixture and aether, 
by swallowing which the impending paroxysm may sometimes be repelled. 



LECTURE XXXVII. 

Chorea. Symptoms ; Pathology ; Complications ; Causes ; Treatment. Chrome 
Chorea. Other Nervous Disorders to which the same name has been applied. 

Another disease of a spasmodic kind, and essentially belonging to the nervous 
system, is Chorea — St. T'ltus^s dance. This is far less serious than the complaints 
which we have recently been considering; but it is a very unpleasant disorder to 
suffer, and it has several points of analogy with the other nervous and spasmodic 
ailments. Its prominent symptom is an irregular and involuntary clonic contraction 
of some of the voluntary muscles, which, however, are not wholly or constantly 
withdrawn from the government of the will. In tetanus we had a rigid spasm, 
while the mind was clear and free ; volition was unaffected, but the muscles which 
should have obeyed the effort of the will, were seized upon by some stronger over- 
ruling power. In epilepsy, with convulsive spasm, there was suspension of the 
mental functions : a temporary interruption of consciousness, and therefore of volition. 
But in chorea we have a different state from either of these. There is no loss of 
consciousness ; no defect of vohtion. The ordinary movements of the body can be 
performed in some degree, or sometimes, under the direction of the will ; but it 
would seem as if some other power wantonly interfered to excite them when they 
are not needed, to render them unsteady and imperfect, to arrest the natural action, 
and give a new direction to the hmbs, and to cause the patient to gesticulate and 
grimace Hke a Merry-Andrew. Moreover, these apparently absurd movements do 
not occur in paroxysms, but continue throughout the day, sometimes for weeks toge- 
ther ; but they generally cease during sleep : for the most part, but not always, the 
agitated hmbs are still, while the senses are shut up in slumber. The complaint is 
not attended with fever. 

This disorder was first distinctly described by Sydenham, whose account of it is 
very graphic and excellent, and has been copied by most subsequent writers. With- 
out reference, however, to the portrait which he has left us, I will sketch the disease 
as it has occurred under my own observation. It usually begins with slight twitches 
of a few musles in the face, or in one of the extremities ; and by degrees the spas- 
modic action becomes more decided and more general. All the voluntary muscles 
are hable to be affected by it. Those of the face seldom escape. The features are 
twisted into all sorts of ridiculous forms ; you might suppose that the patient was 
what is called pulling a face, or making mouths at you : but there is neither mirth 
nor mockery in the contortion ; it is a convulsion. It is succeeded by a vacant look, 
and then it begins afresh. The disease occurs much oftener in young girls than in 
any other persons. If you ask the patient to put out her tongue, she makes sundry 



400 



CHOREA. 



aitempts to do so before she can accomplish it ; and then the tongue is suddenly 
thrust out, and as suddenly withdrawn, and the jaws snap together as if she were 
resolved that you should have as short a ghmpse of it as possible. She writhes and 
contorts her shoulders. She cannot keep her hand or arm half a minute in the same 
position. When, at meals, she desires to carry her hand to her mouth, it is arrested 
midway, and suddenly pulled back again, or pushed off in some other direction ; and 
it is only after many deviations and fruitless efforts that she succeeds. The lower 
extremities are equally affected. When the patient intends to sit or stand still, her 
feet scrape and shuffle on the floor, or one is thrown over the other ; and if she en- 
deavours to walk, her progress is most uncertain ; she halts and drags her leg rather 
than lifts it up, and advances in a jumping manner by fits and starts. In short, the 
voluntary muscles are moved in that capricious and fantastic way in which we might 
fancy they would be moved if some invisible mischievous being, some Puck or Robin 
Goodfellow, were behind the patient, and prompted the discordant gestures. With 
all this the articulation is impeded : there is the same perverse interference with 
some of the muscles concerned in the utterance of the voice. By a strong figure 
of speech, the disorder has been called "insanity of the muscles." 

Such is a picture of the main symptoms of this strange malady, as they have 
presented themselves to me ; and such, I venture to say, you will often see in your 
future practice. You will find, moreover, that the irregular jactitations are usually 
more marked and general on one side of the body than on the other : and sometimes 
they are confined to the muscles of one side. Here, therefore, we have a trait of 
resemblance to epilepsy and to hemiplegia. If you take hold of the only limb which 
happens to be thus agitated, and keep it still by main force, some other hmb or part 
will take on the convulsive action. The persons who are subject to chorea are 
always inordinately sensitive, and what is popularly called " nervous." They are 
easily stirred up by new ideas and sudden feehngs, and pass readily, and upon 
sHght occasions, from one mood of mind to another. The mind is affected, as Dr. 
Culien remarks, in the same way, and often shows the same varied, desultory, and 
causeless emotions, as in hysteria. You see the indication of this nervousness in 
the fact that the fidgety catching of the muscles increases when the patient is spoken 
to, especially by a stranger — by the physician, for example. The nurses of the 
hospital constantly tell me that such or such a patient, who has chorea, is much 
more composed at other times than she is during my visit, when she is surrounded 
by students, and made the object of their attention. In most cases the jactitations 
are partly and in some degree under the influence of the will. Sometimes the pa- 
tient seems to give way to them, indulges in or exaggerates them : at other times 
she can, by making an effort, control them. Many of the patients, especially such 
as are old and intelligent enough to understand the directions given them, and to 
make the trial fairly, can suspend for some seconds the convulsive movements, by 
taking a deep inspiration, and resting upon it, without expiring, for a little while. 
Like other spasmodic diseases occurring in movable constitutions, chorea is hable to 
be propagated also by a species of contagion, or rather of involuntary imitation. 
These diseases constantly approximate and touch each other in some of their 
characters. 

Chorea, in this its standard form, is essentially a disease of youth. Sydenham, 
and Culien, who closely copies him, state that for the most part it attacks boys 
and girls, who have not reached the period of puberty ; between the tenth and 
fourteenth years of their age. These hmits are, however, too scanty. It is very 
common between the eighth and sixteenth years ; it sometime comes on as early 
as five or six : and now and then it begins in adult life, or in old age. I have 
already intimated that it is much more frequent in girls than in boys. Dr. Heber- 
den says the proportion is as 3 to 1. Dr. Elhotson, out of 30 patients, had 33 
females and 8 males. Of 84 cases reported by Dr. Reeves, of Norwich, 57 were 
females, and 27 males. Of 72 occurring in Dr. Manson's practice, at Notting- 
ham, 53 were females, 19 males. Of 18 cases in the Hampshire County Hos- 
pital, 12 were girls, and the rest boys. Now taking all these numbers together, 
we have 204 cases, of which there were 144 females and 60 males ; the propor- 



CHOREA. 



401 



tion is as 12:5, or a little more than 2:1; and leaving out Dr. Reeves' list — 
which differs considerably from the others in containing a larger number of males 
—we have 129 cases, of which 87 were females, and 83 males ; this ratio is as 
29 : 11 ; or nearly, but not quite, 3 : 1. [In 429 cases referred to by Dufossi 
and Rufz, 130 occurred in boys and 299 in girls. — C] I have also observed 
that the disease occurs much more frequently in children having dark hair and eyes, 
than in those of a light complexion ; and I think I have seen the same remark in 
some book, but I forget where. 

[According to Mr. W. H. Bell — {Did. des Etudes Medicales) Dufosse (ibid.), and Rufz (Ar- 
chives Gerierales de Med.^ iv. 239) — the subjects of chorea have chiefly light hair. — C] 

When the disease is strongly marked, or lasts long, there is usually some imbe- 
cility of mind manifested ; a shght degree of fatuity, and a foolish expression of the 
features. But this goes off with the other symptoms. The child generally recovers, 
but the malady is apt to recur, and that more than once. In this respect we may 
trace a distant resemblance to epilepsy ; if we regard each, attack as a long and 
mild paroxysm, then these paroxysms are liable to repetition. No doubt the du- 
ration of the disorder is often abbreviated by proper treatment ; there are cures in 
this disease as well as recoveries. It is a very rare thing for chorea to prove fatal ; 
and the few fatal cases that have occurred have throv/n no light on its pathology. 
Dr. Elhotson saw a strong girl affected with it die of apoplexy ; but perhaps she 
would have died of apoplexy whether she had had chorea or no. Chorea offers 
no protection against the invasion of other diseases. My colleague at the Middle- 
sex Hospital, Dr. Hawkins, had a fatal case. He found great vascularity of the 
uterus, earthy concretions in the pancreas, omentum, and mesentery, and tubercles 
in the lungs. But these conditions had no connection probably with the chorea. 
In an instance that proved fatal under Dr. Bright's observation, there was consider- 
able disease in the uterus and its appendages. I am afraid that we shall seek in 
vain in the dead body to discern the nature of chorea. When we find organic disease 
accompanying it, we must look upon such organic disease, if it have any connection 
with the chorea at all, as being a predisposing cause ; as producing or increasing 
that irritabihty and mobility of the nervous system which fit it for submitting to the 
exciting causes of various nervous diseases. 

There is a speculation of some of the French writers respecting the seat and 
nature of chorea so ingenious, that I cannot refrain from mentioning it. 

It is affirmed by certain modern physiologists, as you may perhaps know, that 
one of the functions, the principal office indeed, of the cerebellum, is to preside 
over and regulate the faculty of locomotion ; to keep the muscles in due subordi- 
nation, as it were, to the will. No voluntary movement, almost, can be executed 
without the combined and consenting action of many muscles ; it is the business of 
the cerebellum, they say, to maintain this consent and community of purpose ; to 
prevent any mutiny of individual muscles, and to make them unanimously co-ope- 
rate in producing a given movement. How far this doctrine is true I do not intend 
to inquire: but supposing it well founded, then they very ingeniously assign the 
cerebellum as the seat of that change, whatever it is, which gives rise to the phe- 
nomena of chorea. And it is most certain that the irregular movements by which 
chorea is characterized can neither be considered as the effects of imperfect paraly- 
sis, as some have stated, nor of convulsion, in the proper sense of that word, as others 
have asserted ; but rather as consequences of the want of due harmony and agree- 
ment between the various muscles, which should combine to produce the desired 
state either of rest or of motion. There is a defect of the requisite association in 
the actions of the different muscles ; and it is in this sense that chorea has been de- 
nominated insanity of the muscles. There is a certain portion of the brain which 
ministers to the intellectual functions ; there are certain altered states of that portion, 
which lead to mental aberration ; the persons so affected form false judgments ; 
cannot associate their ideas aright. So also there is a certain portion of the ence- 
phalon which presides over the locomotive functions ; and there are altered states of 
that portion, which lead to a loss of the due association of muscular contractions. 
26 2i2 



402 



CHOREA. 



That portion is the cerebellum. Such is their theory ; and it is a very plausible and 
pleasant, but withal an unsatisfying theory. The disorder really belongs, I appre- 
hend, to the excito-motory department of the nervous system. From some infirm 
or unnatural state, either of the cord or of the incident nerves that convey impres- 
sions to it, its reflex function is called into irregular play, and voluntary muscles con- 
tract independently of volition. Sometimes, at the same instant, the patient wills 
certain definite movements through the instrumentahty of the very same muscles. 
But the authority of the will is impaired, and the automatic motions are proportion- 
ally strong and unruly. The consequence is, that the same muscles, receiving at 
the same time contradictor}'' orders from these two sources, obey neither mandate 
completely, but give rise, by their discordant action, to the grotesque and seemingly 
antic gestures which these patients exhibit. 

But to leave these seductive theories, and return to duller matters of fact. Chorea 
is a complaint that is seldom attended with any bodily pain. I have in several 
instances, however, known it to be accompanied by pain in the head ; and in some 
of them, with pain on that side only of the head which was opposite to the agitated 
limbs. I mention this as being of some practical importance ; for I have found the 
disease- to become sensibly less severe, and very soon to cease, upon drawing blood 
by leeches, or cupping, from the painful side of the head. In a greater number of 
cases, however, no such pain is experienced. Sometimes you will find that in all 
respects, excepting the nervousness, and the irregular movements, the patient is in 
the enjoyment of perfect health. But neither is this very common : generally there 
is something manifestly wrong in the state of the stomach and bowels, either before 
or during the complaint ; a capricious appetite, costiveness, a tumid abdomen, offen- 
sive breath, a foul tongue. 

Chorea is sometimes complicated with other disorders, and above all with hysteria : 
and no wonder, since they both occur chiefly in persons of the same sex, of the same 
susceptible temperament, and at nearly the same period of life. It is said also to 
happen in conjunction with acute rheumatism and rheumatic pericarditis; and with 
certain affections of the skin. Its coincidence with cutaneous complaints, if not 
merely accidental, may perhaps be owing to irritation of the peripheral extremities 
of afferent nerves, by the eruption. Judging from my own experience alone, I should 
not say that the disease was often associated with acute rheumatism. Dr. Copland 
and Dr. Bright have both, however, noted that connection, and therefore I cannot 
doubt that it does sometimes exist. I certainly have seen jactitations hke those of 
chorea in a few instances of rheumatic carditis. Very lately a boy, affected with 
chorea, became my patient in the hospital. We soon detected a strong bellows sound 
of his heart ; and tracing his history back a little, we found that he had suffered 
acute articular rheumatism. In a recent volume of the Medico- Chirurgical Trans- 
actions^ there is a paper by Dr. Bright, detaihng " cases of spasmodic disease, 
accompanying affections of the pericardium." Now we do not perceive any obvious 
or direct connection between the cardiac disorder and the nervous disorder. There 
are just two conjectures which occur to me upon the subject. Rheumatism (as we 
shall see by and by) is especially a disease of fibrous structures, and it usually affects 
various fibrous parts at the same time. It is not improbable, therefore, that in the 
cases in question, some morbid condition of the membranes of the spinal canal may 
have arisen, simultaneously with the inflammation of the pericardium. Or the car- 
diac disease may perhaps operate, by some ill-understood influence, upon afferent 
nerves of the cord, as an eccentric cause of the irregular movements. 

Probably any thing which makes a forcible impression upon the nervous system 
may act as an exciting cause of chorea. Strong mental emotion, or a sudden mental 
shock, is very likely to bring it on in those of a movable constitution who are pre- 
disposed to it. Of its ascertained or alleged exciting causes, fright is beyond all 
comparison the commonest. It has been known to follow a blow or fall on the head ; 
but even in these cases the alarm may have had more to do with the disorder than 
the blow itself. It sometimes seems to depend upon irritation of the stomach or 
bowels, by improper diet, by accumulated feces, or by worms ; and it is found to be 
connected, in not a few cases, with difficult and painful menstruation. It frequently 



CHOREA. 



403 



begins about the period of the second dentition : the late Dr. Gregory, of Edinburgh, 
was in the habit of relating instances of that kind. In one case, the old teeth were 
remaining while the new ones were appearing by their sides. The old teeth were 
drawn, and the removal of the chorea were complete. This Dr. M. Hall would 
justly call eccentric chorea. But even in such cases the state of the gums cannot 
be regarded as the sole cause of the chorea : there must be the predisposition, as 
well as the accidental exciting cause; for the complaint is apt to recur under the 
agency of some new irritation, and may then be removed by other means. 

[We have not found the disease to be much influenced by the season of the year or con- 
dition of the atmosphere. Duges, Rufz, Spangenburg, and Blache state that it occurs most 
frequently in summer. According to the statements of Rochoux, Chervin, and Danste, it is 
a rare affection in the southern hemisphere. It is not a very frequent disease in Philadel- 
phia.— C] 

Chorea, such as I have been describing it, may last from a week or two to some 
months. In those eighty-four cases which I have already mentioned as having been 
reported by Dr. Reeves, the shortest period of medical treatment was two weeks ; 
the longest eight months ; and the common average seven weeks. This appears to 
me a long average. The disorder often terminates — at any rate much more often 
than epilepsy does — at the period of puberty ; especially upon the first coming on 
of the menstrual discharge in the female. 

[Chorea, like epilepsy, may be excited by imitation (Andral) ; the fact is, however, denied 
by Rufz and Blache. — C] 

I had occasion, in the last lecture, to remark, that when a vast number of different 
drugs are recommended as specifics in any given disease, we may sometimes infer 
from that very circumstance that the disease is difficult of cure, and generally in- 
tractable under all plans of management. But there is another class of diseases 
which a variety of drugs are supposed capable of curing, — those, namely, which 
tend to terminate in health. I believe that many cases of chorea — most cases — 
would at length get well without any aid from physic : I believe also that many of 
the boasted specifics have been quite innocent of any share in the recovery of the 
patients to whom they were administered ; at the same time 1 am quite certain that 
treatment has a great influence over the disease. 

It was Sydenham's practice first to bleed and purge his patients, and then to ad- 
minister bitters, aromatics, and antispasmodics, with a view of strengthening the 
nerves. After his time the blood-letting and purgatives fell into disuse, until the 
pubhcation of Dr. Hamikon's well-known work again brought the latter deservedly 
into favour. 

The treatment of chorea embraces two definite objects. The first, and chief, is to 
give stability to the unduly movable nervous centres. The second is to remove 
or avert whatever may be hkeJy to produce unnatural excitement of their incident 
nerves. 

Now the complaint is seldom (in its genuine form I may say it is never) dependent 
upon any organic or inflammatory disease. The instrument is not^broken anywhere, 
but it is slackened, jangling, and out of tune : and (to pursue the metaphor) we 
often can restore its harmony by bracing it up again. 

I can confidently recommend you to abstract blood locally in those cases in which 
there is a fixed pain in the head ; but with this exception, blood-letting is neither 
useful, nor even (in my opinion) justifiable. There is oftener a deficiency than a 
redundance of red blood in the system. 

I shall not attempt to distract your attention by discussing the various remedies 
that have been vaunted against chorea ; but shall take the liberty of referring you to 
books (to Dr. Copeland's Dictionary, for example) for further information on that 
subject, and content myself with telling you what modes of treatment I have been 
in the habit of employing, with very satisfactory results. I think, then, setting aside 
the complication with headache just mentioned, you will be able to deal successfully 
with most of the cases of chorea which you may have to treat, if you have at your 



404 



CHOREA. 



command purgative medicines, the shower-bath, preparations of iron and of arsenic, 
and the oil of turpentine. 

It will be right, in all cases, to begin by clearing out the bowels with calomel and 
jalap, or some active aperient ; and you should persist in the regulated use of purga- 
tive medicines, if they continue to bring away much fecal matter. You are to be 
g-uided less by the amount of the doses than by the effects they produce ; at any 
rate one full evacuation of the bowels should take place every day. But though 
purgatives are good auxiliaries, we cannot trust to them alone for the cure of the 
complaint. 

One of the most effectual of the tonic remedies is the cold shower bath. If the 
patient be of a feeble constitution, the water may at first be used tepid ; hy degrees 
it should be used cold. This remedy should be employed every morning, or every 
other morning, early, as soon as the patient gets out of bed. Of the best indications 
of the propriety of its continuance I spoke in the last lecture only ; I need not tire 
you, therefore, by repeating the observations I then made. 

With this external tonic it will be right to combine some internal one ; and for the 
most part, the best for the purpose is some preparation of iron. The carbonate of 
iron is an exceedingly good form, and it may be given in the Vv^ay recommended by 
Dr. Elliotson, one of whose pets it is, — namely, mixed with twice its weight of 
treacle, so as to form an electuary. You may begin with it in half-drachm doses, 
and presently increase the quantity to a drachm, or a drachm and a half, or two 
drachms. Much larger quantities indeed have been given, and that for a long time 
together ; but I am not in the habit of so pushing this drug. Patients do not like to 
swallow from half an ounce to an ounce of the powder and twice as much treacle 
three or four times a day ; and some of them cannot get so much down. And I 
raentioned on a former occasion that the iron is apt to accumulate in the large intes- 
tines, and to be expelled at last, often with difficulty and pain, in large, hard, red 
masses, like what is called, I fancy, slag, or the dross of iron ore from a furnace. 
When one or at most two drachms given three or four times a day, make no impres- 
sion on the disease, you had better (in my humble judgment) change the form of 
the medicine. Give two or three grains of the sulphate of iron for a dose, or fre- 
quent draughts of Griffith's mixture (mistura ferri composita), or twenty or thirty 
minims of the tinctura ferri muriatis. Dr. Bright says he has found the sulphate of 
zinc answer when the carbonate of iron had failed, and the iron succeed when the 
zinc had done no good. One most severe case, about which I was consulted, and 
which had resisted other remedies, got well under the use of the sulphate of zinc ; 
the dose of which was gradually increased to ten grains, given three times a day. 
Wlienever the medicine was pushed beyond this point it became emetic. Certainly 
the disease is often very obedient to arsenic ; but, for plain reasons, it is better to 
effect a cure, when we can, by less hazardous substances. The gravest case I ever 
had to treat occurred, not long since, in one of my hospital patients. I tried the carbo- 
nate of iron in vain. The shower bath so terrified and agitated the girl that I could 
not persist with it. I then gave her arsenic, under which she improved at first, but 
it ultimately was very injurious ; her bowels were greatly irritated by it, she became 
paralytic in her l?>wer extremities, and sank into a typhoid state ; and I really was 
afraid that I should lose her. But she recovered from this condition, which 1 could 
not but ascribe to the arsenic ; and as soon as I dared venture, I began to give her 
the muriated tincture of iron, twenty drops at a time, every six hours. Under this 
treatment she steadily and rapidly improved, and was soon quite well. 

[Recently very decided testimony has been presented by Young, of Pennsylvania, Lindsly, 
of Washington, Hildbreth, of Ohio, Kirkbride and Professor Wood, of Philadelphia, and 
Beadle, of New York, in favour of the efficacy of the cimicifuga, or black snake-root, in cases 
of chorea. It may be given in the dose of half a teaspoonful of the powdered root three 
times a day : or from one to two drachms of the saturated tincture, or a wineglassful of the 
decoction. The cyanuret of iron, in the dose of three grains three times a day, in the 
form of a pill, has been strongly recommended by Dr. Zollickoffer, of Maryland. The 
cyanuret of zinc, in the dose of one-third of a grain, twice a day, gradually increased to 
fourteen grains in the twenty-four hours, has recently been highly spoken of by the physi- 
cians of Berlin and elsewhere. See Condie on Diseases of Children. — C] 



CHOREA. 



405 



The oil of turpentine also is certainly a valuable medicine in this disease ; whether 
Ihere be worms at the bottom of it or not. When the bowels are torpid, and the 
girl is of that age when menstruation may be conjectured to be at hand, its arrival 
seems sometimes to be accelerated, and great relief to be produced by the turpentine. 
The best way of exhibiting it in such cases is in combination with an equal quantity 
of castor oil; two drachms or half an ounce of the mixture may be given every 
morning, or every other morning, according to its effect upon the bowels ; and when 
they are very sluggish, or the stools are unnatural, it will often be serviceable to give 
a couple of grains of calomel also, twice or thrice a week, at bed-time. 

It is scarcely necessary for me to say that due attention must be paid to the diet. 
This ought to be plain and simple, but at the same time nourishing, and even gene- 
rous. Exercise, short of that which produces fatigue, in the open air, in fine and 
dry weather, will also conduce much to the patient's recovery. And all kinds of 
immoderate emotion should be guarded against: for the contest often seems to lie 
between the emotional and the voluntary impulses to action. The stillness of the 
muscles during sleep is in accordance with this behef. 

There is an affection (it scarcely deserves to be spoken of as a disease) which is 
sometimes called chorea, of a chronic nature, and resembhng the disorder I have just 
been speaking of, inasmuch as it commonly is met with in nervous persons, and 
consists in the irregular, unmeaning, and involuntary contraction of certain muscles, 
especially in the limbs, neck, or face : but differing from it in this, that the same 
muscles are always affected, and in the same way ; that it lasts long, almost always 
for life, and imphes no accompanying derangement of the general health. In its 
slighter form the irregular movements are rather awkward tricks than spasms : a 
repeated shake of the head, or knitting of the eyebrows, or corrugation of the integu- 
ments of the nose, or shrugging of the shoulders — which the person seems hardly 
conscious of. At other times, however, the motions are more extensive ; a hmb 
starts out, or the head is turned awry ; and the individual who performs these evolu- 
tions is quite aware that he does so, and vexed and annoyed at the ridiculous figure 
he makes, but he cannot help performing them ; or if he can prevent it, the necessary 
effort is worse than the disease. One young man who was subject to this infirmity 
told a friend that he could stop the movement by a strong exertion of the will ; but 
that that exertion was extremely painful, and was followed by languor and much 
discomfort. In some instances I make no doubt that the continuance of the affection 
is the result of a long-established habit. It occurs m^re frequently in men than in 
women. I had for a long time, as an out-patient at the hospital, a girl about seven- 
teen years old, in all other respects the picture of health, but who was annoyed by 
an involuntary shake of the head, which took place two or three times in a minute. 
She received no benefit from medicine. A lad in my own service was affected in a 
similar manner. He seemed to be giving me, and my friends, from time to time, a 
familiar nod ; and I was obhged to part with him. Others are subject to twitchings 
of the face. I am acquainted with one gentleman who is perpetually wrinkhng his 
nose : and he has assured me that he was subject, when young, to an involuntary 
shake of the head, like the two persons just mentioned ; but a blister having been 
once applied to his throat for some disorder in his air-passages, the shaking of the 
head was thereby rendered painful and difficult, and the movement there ceased : 
but (as he expressed it) it broke out in his nose, where it triumphs to this day. This 
chronic chorea, as it has been called, I merely mention to prevent your confounding 
together two affections which, though they have received the same name, and are in 
some respects analogous, yet differ in still more points, and those points of more im- 
portance. I believe that medicine has no power over any of these tricks. They 
are distressing and unsightly ; but in no way dangerous. 

The word chorea, which you know signifies a dance — and the trivial term of St. 
Vitus's dance — are not very appropriate to either of the modifications of the nervous 
affection which I have been noticing. In fact that term was originally apphed, and 
much more suitably, to another set of symptoms of a most singular kind, concerning 



406 



CHOREA. 



the real occurrence of which we might well be sceptical, if we had not authentic 
narratives of many instances of such disorder from different persons of credit, as 
well in this country as in others. What has happened many times before, may 
happen again ; and you ought not to be in ignorance of the histories to which I 
allude. They relate to an affection characterized by movements that cannot be 
called spasmodic, but are rather owing to an irresistible propensity to muscular action, 
increased sometimes to a sort of mania by the force of imitation, or by the sound of 
music. Tt is the volition that, in these cases, is morbid and perverse. You might 
fancy the patient to be possessed and coerced by an evil spirit, like the Sac^oyt^o^fwe. 
of the Gospel history. 

Some of the subjects of these extraordinary affections, impelled by a strange unin- 
telligible necessity, execute measured and regular movements with surprising energy, 
rapidity, and perseverance. AVhen music is performed in their hearing, the move- 
ments become an actual dance ; and where crowds are collected together, the dancing 
mania is apt to spread from person to person by a sort of imitative infection ; real- 
izing the fable of Orpheus, and giving origin (it may be presumed) to those romantic 
legends met with in the literature of most ages and countries, of universal, involun- 
tary, and unceasing saltation, at the sound of a magic pipe. To these feats the term 
chorea is apposite enough. Indeed I have seen it somewhere suggested that the 
phrase chorea Sancti Viti is but a vulgar corruption of chorea Sancti inviii ^ and 
took its rise in the misfortune of some holy person who chanced to be afflicted with 
one of these unwilling but invincible impulses to caper. The common explanation 
makes this holy person to have been a certain German saint Weit, to whom a chapel 
is said (I know not with how much truth) to be dedicated at Ulra, in Suabia. 

Sometimes, instead of dancing on their feet, these patients drum and beat with 
their hands, either upon their own knees, or upon the objects near them. This 
variety has received the bombastic title of " malleation." Sometimes they circum- 
volve with great rapidity ; or they turn their heads repeatedly from side to side with 
great velocity : this is "rotation." Vv^hen they are irresistibly impelled to move in 
a given direction, the term " propulsion" is employed. The very invention of these 
names attests the reality of the disorder. 

You will find one of these singular cases related by Mr. Kinder Wood in the 
seventh volume of the Medico- Chirurgical Transactions. 

The patient was a young married woman. After having suffered severe pain in 
one side of her face, she began to be troubled with involuntary movements. They 
commenced in the eyelids, which were opened and shut with excessive rapidity. 
Then the muscles of the extremities became affected. The palms of the hands were 
beat rapidly upon the thighs, and the feet upon the floor. The mictions soon ex- 
tended to the trunk and pelvis. The patient was suddenly half raised from her 
chair, and instantly reseated. This was repeated as quickly as one action could 
possibly succeed another. Sometimes she had a propensity to leap upwards, and 
strike the ceihng with the palm of her hand ; or to touch httle spots or holes in the 
furniture of the room. Or she would dance on one leg, holding the other in her 
hand. These attacks were accompanied by headache, sickness, and vomiting. At 
last she took to making steps about the room, regulated by an air, or by a series of 
strokes on the furniture as she passed, her lips moving as if words were articulated, 
but no sound escaping them. A person, thinking he recognized the tune which she 
beat on the furniture, began to sing it; and she danced directly up to him, and con- 
tinued dancing till he was out of breath. A drum and fife were now procured, and 
the same air played upon them. She immediately danced up to the drum, and as 
close to it as possible, till she missed the step, when the motions instantly ceased ; 
and this was found always to be the case. The motions stopped also when the 
measure was changed ; or was increased in rapidity beyond her power to keep pace 
with it. A continued roll on the drum had also the effect of putting an end to her 
movements. This being discovered, their approach was watched ; and by always 
rolling the drum as soon as they threatened to begin, the chain of association which 
seemed to constitute the disease was at length broken. The bowels were in an 
unnatural stale during the complaint ; and the menstrual discharge appeared on the 



CHOREA. 



407 



evening of the day on which it ceased. One might conceive that the conduct here 
described was an indication of folly or of insanity ; but Mr. Wood declares that the 
patient's spirits were good, and her perception and judgment accurate and just ; that 
during the absence of the paroxysms she went about her household affairs as usual ; 
and that she had a correct knowledge of her situation, and of the advantage she 
derived from the drum, with an anxious desire to continue its use. She stated " that 
there always was a tune dwelling upon her mind, which at times becoming more 
pressing, irresistibly compelled her to commence the involuntary motions." 

In a lady, whom Dr. Abercrombie saw, the following symptoms, among others, 
occurred : — After she had been ill with various nervous affections for two years, she 
began to suffer convulsive action of the muscles of the back, and involuntary twitches 
of the legs and arms, producing a variety of movements of the whole body very diffi- 
cuk to describe. These were much increased by touching her, especially on any 
part of her back. This is a symptom quite in conformity Avith Dr. Hall's doctrine 
of eccentric irritation. At one time there was difficuhy of deglutition, so that attempts 
to swallow produced spasms, resembling those of tetanus. At other times, after lying 
for a long while quiet, she would in an instant throw her whole body into a kind of 
convulsive spring, by which she was jerked entirely out of bed : and in the same 
manner, while sitting or lying on the floor, she would fling herself into bed, or would 
leap, as a fish might do, upon the top of a wardrobe fully five feet high. These are 
feats that surpass the powers of a person in health : and I say we should hesitate to 
beheve them if they were not related by a physician of such sober judgment and 
unquestionable veracity as Dr. Abercrombie. He tells us that during the whole of 
these symptoms her mind continued entire : and the only account she could give of 
her extravagance was, a secret impulse which she could not resist. 

But after a time motions still more wonderful commenced, affecting the muscles 
of the upper part of the back and neck, and producing a constant semi-rotatory mo- 
tion of the head. This sometimes continued without interruption night and day for 
several weeks together ; and if the head or neck were touched, the motion was 
increased to a most extraordinary degree of rapidity. These paroxysms were 
relieved by nothing but cupping on the temples to the amount of ten or twelve 
ounces, when the affection suddenly ceased, with a general convulsive start of the 
whole body. She was then immediately weU, got up, and was able to walk about 
in good health for several weeks ; when the same symptoms returned, and required 
a repetition of the same treatment. Ail this went on, at intervals, for four years ; 
the menstruation during that time being irregular and scanty, and the bowels torpid. 
She was pale and bloodless from the frequent bleedings, but not reduced in flesh. 
At last, in the spring of 1829, she had a severe paroxysm of the rotatory motion of 
the head ; and it was then determined to allow the attack to take its course, and to 
direct the treatment entirely to the menstruation. Sulphate of iron, and Barbadoes 
aloes, were prescribed. She went on for three weeks, the convulsive motion of the 
head continuing without intermission night and day. At length, in the middle of 
the night, the paroxysm ceased in an instant, with the same kind of convulsive start 
of the whole body with which it used to cease after cupping. At the same instant 
menstruation took place in a more full and healthy manner than it had done for 
many years. From that time she remained well ; at least up to the period when 
Dr. Abercrombie wrote the account. 

The alternating rotatory motion of the head is by no means an uncommon feature 
of these singular cases. It occurred in a patient of Dr. Conolly's ; in whom the 
menstruation was irregular, and about to cease altogether. It came on in paroxysms 
which were repeated many times a day, and was attended with inordinate loquacity. 
The head was turned from side to side about eight times in a second, and each 
paroxysm lasted three or four minutes. The patient got well after being cupped 
and leeched, and thoroughly purged. I have seen precisely the same thing in a 
hospital patient. Dr. Crawford met with an instance of involuntary rotation of the 
head, without pain, but attended with intolerance of light. And there is a striking 
example of it described in the twent3^-third volume of the Edinburgh Medical and 
Surgical Journal, by Mr. Hunter, of Glasgow, who speaks of it under the name of 



408 



CHOREA. 



" rotatio or chorea." The motions are said to have been furious and alarming : they 
were executed with such extreme rapidity, that it was difficult even for the eye to 
follow them. She appeared, Mr. Hunter says, absolutely to be looking backwards 
and forwards, and in every direction, at the same moment. This woman had some- 
times fifty paroxysm.s of this kind in a day : they greatly exhausted her ; but she 
was perfectly rational in the intervals. A modification of the same kind of affection 
took place in a most extraordinary case recorded by Dr. Watt, of Glasgow, in the 
fifth volume of the Medico- Chirurgical Transactions. His patient was a girl ten 
years old. First she had headache, accompanied by vomiting, and increased by the 
slightest deviation of the body from the erect posture, either backwards, or forwards 
or to one side. These symptoms lasted about a month ; and during that time she 
lost the power of speech and of walking. At the end of that period she was seized 
with a propensity to twirl round on her feet, like a top, with great velocity, always 
in one direction ; and was pleased when those about her assisted in increasing the 
rapidity of her movements. After continuing nearly a month, these motions ceased, 
the headache returned, and she became unable to move her neck, or support her 
head. Soon after, she was visited with a new kind of motion ; she would lay her- 
self across the bed, and turning over Hke a roller, move rapidly from one end of it 
to the other. At first the fits of this kind lasted two hours ; but they gradually 
extended to six or seven hours every day. On being carried into the gard-en she 
rolled rapidly from one end of a gravel walk to the other ; and even when laid in 
the shallow part of a river, though apparently on the point of being drowned, she 
began to turn round as usual. The rotations were about sixty a minute. She made 
httle or no use of her arms in revolving. In about another month or six weeks an 
entirely new set of movements began. She lay upon her back, and, by drawing her 
head and heels together, bent herself like a bow, and then allowing her head and 
heels to separate, her buttocks fell with considerable force upon the bed. She 
repeated these movements ten or twelve times in a minute, first for six hours daily, 
and at length for fourteen. After another space of about five weeks had elapsed, 
the most singular freak of all ensued ; she became possessed with a propensity to 
stand upon her head with her feet perpendicularly upwards. As soon as the feet 
were elevated in this manner, all muscular exertion seemed to be withheld, and the 
body fell down as if dead ; her knees striking the bed first. This was no sooner 
done than she instantly mounted up as before ; and continued to do so from twelve 
to fifteen times in a minute, for fifteen hours a day. After a variety of fruitless 
treatment, a spontaneous diarrhoea came on, and she recovered. 

The spinning motions observed during a part of this case have been observed in 
other instances. 

In Magendie's Journal de Physiologie, the two following singular forms of dis- 
ease are referred to. A man, after some other symptoms of cerebral disorder, was 
seized with an irresistible inclination to move forwards, stopping only when ex- 
hausted. He would sally forth into the streets, and continue walking straight 
forward until he dropped down from fatigue, and was obhged to be brought home in 
some conveyance. This man at length died, and several tubercles were found in 
the anterior hemispheres of his brain. Dr. Laurent of Versailles, exhibited to the 
Academy of Medicine a young girl, labouring under the exactly opposite necessity. 
In the attacks of a nervous disease she was irresistibly propelled backwards, and 
with some rapidity : being unable to avoid obstacles or hollows, she received many 
falls and bruises in her course. 

I say that histories such as I have been giving you some samples of, and those 
mostly in an abridged form, would sound very hke romances, if they were met 
with in the old authors alone, or if they were not attested by unimpeachable au- 
thority. They resemble chorea in this respect, that they are examples of muscular 
actions performed by persons in possession of consciousness, and performed in 
5pite of themselves. But in most other respects they differ from what we now-a- 
days mean when we speak of chorea. Perhaps they may rank among hysterical 
vagaries. It is remarkable that the majority of them occur in young women, in 
whom the menstrual function is suspended or irregularly performed. Some persons 



CHOREA. 



409 



may consider them as varieties of insanity. The patients certainly did not feign to 
be ill, for the feats of strength and agihty which many of them enacted were much 
beyond their natural power and endurance. The truth seems to be, that there are 
innumerable modifications of the nervous functions, and that some of them are more 
common and more capable of being arranged into groups than others ; but that they 
all ofTer points of resemblance, like (as I observed before) the different members of 
a large family, in which the individuals have the same general cast of features, and 
yet preserve each his particular identity. 

I advert to these odd forms of disease with a view of directing your attention to 
such of them as may come in your way. We are yet terribly in the dark about 
morbid affections of the nerves, both organic and functional. Hereafter some medi- 
cal Newton will arise, and reduce all these apparently complicated phenomena 
under one simpler law. At present all that v/e can do is to collect and, as far as we 
may, to arrange facts, in the hope that at length some better hght will be shed upon 
the subject. And it must be observed that some of the modern researches into phy- 
siology do throw a httle glimmering of illumination into these dark corners of pa- 
thology. In certain of M. Magendie's experiments on animals the following curious 
facts were ascertained : — When a vertical section of the cerebellum of a rabbit was 
made, leaving one-fourth of the whole adhering to the crus of the right side, and 
three-fourths to the left, the animal rolled over and over incessantly, turning itself 
towards the injured side. The same phenomenon occurred upon the division of the 
crus cerebelH. The animal lived for eight days, and continued during the whole of 
that time to revolve upon its long axis, unless stopped by coming in contact with 
some obstacle. How like is this to the symptoms exhibited at one period in the 
girl whose case is related by Dr. Watt ! Nor is Dr. Watt's case a singular one ; M. 
Serres has described another much resembhng it. A shoemaker, sixty-eight years 
old, of intemperate habits, after one of his debauches, exhibited a kind of drunken- 
ness which surprised his friends. Instead of seeing objects turn round him, as a 
drunken person is apt to do, he thought he was himself turning, and soon began to 
revolve ; and this lasted till he died ; and when his head was examined, extensive 
mischief was found in one of the peduncles of his cerebellum. 

Again, M. Magendie noticed that when the upper part of the cerebrum is gently 
removed in birds and mammalia, they become Wind ; but no affection of the locomo- 
tive powers is produced. No further result is occasioned by the removal of a portion 
of the gray matter of the corpus striatum : but when the striated part is cut away, 
the animal immediately darts forward with rapidity, and continues to advance as if 
impelled by some irresistible force, until stopped by an obstacle ; and even then it 
retains the attitude of one advancing. The experiment was tried with the same 
result upon various species of animals — dogs, cats, hedgehogs, rabbits. Guinea-pigs, 
and squirrels. It seems that there are horses that cannot back; although they make 
good progress enough in a straightforward direction. Now iMagendie says that he 
has opened the heads of such horses ; and has always found, in the lateral ventricles 
of their brains, a collection of water, which must have compressed and even disor- 
ganized the corpora striata. It has further been ascertained, by the same experi- 
menter and by others, that certain injuries of the cerebellum cause animals to move 
backwards contrariiy to their \\\\\. If the tail of the animal so mutilated be pinched, 
he still persists in his retrograde course. Injuries of the medulla oblongata had the 
same effect. Pigeons into which he forced a pin through that part, constantly re- 
ceded for more than a month, and even flew backwards. A section of the medulla 
oblongata, where it approaches the anterior pyramid, gives rise to a movement in a 
circle, like that of a horse in a mill: the animal, in its walk or its flight, bearing 
round continually to the injured side. Surely we have, in these facts, supplied by 
experiments on living animals, and by observation of the phenomena of disease in 
the living human body, some of the materials for a more exact knowledge, both of 
the physiology and of the pathology of the nervous system, than we have yet 
reached. M. Magendie supposes that different portions of the encephalon are en- 
dowed w'wh energies which tend to cause motion in various directions ; that in the 
healthy state these balance each other, and that a preponderating impulse can bo 

2k 



410 



CHOREA. 



given to any one of these forces by the will; but that when the equilibrium is 
destroyed by disease, the wiil is not sufficient to counteract the tendencies which are 
then brought into play. Mr. Mayo offers a different explanation of the phenomena. 
He supposes that the injuries inflicted on the nervous matter produce a sensation 
analogous to vertigo ; and that the animal conceives itself either to be hurried for- 
ward, and makes an exertion to repel the imaginary force ; or to be moving back- 
ward, or turning round in one direction, and endeavours to correct this by moving 
the corresponding muscles. Whatever may be the true explanation, the facts 
themselves are abundantly curious and interesting, and I recommend them to your 
attention. 

Some of the affections that I have been describing, fall, perhaps, under the cate- 
gory of those to which the appellation of the leaping ague has been given in some 
parts of Scotland. There is a class also of convulsive spasmodic affections which 
resemble epilepsy on the one hand, and chorea on the other, or rather form a Knk of 
alliance between the two, and which are especially remarkable for this, that they are 
capable of being propagated by that kind of imitative contagion of which I have 
several times spoken. This point might be well illustrated by the history of various 
sects of religious enthusiasts. One or two of those enthusiasts have apparently at 
first worked themselves up into a state approaching to epilepsy, accompanied even 
by insensibility sometimes ; and then this state has been communicated by sympathy 
to the more susceptible of their auditors. I must not, however, go into any further 
details on this subject; and perhaps ! have prosecuted it too far already. Those 
among you who are inchned to pursue it further may find some curious accounts of 
an epidemic which occurred in Lanarkshire, in Sir John Sinclair's Statistical Ac- 
count of Scotland, under the head of the "Conversions of Cambuslang ;" and in 
one of the early volumes of the Edinburgh Medical and Surgical Journal. Dr. 
Robertson has described, in an inaugural dissertation De Chorsed Sancti Viti, a 
similar epidemic, which occurred in the states of Tennessee and Kentucky, in the 
western districts of America. This is also referred to in the same volume of the 
journal. Among other things. Dr. Robertson says, that while extravagant sounds, 
and actions, and gesticulations, were in the first instance wilful, the actors " at length 
to their own astonishment, and the diversion of many of the spectators, continued to 
act from necessity the curious character which they had commenced from choice^ 
I will only remark further of such forms of nervous disease, that as they spring often 
from moral causes, so they admit, in a great degree, of m_oral remedies. The pranks 
played by the Scotch enthusiasts were brought to an end by threatening to duck 
every one who should thereafter be attacked ; and, I believe, a few of them ivere 
horseponded, by way of example. With respect to the solitary instances of per- 
verted locomotion, our business must be to correct whatever is wrong in the state of 
the bowels : in women, to amend the disordered uterine functions ; to strengthen and 
confirm the system generally ; and, in addition to the measures proper to effect these 
objects, I suspect that the cold sousing would in many cases be found of most 
material service. 



LECTURE XXXVIII. 

Paralysis Agitans. Mercurial Tremor. Hysteria : Two forms of Hysteric Fa- 
roxysm ; Diagnosis from Epilepsy ; Class of Persons most liable to Hysteria ; 
Diseases apt to be simulated by Hysteria ; Treatment ; Prevention. 

In the last lecture I spoke of chorea, and of some singular forms of disorder that 
laave sometimes been included under the same appellation ; and I shall begin the 
present with a fevv observations concerning a disease very closely allied to some of 
those which we were then considering, and yet distinct enough to deserve and require 
a separate notice. I refer to what has been called the shaking palsy —paralysis agi- 



PARALYSIS AGITANS. 



411 



tans. Allusions to this form of disease are to be found in manjr of the older sys- 
tematic writers on physic ; but it never was much attended to in this country until 
Mr. Parkinson published an essay upon it in the year 1817; and a very interesting 
little pamphlet it is. He defines the disease thus : — -"Involuntary tremulous motion, 
with lessened muscular power, in parts not in action, and even when supported: 
with a propensity to bend the trunk forwards, and to pass from a walking to a run- 
ning pace ; the senses and intellects being uninjured." The latter symptoms consti- 
tute the scelotyrbe festinans of Sauvages ; and the former symptoms of the definition 
are not always attended by the latter. In old persons you may often observe incessant 
and involuntary nodding and shaking of the head, without any tendency to run for- 
wards. There is an old woman whom I see regularly sitting in the aisle at church 
every Sunday ; she walks to her seat slowly and steadily enough, and sufficiently 
upright ; but her head never ceases to nod, and wag, and tremble in various directions. 
It may be that she is in the less advanced stage of the malady ; but I have remarked 
her for three or four or more years, and I see no change. 

Mr. Parkinson's notice was first called to the disease during his professional attend- 
ance upon a person affected by it. From observation of that case, and of several 
others that he subsequently met with, his account of the disorder was drawn up. 
He states that its first approach is insidious, and its progress often so slow and imper- 
ceptible that the patient cannot recollect precisely when it began. A sense of weak- 
ness, and a disposition to trembling, fastens on some particular part : sometimes it is 
the head, but more commonly it is one of the hands or arms. These symptoms 
gradually become more decided ; and at length the morbid influence is felt in some 
other part. At a still more advanced period the patient is found to be less strict than 
usual in preserving an upright posture, even when standing or sitting, but especially 
when walking. By degrees he finds a difficulty in making the hand obey the dictates 
of the will wlien he is engaged in any delicate manipulation— in writing, for exam- 
ple ; and he is obliged to walk with circumspection and care : his legs are not raised 
to that height, nor with that promptitude which the will directs ; so that much 
attention is necessary to prevent frequent falls. Then, as the malady proceeds, the 
propensity to lean forvv^ards becomes more strong — the patient is forced to step on 
the toes and fore-part of the feet, while the upper part of the body is thrown so far 
forward as to render it difficult to avoid falling on the face : in some cases he is irre- 
sistibly impelled to take much quicker and shorter steps than common, and thereby 
to adopt unwillingly a running pace. When once this state has been pointed out, I 
make no doubt that some of you may recognize it in old persons whom you may 
have seen walking about. But the disorder does not stop here ; the unhappy patient 
becomes unable to feed himself ; or to walk at all without an attendant, who walks 
backwards before him, and prevents his falhng forwards by the pressure of his 
hands against the fore part of the patient's shoulders : his powers of speech and 
deglutition fail ; and the saliva dribbles from his mouth ; he can no longer retain his 
urine or feces ; and at length death closes the miserable scene. 

Mr. Parkinson conjectures that this complaint results from some chronic change 
of the upper part of the spinal cord, or of the medulla oblongata : but dissections 
are wanting to support or to refute that conjecture. Some of the patients, whose 
cases he has given, had been intemperate hvers ; hard drinkers ; others had not 
been guilty of any such excesses : several had suffered a good deal from rheuma- 
tism, which he thought might have laid the foundation of their lamentable disease. 
But a more exact pathology of the shaking palsy is siill needed. Dr. M. Hall 
observes that the symptoms have, in several particulars a marked resemblance to the 
effects observed by M. Serres (and related in his Anatomie du Cerveau) of disease 
of the tuber annulare, or of the tubercula quadrigemina. 

Nor have we any ascertained means of curing this disease ; or rather this state of 
decay. Dr. Elliotson indeed says that he succeeded in one instance (of which, how- 
ever, the particulars are not given), with the carbonate of iron ; but that he had 
tried the same medicine in vain in several other cases. We must administer to 
symptoms, and endeavour to set those functions right which may be obviously 
wrong: to regulate the bowels, to procure sleep, to nourish and uphold the pa- 



412 



MERCURIAL TREMOR. 



tient without unduly stimulating him; and this is ail that I can tell you of the 
shaking palsy. 

Another analogous disorder, meriting a moment's notice, is that peculiar kind of 
trembhng which is apt to occur in persons w-ho are much, exposed to the poisonous 
fumes of mercury : mercurial tremor it is called ; and popularly, the trembles. It 
consists of a sort of convulsive agitation of the voluntary muscles, which is most 
violent whenever efforts are made to move the limbs by the help of those muscles; 
W'henever, in fact, volition is brought to bear upon them. It differs, therefore, from 
the shaking palsy, inasmuch as the tremor ceases when the muscles are supported, 
or are not called into action. It is also more susceptible of relief by medicine. The 
last person in whom I have witnessed this curious affection has been twice my patient 
in the Middlesex Hospital, and has twice got well there. John Chattin, 8^ years 
old, was first admitted in August, 1837. He was led into the room, walking with 
uncertain steps, his hmbs trembhng and dancing as though they had been hung upon 
wires. While sitting on a chair he was comparatively quiet ; you would not have 
supposed that he ailed any thing ; but as soon as he attempted to rise and to walk, 
his legs began to shake violently with a rapid, incessant, and irregular motion. He 
^ could neither hold them steady, nor direct them with precision. Indeed without sup- 
port he must have fallen down. His arms were agitated w^ih similar involuntaiy 
movements. His tongue was tremulous, and he spoke in a hurried, abrupt, inter- 
rupted, staccato manner, not natural to him. He had no fever. His pulse was 66, 
and soft ; his skin natural : his bowels costive. He complained of shght nausea. 
At the end of six weeks he went out well, or with very slight remaining weakness 
of his knees, and a little occasional tremor upon unusual exertion. In June, 1839, 
he again presented himself, in a similar state of agitation and helplessness. 

This man was a w^ater-gilder ; and had been employed in that business for 18 years. 
Till somewhat more than a twelvemonth prior to his first appearance at the hospital, 
he had been free from disease. Then he began to tremble a httle ; but for a fortnight 
before his admission the shaking had become so much worse that he could not go up 
stairs, nor even walk upon uneven ground. The trembling, when once brought on 
by efforts to move, did not cease until he sat down, or got one of his fellow- workmen 
to grasp his limbs tightly. 

This singular disorder is produced by the agency of mercury as a poison upon 
the body ; and especially by the absorption of that metal when raised into vapour 
by heat, and inhaled in breathing. It is accordingly very common among water- 
gilders. Water-gilding is the gilding of metals, and of silver in particular, by means 
of fire. It is called ivaier-gil^ing, I believe, to distinguish it from other kinds of 
gilding, called gilding in oil. The silver to be gilded is covered w^ith an amalgam 
of gold and mercury, and then is placed over a charcoal fire, by which the mercury 
is raised in fumes and driven offj and the gold alone is left adhering. To these 
fumes the wwkmen are necessarily exposed; and numbers of them become affected 
with this tremor, which is not a common result of mercury applied to the system 
in other ways. The same complaint is frequent among the workmen in the quick- 
silver mines of Friuh and of Almaden, where the crude ore is purified by the aid of 
heat. Dr. Bateman relates, in the 8th volume of the Medico-Chirurgical Transac- 
tions, some cases like that w^hich I have been describing. But the best account of 
the disorder that I have seen is given by Merat, in an appendix to his book on the 
Colique Metallique. 

The malady comes on sometimes suddenly, more often by degrees. The patient 
is less sure of his arms than usual: they become tremulous, and at last shake, and, 
if he continues to pursue his employment, the force of the trembling goes on 
increasing, till at length it is so general and violent that he can persist no longer. 
His power of locomotion is impaired ; his mastication, his speech, all his manual 
operations, are interfered with ; he becomes unable to convey food to his mouth, and 
is obliged to be attended to and fed, hke an infant ; and by and by, if he does not 
quit the poisonous atmosphere, graver symptoms supervene — wakefulness, dehrium, 
loss of consciousness. 



MERCURIAL TREMOR. 413 

As the tremor increases, the digestive organs become disordered ; the appetite falls 
off ; nausea is felt, the tongue becomes furred, and gas collects in the intestines. The 
patients acquire a remarkable brown hue ; and their teeth turn black. The pulse is 
generally full and slow. 

The time required for the production of these effects varies much in different 
cases ; from two years to five-and-twenty. Something depends no doubt upon the 
quantity and intensity of the fumes. Chattin told us that the workmen became ill 
whenever they had a large job on hand. In both his severe attacks (and very often 
besides, both in him and his companions) the mercury produced salivation. This 
was unfrequent in the patients observed by Merat. The duration of the complaint 
is considerable : it may last two or three months, or longer ; and sometimes it is not 
completely recovered from at all. Yet it is not a fatal disorder. 

Although the visible affection is of the muscles, the mischievous operation of the 
poison is reaily upon the nerves, weakening their natural influence. When the will 
is directed upon the muscles, they contract unsteadily, and with frequent remissions ; 
their action is not sustained ; and it is a general observation by all who have written 
upon the disease, that it is agoravated hj all kinds of mental emotion, by alarm, 
anger, surprise. My patient's shaking was, at first, augmented by the shock of the 
shower-bath : and alwa3^s became excessive in thundery weather. So, on the other 
hand, it has been noticed that whatever tends to stimulate and fortify the nervous 
power, does temporary good : a glass of wine for example. Chattin informed us 
that, while the malady was coming on, he could not get up stairs to his work with- 
out first swallowing half a quartern of gin ; and that he v/as obliged to drink porter 
two or three times a day. 

The treatment consists in withdrawing the patient from the injurious atmosphere, 
and in administering tonics. 

Conium has been recommended by Mr. M'Whinnie. Gluina has been found 
useful. But I have most faith in preparations of iron. My patient Chattin mended 
decidedly and rapidly when he began to take steel. It was not the mere avoidance 
of the cause of the complaint that produced the improvement, for he had been away 
from his work for a fortnight before he applied for admission. 

To prevent this effect of mercury, the workmen should be instructed to avoid, as 
much as possible, inhaling the poisonous fumes, to ventilate the room thoroughly, 
and to pay great attention to cleanliness. I believe the furnaces may be so built 
that the metallic vapour shall not reach the operator. If he cannot avoid being in- 
volved in it, perhaps some sort of respirator might afford protection. 

[A very peculiar form of convulsive disease has recently been described. It is character- 
ized by repeated bobbings of the head forward, at first slight and occasional, but becoming, 
in process of time, so frequent and powerful, as to cause a heaving of the head forwards, 
towards the knees, succeeded by an immediate return to the upright position, somewhat 
similar to the attacks of emprosthotonos. In one case, related by J. W. West, these bobbings 
were repeated at intervals of a few seconds, ten, twenty, or more times, in each attack, which 
continued from two to three minutes, and recurred twice, thrice or oftener in the day ; the 
attack occurring whether the patient was sitting or lying. During the attack, the child re- 
tained his consciousness. The other cases that have been since recorded by Drs. Barton and 
Bennett, in their general symptoms, differ in no degree from that of Mr. West, Math the 
exception of that of Dr. Bennett, in which the disease was of a more aggravated character. 
Sir Charles Clarke has seen four cases of the disease, and from the peculiar bobbing of the 
head, has named it the Salaam Convulsion ; Dr. Locock has seen two cases. One of Sir 
Charles Clarke's patients recovered perfectly, the other became paralytic and idiotic, and died 
at the age of seventeen. Mr. West has heard of two other cases — one of the patients lived 
to the age of seventeen ; the other to nineteen, — both became idiotic. The sex and ages of 
the patients whose cases are on record, are one female of seven years, and two boys of one 
and six years — death did not occur in either ; in the female and one of the boys the disease 
appears to have ceased. 

Of this strange form of convulsions, the pathology is still a subject for future investigation; 
and until that is ascertained, its treatment must be tentative and experimental. — C] 

I proceed to the subject of hysteria : a subject highly interesting and important, 
as well as obscure and difficult. I scarcely know how to arrange what I have to say, 
so as to present the disorder to your notice in the most intelligible manner. Hysteria 

2k2 



414 



HYSTERIA. 



has characters peculiar to itself: but it is apt also to assume the form, and mimic 
the symptoms, of various other diseases of a much graver nature. If we are not 
capable of distinguishing the true malady from that which is its double, we shall be 
constantly committing most serious mistakes in the prognosis, to our own damage 
and discredit ; and in the treatment, to the injury of our patient. I shall first- 
attempt to describe to you the phenomena which are peculiar to hysteria; and then 
to point out the class of persons who are most subject to it; and afterwards I shall 
briefly advert to the imitative freaks which we are almost daily witnessing in hys- 
terical constitutions, and to some other points connected with this extraordinary 
complaint. 

I need not tell you that the bystencal paroxysm is almost exclusively confined to 
women. 

[We have repeatedly seen all the phenomena characteristic of hysteria in the male sub- 
ject. The fact of their occurrence in males is also stated by Sydenham, Louyr ViJlermay, 
Georget, Ferriar, Frotten, Conolly and others. See also the admissions of Dr. Watson to- 
wards the close of his remarks on the pathology of the disease. — C] 

It occurs under a great variety of forms, but they may all be reduced, for conve- 
nience of description, to two. The first of these has a general resemblance to an 
epileptic fit. The trunk and limbs of the patient are agitated with strong convulsive 
movements ; she struggles violently, like a person contending ; rises into a silting 
posture, and then throws herself back again; forcibly retracts and extends her legs, 
while her body is twisted from side to side; and so powerful are these muscular 
contortions that it often is all that three or four strong persons can do to restrain a 
shght girl, and prevent her from injuring herself or others. The head is generally 
thrown backwards, and the throat projects ; the face is flushed ; the eyehds are 
closed and tremulous ; the nostrils distended; the jaws often firmly shut ; but there 
is no distortion of the countenance : the cheeks are at rest, unless when, as often 
happens, the patient is uttering screams, or exclamations. If the hands are left at 
liberty, she will often strike her breast repeatedly and quickly, or carry her fingers 
to her throat, as if to remove some oppression there ; or she will sometimes tear her 
hair, or rend her clothes or attempt to bite those about her. With all this her breath- 
ing is deep, labouring, irregular ; and the heart palpitates. After a short time this 
violent agitation is calmed : but the patient lies panting and trembling, and starthng 
at the slightest noise or the gentlest touch ; or sometimes she remains motionless 
during the remissions, with a fixed eye ; till at once the convulsive movements are 
renewed : and this alternation of spasm and quiet wih go on for a space of time that 
varies considerably in different cases : and the whole attack frequently terminates in 
an explosion of tears and sobs, and convulsive laughter. 

There is a variety of this form of hysterical paroxysm, in which the patient sud- 
denly sinks down insensible, and without convulsions : with slow and interrupted 
breathing, a turgid neck and flushed cheeks ; and she recovers from that condition, 
depressed in spirits, fatigued and crying. 

You will observe that the symptoms I have been enumerating belong to the nerv- 
ous system ; and indicate great derangement in the functions of animal life. In the 
other of the two forms to which all the various modifications of the attack may be 
reduced, the principal marks of disturbance are referable to some of the viscera. 
The patient experiences a sense of uneasiness in some part of the abdomen, fre- 
quently towards the left flank ; a ball appears to roll about, and to rise first to the 
situation of the stomach, and then to the throat, where the patient feels a choking 
sensation ; the action of swallowing is frequently repeated ; the abdomen becomes 
distended with wind, loud rumblings and sudden eructations take place ; there 
is much palpitation of the heart, the patient is sad and sorrowful, and prone to 
shed tears. 

After the paroxysms, these patients commonly void a large quantity of hmpid, pale 
urine, looking almost like water; and this sometimes expelled during the fit. 

Such is a brief, and, I am aware, incomplete account of the hysterical paroxysm. 
It sets forth, however, in outHne, the two principal varieties of the attack : and you 



HYSTERIA. 



415 



are to observe that the last, the quieter form, is often the prelude to the convulsive ; 
but it not seldom also occurs alone, and then is as indicative of hysteria, as the petit 
mal, to which it is somewhat analogous, is of epilepsy. 

And before I go any further, let us again inquire into the circumstances which 
distinguish the paroxysms of those two diseases, epilepsy and hysteria. I have 
shortly adverted to these discriminative circumstances before ; but we shall be better 
able to appreciate them now that the main features of each diseased state have been 
under our consideration. It is of great importance to be able to render the diagnosis 
certain and accurate. It is a dreadful announcement to have to make to a father or 
a mother that their child is epileptic; whereas hysteria, though it is sufficiently dis- 
tressing, is attended, in nine hundred and ninety cases out of a thousand, with no 
ultimate peril either to mind or body. In some instances the diagnosis is perfectly 
easy : in others it is dubious and full of anxiety. Whenever you fail to satisfy your- 
selves completely as to the nature of a given case, you will do well, in legal phrase, 
to give your patient the benefit of your doubt, and acquit her of epilepsy ; or pro- 
nounce her guilty of the minor offence of hysteria. 

The points of resemblance, and the points of distinction, belonging to the hys- 
terical and epileptic paroxysm respectively, have been very clearly summed up by 
Foville. 

There are two principal forms of each disorder. In each, one of these forms is 
convulsive, and the other is not. The non-convulsive form of epilepsy relates exclu- 
sively to the sensorium : it is characterized by vertigo, and by a suspension (how- 
ever brief and transitory) of the mental powers. The non-convulsive form of hysteria 
has little apparent connection with the animal functions : its palpable phenomena 
consist in derangement of the organic functions of the thorax and abdomen. It is 
the ganglionic portion of the nervous system that seems chiefly disturbed. 

In the epileptic fit there is an entire loss of consciousness. The patient, on 
emerging from the paroxysm, recollects nothing of what has been going on during 
its continuance. It is not so in the hysterical fit. The loss of consciousness is very 
seldom complete ; and it never occurs at the outset of the attack. The patient often 
is able to repeat (though she may not always choose to confess it) what has been 
said by the bystanders during the period when she seemed insensible. This is a 
point of distinction well worth remembering, for more reasons than one. It not only 
helps the diagnosis when the fact comes out ; but it suggests certain cautions to our- 
selves. We must take care not to say any thing by the bed-side of an hysterical 
patient which we do not wish her to hear ; and we may take advantage of her appa- 
rent unconsciousness, and pretend to believe in it, and speak of certain modes of 
treatment which she will not much approve of, but the very mention of which may 
serve to bring her out of the fit. 

In the epileptic paroxysm the face is usually hvid ; and foam, which is frothy 
with air, or red with blood, escapes from the patient's mouth. These are symp- 
toms which we do not see in the fits of hysteria. The convulsive movements even, 
offer some characteristic shades of distinction. In epilepsy they are often more 
marked on one side of the body than on the other, and less irregular : the same 
movements are rapidly repeated: there is a strangling rattle in the breathing: 
while in hysteria the forcible flexion and extension of the limbs, and the contortions 
of the trunk, are more sudden, and, as it were, capricious ; the respiration is deep, 
sighing, mixed with cries, and sobs, and often with laughter. But, perhaps, the con- 
vulsive motions differ most in the face. The epileptic expression is usually fright- 
ful ; the eyehds half open, the eyeballs roUing, the mouth drawn to one side, the 
teeth grinding, the gums exposed by the retraction of the lips, the tongue protruded 
and bleeding, the complexion leaden : while in hysteria the cheeks are red, but at 
rest ; the eyelids are closed and trembhng ; if you raise the upper one, you will see 
the eye fixed, perhaps, but it is bright, and very different from that of the epileptic, 
which, if it be not rolling, is dull, projecting, and the pupil usually dilated. 

Foville states that when, besides a sudden loss of consciousness with convulsive 
movements, there are also lividity of the face, and an escape of frothy saliva from 
between the lips, and the convulsions are more pronounced on the one side of the 



416 



HYSTERIA. 



body than on the other, the disease is epilepsy, and not hysteria : and I think he is 
right. 

By Dr. Marshall Hall the grand distinction between the two diseases is affirmed 
to be this : — that in hysteria, much as the larynx may be affected, it is never 
closed ; in epilepsy, it is closed. Accordingly, in the former we have heaving, 
sighing, inspiration ; in the latter, violent ineffectual efforts at expiration. In 
the very outset of the epileptic paroxysm the respiration, I believe, is thus sus- 
pended. 

The hysterical seizure may be over in a quarter of an hour, or in less time than 
that ; or it may last many hours, or even several days. 

The hysterica] seizure is almost peculiar to women : and it seldom occurs in them 
except during that period of their lives in which the menstrual function of the uterus 
is or ought to be in activity. In this country it is most apt to occur between the 
ages of fifteen and forty ; and in the vast majority of patients who do suffer it, you 
■will find some marked derangement of that particular function. These facts alone 
afford a strong corroboration of the ancient theory, which ascribed the whole of the 
phenomena to uterine disorder ; and named the disease accordingly. You will hear 
or read of disputes as to Avhether the womb, with its appendages, or the nervous 
system, is the seat of hysteria. But such disputes are merely verbal, I conceive. 
No doubt the convulsive movements, and the mental affection, and the unnatural 
sensations, depend upon some altered condition of the brain and nerves ; but it does 
not follow that the disease originates in that altered condition. We know that the 
uterus or the ovaries cannot of themselves determine the muscles to contract ; 
but if they be in an unhealthy state they may act upon the muscles through the 
mediwn of the nervous system : and such I take to be the fact. How they do so 
we no more know than we know how the httle finger is bent when we resolve to 
bend it. 

But, say some, we every day meet with diseased conditions of the uterus and 
ovaries — amenorrhcea, dysmenorrhcea, menorrhagia, even disorganization — without 
any of these nervous symptoms. True ; and we cannot always fathom the mj^stery 
of this. But one thing is certain, that there exists in some persons a much greater 
readiness to take on the disease, upon the application of the exciting cause, than in 
others. This predisposition I have had occasion to advert to again and again, since 
I began to speak of the spasmodic diseases of the nervous system. Such diseases 
occur in certain individuals only ; and in these individuals there pre-exists a pecu- 
liar condition of the nervous system, " for which," says Dr. Ahson, " w^e have no 
more precise or definite expression than nervous irritability or mobility^ a con- 
dition which is more common in women and children than in men ; and more com- 
mon in all persons when in a state of weakness, than when in the full enjo5^ment 
of muscular strength ; in women, particularly, more common about the menstrual 
periods, and immediately after delivery, than at other times ; more common likewise 
in those in whom the monthly discharge is habitually excessive or altered as in leu- 
corrhcea, or suddenly suppressed, or more gradually obstructed in the different forms 
of amenorrhcea, than in others. In this condition of mobility, both sensations and 
emotions are intensely felt; and their agency on the body is stronger and more 
lasting than usual ; continued voluntary efforts of the mind, and steady or sus- 
tained exertions of the voluntary muscles are difficult, or impossible ; the muscular 
motions are usually rapid and irregular, and the ' animus, nec sponte, varius et mu- 
tabilis.' " In persons of this movable temperament, spasmodic complaints are easily 
excited : and the tendency to their recurrence is increased by each repetition of 
them. 

Now the persons who suffer hysteria are of this class. They are commonly 
young women, in whom the process of menstruation is in some way or other dis- 
ordered ; and who either are naturally of a feeble constitution, or have been debili- 
tated by disease, or by their habits of life. They often are pale ; have cold hands 
and feet ; are subject to chilblains ; eat but little, and do not fancy meat, which they 
sometimes absolutely dislike and refuse ; or their taste is depraved and capricious ; 
they will devour wax candles, wafers, chalk, seahng wax, slate pencil, and such 



HYSTERIA. 



417 



trash. And, what is very curious and characteristic, although they often abstain 
almost entirely from, animal food for weeks or months together, and take very httle 
nourishment of any kind, they do not in general emaciate. You might expect that, 
under such a mode of life, they would waste away : but they continue round, and 
plump, and smooth. Some of them are even ruddy. 

And belonging to women of this peculiar constitution there is one other very re- 
markable character, which it behoves us to make ourselves thoroughly acquainted 
with. Almost any part of the nervous system, in these persons, is liable, under the 
influence of slight causes, and even without any obvious cause, to fall into a disor- 
dered state of action and suffering more or less resembhng that which inflammation 
or organic disease might excite in the same part. 

This is a most important fact ; because if we erroneously ascribe symptoms which 
really result from inflammation to mere nervous or hysterical disorder, we may 
suffer the patient to perish for w^ant of active measures that would have saved her: 
and on the other hand, if we apply to these nervous, imitative, hysteric complaints, 
the treatment proper for inflammation, we shall generally, indeed, relieve our pa- 
tient for the time ; but we shall leave her more prone to the nervous affection than 
before, and permanently damaged by our mischievous activity. 

[On the subject of the pathology of hysteria the reader is referred to the very judicious 
paper of Dr, Conolly in the 2d vol. of the Cyclopaedia of Practical Medicine, Philadelphia 
edition. 562 et seq. — C] 

I say that almost every kind of serious disease may be mimicked hy what we must 
call hysteria. And your skill will sometimes be severely tasked to determine the 
true import of the symptoms, and the real nature of the case. 

One of the diseases which is most often copied by hysteria, is inflammation of 
the peritoneum. You will find a patient complaining of acute pain of the abdomen, 
aggravated by the slightest pressure ; and she shall have, perhaps, a hot skin, a 
quick pulse, and a furred tongue. When you meet with such symptoms in a 
young female, in whom there is any derangement or irregularity of the uterine 
functions, you will do well, before you bleed her to syncope, and cover her abdomen 
with leeches, to ask yourselves whether all this suffering may not be simply ner- 
vous. Search into her previous history as narrowly as you can ; if you find that 
she has had similar attacks before ; if she has been known to suffer hysterical fits ; 
and if the tenderness is excessive, and, as it were, superficial, felt upon the shghtest 
touch as much as when firmer pressure is made, you may generally spare the blood- 
letting, purge the patient well, and cause an asafoBtida enema to be thrown into the 
rectum ; and in a few hours you will find that the peritonitis has vanished. 

Among the pains which infest females of the hysteric constitution, and which are 
apt to be erroneously ascribed to inflammation, stitches and pains in the hypochon- 
dria are probably the most common. They are oftener complained of in the left 
hypochondrium than in the right. These things are much more generally under- 
stood now than they used to be even a few years ago. I cannot tell you how many 
persons I have seen who had been diligently treated with leeches, and blisters, and 
blue pill, for supposed chronic inflammation of the liver or spleen, or still more 
actively depleted for presumed pleurisy or pericarditis, when no such inflammation 
existed, and when the treatment, by reducing the strength, tended to rivet that 
mobility of system which was the chief predisposing cause of the pains. 

You would scarcely suppose ihsit palsy — perfect hemiplegia or paraplegia — could 
be simulated by hysteria : yet this certainly is the case ; and I have seen instances 
of it even among hospital patients. They are difficult and perplexing cases. The 
sudden occurrence of the paralysis, without any of the other symptoms which 
commonly mark the real disease, its sudden disappearance, and, above all, the 
supervention of an hysterical paroxysm, will often disclose the true nature of the 
affection. Hysterical affections referred to the throat are very common. Aphonia^ 
for example : the voice being lost on a sudden, and returning as suddenly. Mock 
laryngitis. I remember being asked by Sir Charles Bell some years ago to see a 
young woman in the Middlesex Hospital under his care. She had recently arrived, 



418 



HYSTERIA. 



and was breathing with the stridulous noise peculiar to inflammation of the larynx. 
She had twice before, in the country, had tracheotomy performed for similar attacks ; 
and there were tlie scars of the operations on her neck : but both Sir Charles and 
myself were satisfied, upon considering ail the circumstances of the case, that the 
difficult inspirations were spasmodic and hysterical; and she recovered under the 
remedies which do good in hysteria. Inability to swallow, dysphagia, is another 
of the hysterical vagaries relating to the parts about the throat. Dr. Bright has a 
very instructive case of that kind. A patient was sent to Guy's Hospital for stric- 
ture of the oesophagus. It was stated that the difficulty of deglutition had existed 
for several weeks, and was increasing. The surgeon under whose care she was 
admitted was instantly struck by certain circumstances which did not seem to consist 
very well with the notion that there was organic disease. Her appearance behed it, 
and her age. But he thought it right to examine the oesophagus by means of a 
probang ; and no sooner was the instrument introduced, than the patient went into 
an hysterical fit, which was followed immediately by hysteria in several females in 
the same ward. The complaint turned out to be nothing but an hysteric constric- 
tion, and was soon completely removed. ' 

Surgeons are familiar with the " hysterical breast." The mamma becomes 
painful, tender, enlarges somewhat perhaps. The girl fears that a cancer is breeding. 
She communicates her alarm to her friends, and a medical man is consulted. If he 
happens to be timid and inexperienced, he makes matters infinitely worse by apply- 
ing leeches and fomentations ; by examining the breast at every visit; and by keeping 
the patient's attention anxiously fixed upon it. Whereas the treatment ought to be 
directed to the state of the general system ; and the local uneasiness spoken lightly 
of, or disregarded. 

Among the hysteric affections of the air-passages, there is a pecuHar kind of cough 
which you ought to be acquainted with. It is loud, harsh, dry, more hke a bark 
than a cough. Sometimes it is incessant, sometimes it occurs in paroxysms which, 
I verily believe, are more annoying to hear than to suffer. Hysterical affections of 
the diaphragm again are by no means rare. I had a very obstinate case of that sort 
in one of my hospital patients. She would sit in her bed all day long, uttering 
every eight or ten seconds a loud and most discordant hiccup. And I remember an 
out-patient, who presented a picture of perfect health, and who came week after 
week, to be cured of what I could consider nothing but an hysterical eructation : it 
was continual and distressing, and prevented her from obtaining any employment as 
a servant. Hysterical vomiting is also frequent, simulating cancer of the stomach. 
Nay, hysterical hxmatemesis. A romantic girl was for some months under my care 
in the hospital with that complaint. She vomited such quantities of dark blood, 
(which did not coagulate, however,) as I would not have believed if I had not seen 
them. Day after day there were potfuls of this stuff ; yet she did not lose her flesh, 
and she menstruated regularly ; and what was very curious, the vomiting was 
always suspended during the menstrual period, and recurred again as soon as the 
natural discharge ceased. I said she was romantic; but I should rather have said 
that she had that peculiar mental constitution which belongs to hysterical females. 
She used to write me long letters of thanks for my attention, though I was heartily 
tired of her ; and these were couched in all the fine language of the Minerva press. 
At last I sent her away : just as bad as when she came into the hospital. This 
■was five or six years ago ; and last year she called at my house with a present of 
some game, and told me that she had got married to a hair-dresser, and was quite 
recovered. 

There is a kind of sanguineous expectoration belonging to females of this class, 
and very likely to mislead the unwary. I meet with two or three instances of it 
every year. The patient excreates daily, or at irregular intervals, a thinnish fluid 
something like saliva, more or less tinged and streaked with brown or florid blood. 
A young hand investigates diligently the source of the bleeding, and puzzles himself 
to determine whether the case be one of hsematemesis or of hoemoptysis. Nine times 
out of ten, it is neither the one nor the other. The blood comes from the mouth or 
the fauces. 



HYSTERIA. 



410 



Hysterical affections of the joints are very common. A young girl became my 
patient in the hospital for some trifling ailment, and after a short time she began to 
complain of great pain in her knee and hip ; she could not stand upon the limb, nor 
bear to have it moved or touched. I got Sir Charles Bell to see her : he was so 
satisfied of the nature of the case — so convinced that it was a genuine example of 
inflammation and ulceration of the hip-joint — that he gave a httie lecture to the pupils 
who stood round the bed upon the characteristic position in which the patient lay ; 
and he took her into one of the surgical wards to be under his own care. Some 
time afterwards I had occasion to go into that ward, and there I found my former 
patient with her heel drawn tight up against her buttock. It turned out that she 
had had no serious disease of the hip at all : both it, and the rigid contraction, gave 
way under measures which could have done no good to an ulcerated joint. I think 
the first clue to the real nature of her malady was the occurrence of a fit of hysteria. 
Sir Benjamin Brodie says, that among the higher classes of society, at least four-fifths 
of the female patients who are commonly supposed to labour under diseases of the 
joints, labour under hysteria, and nothing else. 

Another prank belonging to hysteria, and one which it is very necessary that you 
should be on your guard against, is that of mimicking disease of the bones of the 
spine. The patient complains of pain and tenderness in her back, and of weakness 
probably in her lower extremities ; and it is now become notorious that scores of 
young women have been unnecessarily confined for months or years to a horizontal 
position, and have had their backs seamed with issues, for supposed disease of the 
bodies of the vertebrae, who had really nothing the matter with them but hysteria, 
and who would probably have soon ceased to complain if, instead of being restricted 
to that unnatural imprisonment and posture, they had taken a daily gallop on horse- 
back. 

It is curious enough to notice how the mind is apt to become affected in some of 
these cases. After the patient has been lying supine for some weeks, she is unable 
to stand or walk, simply because she thinks she is unable. The instant she makes 
a fair effort to use her hmbs again, she can and does use them. Her condition is at 
once reversed. Potest quia posse videtur. Mr. Corfe, the present apothecary to 
the Middlesex Hospital, has no httle trouble with patients of this kind ; but he gene- 
rally succeeds in making them walk, and in convincing them, as well as himself, 
that they may do so with impunity. Sometimes, though the authority of the doctor 
may not be efficacious in this respect, some stronger influence prevails. A lady told 
me not very long ago that an acquaintance of hers, a member of a family of distinc- 
tion, had been lying I know not how long on her back ; that position having been 
prescribed to her by some medical man for a presumed disease of the spine. She 
lost all power of using her legs, but she got quite fat, as, indeed, well she might, for 
her appetite was remarkably sharp, and she hved chiefly upon chickens ; and the 
number of chickens she devoured was incredible. She lived at a httle distance from 
town, and at last Sir Benjamin Brodie was sent for to her. Novi^ Sir Benjamin, to 
use a vulgar phrase, is up to these cases ; and he wished to see her try to walk : 
but she declared that the attempt to do so would kill her. He was resolute, how- 
ever, and had her got out of bed : and in a few days' time she was walking about 
quite well, and very grateful to him for his judicious conduct. A medical man of 
less name, or of less determination, would probably have failed. Dr. Bright has a 
good example of a somewhat similar kind ; showing the power of another form of 
influence. He was asked to see a young lady who had been confined to her bed for 
nine months. If she attempted to move she was thrown into a paroxysm of agita- 
tion, and of excruciating agony, affecting more particularly her abdomen. She had 
almost lost the use of the lower extremities ; and she and her friends seemed to have 
given up all hope of her restoration. But she presented no appearance of important 
disease ; her countenance bore no marks of visceral mischief ; nor was it possible to 
discover any proof of organic change. Dr. Bright set the case down in his own. 
mind as one of hysteria. She seemed to have derived relief from some stimulating 
injection, and from certain pills. As her friends were in moderate circumstances, 
Dr. Bright talked seriously to the mother, and recommended that simple water should 



420 



HYSTERIA. 



be employed for the injection, and that bread pills should be substituted for those the 
girl had been taking. The mother soon perceived that these means produced the 
same tranquihizing effects on her daughter which had hitherto been ascribed to the 
medicine. "My visits," he says, "became less frequent ; I was absent a fortnight 
on my renewing my visit, no change had taken place. J. attempted to get her shifted 
gently from the bed to the sofa, but it was impossible ; the paroxysm almost over- 
came her. Once (after having attended altogether about nine months) I called after 
an absence of nearly a month ; her sister met me at the street-door with a smihng 
face to tell me that our patient Avas quite well : and on inquiry, she related how, 
three mornings before, under a deep religious impression, she had completely reco- 
vered all her powers ; and I found her sitting up, working and amusing herself as 
if she were completely convalescent from some ordinary illness." 

These are the cases which suit the purposes of miracle mongers. A few years 
ago all the journals belonging to a certain party in the rehgious world were full of 
i an instance of miraculous cure. The patient was a young woman ; her legs had 
been paralytic, or contracted, I forget which ; some enthusiastic preacher had influ- 
ence enough with her to make her believe that if on a certain day she prayed for 
recovery with a strong faith, her prayer would be successful, she would recover at 
once ; and she did so. No one can doubt that it was just such a case as those I have 
now been mentioning. Many of these pseudo-diseases terminate suddenly under 
some strong moral emotion. A fall — a fire in the house — any overwhelming terror, 
will sometimes put an end to them. And where the joints have been the parts 
affected, several patients have declared that they felt a sensation as if something had 
snapped or given way in the part, immediately before the sudden recovery took 
place. 

Some of the shapes assumed by this pathological Proteus are hideous and dis- 
gusting. Paralysis of the muscular fibres of the bladder, or spasm of its sphincter, 
sometimes really occurs, sometimes is only aped, in hysteria. It is a common trick 
with these patients to pretend that they labour under retention of urine ; and that, 
although the bladder is full, they cannot make water. The daily introduction of the 
catheter by a dresser or apprentice appears to gratify their morbid and prurient feel- 
ings. Sometimes, no doubt, the difficulty is real ; but it is oftener feigned or exag- 
gerated. I have again and again known it to disappear upon the patient's being let't, 
without pity, to her own resources. But girls have been known to drink their urine, 
in order to conceal the fact of their having been obliged and able to void it. The 
state of mind evinced by many of these hysterical young persons is such as to entitle 
them to our deepest commiseration. The deceptive appearances displayed in the 
bodily functions and feehngs find their counterpart in the mental. The patients are 
deceitful, perverse, and obstinate : practising, or attempting to practise, the most 
aimless and unnatural impositions. They will produce fragments of common gravel, 
and assert that these were voided with the u^ine : or they will secrete cinders and 
stones in the vagina, and pretend to be suffering under some calculous disease. A 
young woman contrived, in one of our hospitals, to make the surgeons beheve that 
she had stone in the bladder; and she actually submitted to be placed upon the 
operating table, and to be tied up in the posture for fithotomy, before a theatre-full 
of students ; and then the imposture was detected. Sometimes they simulate sup- 
pression of urine, and after swallowing what they have passed, vomit it up again, 
to induce the belief that the secretion has taken place through the new and unnatural 
channel. 

It is impossible, I say, not to pity the unhappy victims of this wretched disorder, 
when their morbid propensities drive them to such acts as these. I mention them 
because you must expect to meet with such cases ; and because, while you take care 
not to express your suspicions prematurely, or on light evidence, you should be 
upon your guard against the mortification of being deceived, by the false signals 
held out, into active and ill-directed measures of treatment. 

There is another very common hysterical pain which I ought to have mentioned, 
viz., a pain occupying some one point in the head ; the patient speaks of it as a 
sensation like that which would be caused by driving a nail into the part ; and the 



HYSTERIA. 



421 



affection has therefore been called the clavus hystericus. It is often situated just 
above one eyebrow ; and it sometimes comes on every day, at the same hour. Now 
in these cases it imitates very closely the h^micrania, which constitutes no uncom- 
mon form of an intermittent, and is called, accordingly, the brow ague. The dis- 
tinction between the two — whether the affection, I mean, be hysterical or aguish — 
is not of any great consequence : but in many of the previous examples of hysterical 
pain mimicking organic or inflammatory disease, the diagnosis is obviously of the 
greatest moment. 

How, then, is it to be made ? You may, generally, I believe, be led to a right 
judgment if you look to the several points that I have incidentally touched already. 
You may guess that the affection is hysterical if the patient be a young unmarried 
woman : if there be any disorder or irregularity in the uterine functions ; if you can 
gather any history of former hysterical disease; and especially if she is subject to 
Jits of hysteria. The suspicious symptoms may often be traced back, and found to 
spread themselves over a considerable previous period of time : yet there is no such 
wasting, or commensurate deterioration of the general health and strength, as might 
be expected in organic disease. When the complaint simulated is some acute local 
inflam_mation, and there is pain increased upon pressing the part, you will find that 
the pain is aggravated by the gentlest touch ; it is more felt if you brush your hand 
over the surface, or sHghtly pinch the integuments, than when firm pressure is made : 
and you will find also that this exquisite tenderness is not limited to the part com- 
plained of. Suppose it is the abdomen, the patient will shrink and exclaim if you 
suddenly put your finger on her neck, or her arm. The suspicion that the disorder 
is nervous or hysterical will also be corroborated if the symptoms which resemble 
the symptoms of inflammation arise and subside rapidly, without obvious cause for 
such fluctuation ; and if various organs appear to be attacked in succession. Be- 
tween the several symptoms that mark real disease there is always (as we learn by 
experience) a certain congruity and relation ; but in the simulative displays of 
hysteria the symptoms are apt to be irregular, inconsistent, contradictory. When, 
after the most careful investigation of the case, you still doubt, it will be right either 
to pause, or to treat it upon the most w?ifavourable supposition. The consequences 
of suffering active inflammation to go on unchecked would be far worse than the tem- 
porary and slight and remedial injury to the system which might result from once 
applying the remedies of inflammation to a case of mere hysteria. There is another 
hazard also which you must be aware of, and seek to avoid ; that of overlooking real 
disease, when it is mixed with, and masked by hysterical symptoms. It is not easy 
to lay down positive rules of action for all these supposable cases ; but I trust that I 
have said enough to convince you of the importance of making the diagnosis of 
hysteric complaints a careful object of your future study. 

I have hitherto spoken of "hysteria as if it were exclusively a malady of females. 
Etymologically to apply that term to the diseases of males would be absurd. But 
that pecuhar modification of the nervous system which is observed in hysteric girls 
does certainly present itself, though rarely, in young men. I have seen two or three 
instances of what I could give no other name to than hysteria in males. One of 
them was in the person of a young surgeon, who had been house-surgeon to the 
Middlesex Hospital. I believe he applied to not less than a dozen medical men for 
advice ; and in that batch I happened to have my turn. He had some of the symp- 
toms that are ascribed to hypochondriasis ; i. e., he was exceedingly attentive to his 
own sensations, and fancied he had a number of diseases which had no existence 
but in his own imagination : he showed great unsteadiness and infirmity of purpose ; 
was what is called " very nervous ;" and had occasional bursts of choking, and tears, 
and laughter, exactly resembling those which we so often witness in the other sex. 
Many cases of hysteria in the male have been recorded by different writers. The 
same movable state of the nervous system, and the same symptoms referable to that 
system, may exist in both sexes. In females, in nine cases out of ten, or in a much 
larger proportion, the exciting cause of the hysteria is connected with the sexual 
tunctions ; and that is all that can be meant when it is asserted that, for the female 
the complaint is not badly named, but has an intimate dependence upon the uterine 



422 



HYSTERIA. 



sympathies. At the same time it is quite true that the " uterus is not the only organ 
of which the irritation may so affect the nervous system as to produce h3''steria." 

As in epilepsy, so also in hysteria, the treatment to be adopted regards, first, the 
paroxysm itself; secondly, the condition of the patient during the absence of the 
paroxysm. 

One object, during the paroxysm, is' to prevent the patient from injuring herself, 
by her hands, or by her teeth, or in her convulsive movements. Her dress should 
be loosened ; but it may be necessary to confine her hands and arms. The next 
thing to be aimed at is the putting an end to the fit. Various measures are found 
more or less useful for that purpose. The patient should be surrounded, as far as 
that is possible, with cool fresh air. If she is able to swallow, you may sometimes 
shorten the attack by administering a couple of ounces of the mistura assafetida ; or 
half a drachm of ether, with fifteen or twenty minims of laudanum, in camphor julep ; 
or a draught containing a drachm of the ammoniated tincture of valerian. When 
the patient cannot or will not swallow, she may sometimes be brought about by 
stimulating volatile substances offered to the nostrils. Signal good may also be 
effected by fetid or stimulant enemata ; the enema assafetida, for example, made by 
mixing two drachms of assafetida with half a pint of water, by means of the yolk of 
an egg; or the turpentine injection, made in the same manner, and containing'half 
an ounce of turpentine ; or the same quantity of ice-cold water thrown into the rec- 
tum, or apphed to the pudenda, will often bring the fit to a speedy termination. 
Indeed I believe there is more virtue in cold water, in hysterical diseases, than in 
any other single remedy. In the paroxysm it may be freely and repeatedly sprinkled, 
or dashed with some force, upon the face and chest. Active purges are beneficial 
and requisite in almost all these cases. There is commonly a costive, sometimes an 
obstinate, and always an unnatural, state of the bowels. 

In those long paroxysms — if they may be so called — in which some other disease 
is simulated by hysteria, the cold affusion is a most valuable resource : especially in 
those forms of the disorder in which a limb is permanently bent, or incapable of 
motion. In several instances, in which such contraction had existed for a long 
time, it has yielded, in the Middlesex Hospital, to a few minutes' application of the 
cold douche. Mr. Corfe, as I stated before, takes much pains with these cases : he 
pours cold water from a tea-kettle, or any other convenient vessel, in a small stream, 
from a moderate height, upon the contracted limb. It has been bent up for weeks 
perhaps ; no power that you are able to exert can extend it ; and any very forcible 
attempts to straighten it give the patient extreme pain. After the stream of water 
has been kept up for a short time, the patient complains of it very much ; but Mr. 
Corfe is inflexible — more so than the culprit limb — he goes on. Presently the hmb 
begins to tremble, the tight state of the muscles is evidently on the point of yield- 
ing, and in no long time they are entirely relaxed and manageable, and the member 
becomes as lithe and movable as ever. It often happens that the state of contraction 
recurs ; but a repetition of the douche has always the same good effect, and by de- 
grees the habit is broken, and the patient set free. It requires some determination 
to put this expedient in practice. The patient looks upon you as a monster of cru- 
elty : and, in private, the friends will not always allow such " rough" treatment, as 
they consider it. Sir Charles Clarke, who necessarily sees a great number of these 
cases — they are more common in the upper than the lower classes of society — is a 
great advocate of this ducking system. A paper of his upon the subject was read 
before the College of Physicians a few years ago. He recommends a "sudden and 
lavish" application of water to the face ; or the immersion of the whole body. He 
describes the class of patients, in whom the hysterical affection which is curable by 
that method occurs, as being generally females of a pasty complexion, fat, pale, and 
weak ; or such as evince the ordinary signs of debility, a feeble pulse, cold extremi- 
ties, and purpleness of parts distant from the centre of circulation. The age of the 
patients varied from ten to thirty years ; in many of them menstruation was imper- 
fect, or absent. 

A medical practitioner whom I met lately at a patient's house, told me he had 
just come from another patient, upon whom he had seen a surprising cure performed. 



HYSTERIA. 423 

A young lady, for many days, had been affected with trismus. She was unable to 
open her jaws, and therefore could neither speak nor eat. At last Sir C. Clarke 
was called in to see her. He presently comprehended the nature of her ailment, 
had her placed with her head hanging over a tub by the side of the bed : and pro- 
ceeded to pour pitchers of cold water 'on her face. Before he had emptied the 
second the patient began to scream and complain, giving very audible indications 
that she could open her mouth. I say although these patients get great rehef by the 
treatment, they do not like it ; and if they are convinced that it will be put in force, 
they will generally contrive not to require it. 

Of all the spasmodic affections, hysteria is that which is most readily propagable 
by what may be called moral contagion. If, in a large ward, one girl goes off in a 
fit, half a dozen others perhaps, all who happen to possess the hysteric diathesis, will 
experience a strong inclination to follow her example. But this chorus, as it were, 
of hysteria, is much more common in some wards than in others. A stern nurse, or 
a general order that the cold affusion shall at once be employed in every instance of 
an hysterical fit, will keep the complaint wonderfully in check : and on the other 
hand, great sympathy with such patients has a striking effect in encouraging the 
paroxysms. These facts show that the symptoms are, to a certain degree, under the 
patient's control. The fits are not wholly wilful ; neither are they wholly uncon- 
querable. 

I have but little to say respecting the medical management of such patients in 
the intervals between the paroxysms. The objects to be aimed at are, to restore the 
nervous system to the requisite degree of stability: and to correct the disordered 
functions of the uterine system. Now much the same plan of treatment is appHca- 
ble to both these objects ; and I spoke of the remedies that are found most beneficial 
for giving tone and firmness to the system, when I was upon the subject of epilepsy, 
and other nervous spasmodic ailments. The following points must be kept in view. 
The regulation of the bowels, which are mostly sluggish, by aloetic aperients ; the 
exhibition of some form or other of steel ; the steady employment of the shower bath ; 
regulated exercise, both on foot and on horseback ; the avoidance of hot rooms and 
of late hours, both in respect to going to bed, and to rising from it ; the avoidance 
also of strong moral emotions, of novel-reading, and of all the other thousand modes 
of dissipation, mental and bodily, which always accompany, and abate the blessings 
of, a high state of civilization. Marriage often proves a cure : sometimes it does 
not. 

The disposition to hysterical disorder may be more easily prevented than cured ; 
but upon this point medical men are not consulted. Parents do not foresee the 
misery they are often laying up for their daughters by the unnatural mode of life 
to which they are subjected for the sake of filling them with fashionable accomplish- 
ments. I cannot close this subject, and this lecture, better than by quoting Sir Ben- 
jamin Brodie's remarks on the same point, as I find them in a little work recently 
published by him, and containing many highly valuable observations and instruc- 
tions in respect to local hysterical affections. 

" You can render (he says) no more essential service to the more affluent classes 
of society, than by availing yourselves of every opportunity of explaining to those 
among them who are parents^ how much the ordinary system of education tends to 
engender the disposition to these diseases among their female children. If you 
would go further, so as to make them understand in what their error consists, what 
they ought to do, and what they ought to leave undone, you need only point out the dif- 
ference between the plans usually pursued in the bringing up of the two sexes. 
The boys are sent at an early age to school, where a large portion of their time is 
passed in taking exercise in the open air; while their sisters are confined to heated 
rooms, taking little exercise out of doors, and often none at all, except in a car- 
riage. Then, for the most part, the latter spend much more of their time in actual 
study than the former. The mind is over-educated at the expense of the physical 
structure: and after all with httle advantage to the mind itself: for who can doubt 
that the principal object of this part of education ought to be, not so much to fill 
the mind with knowledge, as to train it to a right exercise of its intellectual and 



424 



CATALEPSY. 



moral faculties ; or that, other things being the same, this is more easily accom- 
plished in those whose animal functions are preserved in a healthy state, than it is 
in others." 



LECTURE XXXIX. 

Catalepsy. Ecstasy. Neuralgia: Tic Douloureux; Sciatica; Hemicrania. 

There are yet some strange forms of nervous disorder which require to be men- 
tioned; but upon which I do not intend to dwell. Catalepsy is one of these ; and 
what is called ecstasy another. These affections are very rare as well as very won- 
derful: so wonderful and rare, that weak and superstitious persons have referred 
them to the interposition of supernatural agents in human afiairs ; and stronger- 
minded persons, who happen never to have witnessed such diseases, deny their oc- 
currence as fabulous, or laugh at them as the tricks and cheatings of imposture. 
They certainly do happen, however ; and they happen mostly in the same class of 
persons in whom hysterical and nervous complaints of all kinds are most common. 
They often appear to be produced by similar causes with these ; they resemble hys- 
teria in being seldom attended with any danger to life : their pathology is, if possible, 
still more obscure than that of hysteria: and if I were to speak of the treatment 
which would seem to be most suitable for their cure or prevention, I should merely 
have to repeat what 1 said upon the treatment and prevention of hysteria, in yester- 
day's lecture. I shall content myself, therefore, with a short description of these 
two affections, that you may be aware of their characteristic phenomena, and 
not be taken by surprise in case either of them should occur to you in your 
practice. 

A fit of catalepsy implies a sudden suspension of thought, of sensibihty, and of 
voluntary motion : the patient remaining, during the paroxysm, in the position in 
which she (for it is almost always a female) happened to be at the instant of the 
attack, or in the position in which she may be placed during its continuance ; and 
all this without any notable affection of the functions of organic life. 

This is certainly a very curious state, and one different from any that we have 
yet contemplated. We have had the muscles rigidly contracted with tonic spasm, 
while the powers of the mind, and the sensibihty of the body, were unimpaired. 
We have had the same muscles shaken with clonic convulsions ; both with and 
without coexistent disorder of the intellectual functions. But here we have a new 
phenomenon ; the mental faculties are in abeyance, and the sensibihty is abolished, 
and so also is the function of voluntary motion ; but the limbs are not tied down b} 
spasm; nor agitated by successive contraction and relaxation of their muscles ; noi 
yet left, like portions of dead matter, passively obedient to the laws of gravity : thej 
assume any posture, however absurd, however (to all appearance) inconvenient 
and fatiguing, and that posture they retain, until some new force from without is ap- 
phed to them, or until the paroxysm is at an end. The patient so affected, with 
open staring eyes often, and outstretched limbs, looks like a waxen figure ; or an 
inanimate statue ; or a frozen corpse. Indeed, Hoffman seems to have formed the 
strange conclusion that, as catalepsy, so far as he knew, occurred most frequently in 
winter, it must depend on congelation of the nervous fluid. 

These singular attacks occur in paroxysms ; and they have been known to alter- 
nate with well-marked hysteria; and to take place in connection with insanity. 1 
have never seen an instance of perfect catalepsy; which I now regret, as I once had 
an opportunity .of doing so of which I did not avail myself. Dr. Gooch has described 
a case of it, as he witnessed the disease in a patient who suffered puerperal mania. 
She had long been subject to the common forms of hysteria. This is illustrative of 
what I have often stated respecting the consanguinity of these nervous disorders. It 
had become necessary to confine this patient in a strait-waistcoat ; she was at- 
tended by Dr. Gooch and Dr. Sutherland. I will quote Dr. Gooch's account of the 



ECSTASY. 



425 



cataleptic state ; for it is authentic and modern. He says, " A few days after our 
first visit we were summoned to observe a remarkable change in her symptoms : the 
attendants said she was dying, or in a trance. She was lying in bed, motionless, 
and apparently senseless. It had been said that the pupils were dilated, and mo- 
tionless, and some apprehensions of effusion on the brain had been entertained : but 
on coming to examine them closely, it was found that they readily contracted when 
the light fell upon them ; her eyes were open, but no rising of the chest, no move- 
ments of the nostrils, no appearance of respiration, could be seen; the only signs of 
hfe were her warmth and pulse ; the latter was, as we had hitherto observed it, weak, 
and about 120." 

" The trunk of the body was now lifted, so as to form rather an obtuse angle with 
the Hmbs (a most uncomfortable posture), and there left with nothing to support 
it ; there she continued sitting while we were asking questions and conversing ; so 
that many minutes must have passed. One arm was now raised, then the other; 
and where they were left, there they remained. It was now a curious sight to see 
her, silting up in bed, her eyes open, staring hfelessly, her arms outstretched, yet 
without any visible sign of animation. She was very thin and pallid, and looked 
like a corpse that had been propped up, and had stiffened in this attitude. We now 
took her out of bed, placed her upright, and endeavoured to rouse her by calling 
loudly in her ears ; but in vain. She stood up, but as inanimate as a statue. The 
slightest push put her off her balance. No exertion was made to regain it. She 
would have fallen if I had not caught her." 

" She went into this state three several times. The first time it lasted fourteen 
hours, the second time twelve hours, and the third time nine hours ; with waking 
intervals of two days after the first fit, and one day after the second. After this the 
disease resumed the ordinary form of melancholia ; and three months from the time 
of her delivery she was well enough to resume her domestic duties." 

There is a minor form of this aflection described, in which the patient is incapa- 
ble of moving or speaking, but is conscious of all that goes on around him at the 
time. I saw a lady last year, who was subject to these attacks of imperfect catalepsy ; 
which have been whimsically, but very expressively, called also attacks of daymiare. 
From her time of life, her habits, and some other points in the history of the disease, 
I concluded that in her case these seizures of temporary loss of muscular povv^er 
without loss of consciousness were dependent upon a diseased state of the blood- 
vessels of the brain. She afterwards consulted Dr. Chambers ; and he told me that 
he had formed the same opinion of the nature and cause of the symptoms. 

In what is called ecstasy, the state is different. The patient is lost to all external 
impressions ; but wrapt and absorbed in some object of the imagination. The muscles 
are sometimes relaxed ; sometimes rigid as in slight tetanus : but the loss of volun- 
tary power over them is not complete or universal, for these patients often speak in 
a very earnest manner, or sing. They are, as the term fjccrr'actts imports, out of the 
body at the time, wholly engrossed in some high contemplation. This state is not 
uncommon as forming a part of religious insanity : and sometimes it runs into ordi- 
nary hysteria. Nervous and susceptible persons are apt to be throAvn into these 
trances under the influence of animal magnetism : and grave authors assure us that 
the intelhgence which then deserts the brain concentrates itself in the epigastrium; 
or at the tips of the fingers : that people in that state read letters which are placed 
upon their stomach, or apphed to the soles of their feet; answer oracularly, enig- 
matical questions ; describe exactly their own internal organic diseases ; and even 
foretell future events. Credat Judseus Appella, Non ego. I take for granted that 
they who were in the habit of speaking, a few years since, in some of our places of 
worship, in what they called unknown tongues, were either gross impostors, who 
deserved to be publicly whipped, or persons labouring under this disease, and want- 
ing physic. Dr. Copland mentions a curious fact in connection with this subject. 
He says that many of the Italian Improvisatori are in possession of their pecuhar 
faculty only while they are in a state of ecstatic trance ; and that few of them enjoy 
good health, or consider their gift as otherwise than something morbid. 

I repeat that I can add nothing respecting the pathology or the management of 

2l3 



426 



NEURALGIA. 



these diseases, to what I have already said in reference to the whole class to which 
they belong. 

Leaving these nervous disorders, in which the function of voluntary motion is so 
curiously modified ; and in which there sometimes is no alteration of the intellectual 
faculties, and sometimes very great disturbance, or the complete suspension of them : 
I would beg to turn your attention to another class of complaints, in which the nerv- 
ous system is still the part principally interested, but in which the deviation from 
the natural state is manifested chiefly in the function of sensation ; the powers of 
thought and of voluntary motion, being scarcely affected, or not affected at all. Com- 
plaints, I mean, in which the sensibility is perverted, and augmented ; cases of nerv- 
ous pain. We have considered before that modification of sensation which consists 
in numbness, or anaesthesia, i. e., in the diminution of the natural sensibility, or its 
total privation. We have noticed also incidentally many perversions of sensation ; 
such as giddiness, nausea, faintness, and the like ; and in the same incidental way 
the morbid exaltation of the sensibility which is called pain, has come before us, as 
a symptom of various other diseases ; of inflammation, and of hysteria. But there 
are diseases which consist of pain, and of nothing else, that we can perceive. They 
are often attended by no inflammation, no detectable change of structure in the pain- 
ful part, no fever. These affections are included under the general term, neuralgia. 
Now pain is one of the things which we are oftenest consulted about ; and these 
neuralgic pains are apt to be excessively severe and troublesome ; and it cannot but 
be of importance to understand what has been ascertained of their nature, and causes, 
and capability of cure. 

That pain is owing to some morbid condition, or to some irritation of a particular 
nerve, we may sometimes know, by finding that it occupies exactly the course, and 
follows the distribution of that nerve. But when, as often happens, the pain is con- 
fined to a certain spot, we then conclude it is neuralgic, if and because we can find 
no other explanation of its existence. 

What increases the difficulty of making out the cause and origin of these nervous 
pains, is that they may be produced by some source of irritation situated at a dis- 
tance from the part in which the pain is felt. It may be placed in the brain itself, 
or in the spinal cord ; or in the trunk of the nerve that supplies the affected part ; 
or in one of the branches of the same trunk, which branch is distributed to another 
part. If you strike the inside of the elbow in a certain way, so that the blow lights 
upon the ulnar nerve, a pecuhar tingling sensation is felt in the little finger ; that is, 
not in the part struck, but in the sentient extremity of the same nerve ; and the same 
thing happens continually in disease. There is an excellent paper on this subject, 
by Sir Benjamin Brodie, published in one of the earlier volumes of the Medical 
Gazette, in which he has collected numerous and striking illustrations of the pro- 
duction of nervous pain by irritation situated in a distant part. Thus, to take a case 
in point ; a man was admitted into St. George's Hospital on account of severe pain 
on the inner side of his knee. The joint was carefully examined, but no mark of 
disease could be detected in it. On tracing the limb upwards, however, an aneurism 
of the femoral artery, as big as an orange, was discovered in the thigh. This the 
patient thought nothing of; his only concern was the pain in his knee. Sir E. Home 
performed the usual operation for aneurism : and the moment the ligature was drawn 
firmly round the artery in the upper part of the thigh, the tumour ceased to pulsate, 
and the pain in the knee ceased also. This man died four or five days after the 
operation : and upon inspection of the limb after his death, the aneurism was found 
reduced to one-half its former size ; and some branches of the anterior crural nerve, 
which passed over it, and vi^hich must have been kept on the stretch previously to 
the operation, were seen to terminate in the part to which the pain had been referred 
on the inside of the knee. There is just such another case related by Dr. Denmark, 
in the Medico- Chirurgical Transactions. A sailor was wounded by a musket-ball 
in the arm. The wound healed ; but the patient remained affected with agonizing 
pain, beginning in the extremities of the thumb and fingers, except the little finger, 
and extending up the fore-arm. His sufferings were so great that he willingly sub- 



NEURALGIA. 



427 



mitted to have the limb amputated : and the operation gave him complete and imme- 
diate relief. When the amputated limb was dissected, a small portion of lead, 
which seemed to have been detached from the ball when it struck against the bone, 
was found imbedded in the fibres of the median nerve. 

These examples teach us, when we receive complaints of pain in any part, and 
can discover no cause of pain in the part itself, to look for some possible source of 
irritation in the trunk of the nerve, from which the part in question is supplied with 
nervous fibrils. 

But the source of irritation may be further back than this : it may depend upon a 
diseased state of the spinal marrow, or of the brain. Of this we have had so 
many examples before us already, that I need not seek for any new illustrations 
of it. 

Sometimes, again, irritation applied in the course, or at the extremity of one branch 
of a nerve, will give rise to pain at the extremity of another branch of the same 
nerve. The sensation appears to be reflected, as it were, along the branch which is 
not, directly, the subject of the irritation. Thus filaments of the phrenic nerve pene- 
trate the diaphragm and communicate with the ganglia that lie around the ceehac 
artery; other filaments are distributed to some of the muscles about the shoulder; 
and in this way has been explained the well-known fact, that disease or irritation of 
the fiver is very apt to be accompanied with pain in the shoulder. 

Thus also we have pain in the glans penis, from irritation of the bladder, produced 
by a stone there ; pain of the thigh and testicle, from irritation of the kidney : pain 
in the left arm, from disease of the heart : pain in the feet, from stricture and irrita- 
tion of the urethra. 

There are many pains also, plainly enough connected with irritation of distant 
parts, although no other nervous connection can be traced between the parts, except 
that which is afforded by the nervous centres. In such cases we must suppose that 
the morbid impression travels to the brain, and then the sensation is referred to the 
part affected through another nervous channel of communication. Dr. Wollaston 
was accustomed to relate the following story of himself. He had eaten some ice- 
cream after dinner one day; and his stomach did not seem to be capable of digest- 
ing it. Some time afterwards, when he had left the dinner table for the drawing 
room, he found himself rendered lame by a violent pain in one ankle. Suddenly he 
became sick, the ice-cream was vomited, and instantaneous relief of the pain fol- 
lowed its ejection from the stomach. " A gentleman (says Sir Benjamin Brodie) 
awoke in the middle of the night, labouring under a severe pain in one Toot. At 
the same time certain other sensations, to which he was not unaccustomed, indi- 
cated the existence of an unusual quantity of acid in the stomach. To relieve the 
latter lie swallowed a large dose of alkaline medicine. Immediately on the acid in 
the stomach having been thus neutralized, the pain in the foot left him." 

The lesson that we learn from all these facts is this : that when we can find no 
explanation of a pain in the very spot in which it is fek, we should look for some 
condition that may explain it in the trunk of the nerve supplying that part: or in 
the parts supplied by other branches of the same nerve ; or (if we are still unsuc- 
cessful), we look for other indications of disease in the brain or spinal marrow : and 
if these be wanting, we should extend our search, and inquire whether there be any 
intelligible disorder or cause of irritation elsewhere, which, operating through the 
medium of the nervous centres, may have occasioned the sympathetic pain of which 
our patient complains. 

I say we should institute this search, because, if it be successful, it may teach us, 
on the one hand, that the cause of the pain is fixed and irremediable ; or, on the 
other, 'it may enable us by some simple and obvious expedient to cure the pain. 
But sometimes we shall be quite disappointed in all this seeking. We shall find 
nothing either in the living patient, or in the dead body, which throws the smallest 
fight upon the cause of the neuralgia. 

Now with respect to those neuralgic pains, for which we can discover no ade- 
quate cause, either in any diseased structure, or in any morbid action of the blood- 
vessels, there are certair. general facts observable which I will mention before I 



428 



NEURALGIA. 



specify any particular forms of neuralgia. They occur in all parts of tlie body ; but 
they are more frequent about the head than in any other part ; and next of all, pro- 
bably, in the abdomen. In the head, or face, the branches of the fifth pair of nerves 
are very frequently the seat of neuralgia ; and to such pain, in that situation, the 
name of tic douloureux is generally given. The painful affection called hemicra- 
nia is another example of neuralgia of the head. Certain forms oi angina pectoris, 
and of gastrodynia, seem to belong to the same class of disorders ; and sciatica — 
which depends on different causes in different cases — is often rather a neuralgic than 
a rheumatic pain. I have stated that the pains sometimes follow the track of cer- 
tain nerves; but this is not, I think, very common. Inflammation of the nerve, or 
of its investments, generally causes pain having that property : but the truly nervous 
pains are much better characterized by the suddenness with which they come on, 
and the suddenness with which they sometimes go off also; by their intermittence 
in many cases, and the regularity of the period at which they often, though not 
always, return ; by the total absence (in most cases) of heat and swelling, and often 
of tenderness too, when they are external, and of febrile symptoms when they are 
internal, even although their intensity be extreme ; by their apparent dependence, 
in numerous instances, upon sudden changes of the weather ; by their occurring 
chiefly in persons of a nervous temperament in whom the health is otherwise disor- 
dered ; and by their frequently abating under tonic remedies, or what are called spe- 
cifics, rather than under antiphlogistic treatment. (Alison's Outlines.) There is 
another circumstance, characteristic of these pains, which has been mentioned by Sir 
Benjamin Brodie, and I do not know that the same thing has been noticed by other 
writers. These pains are often suspended by sleep. " A person suffering from tic 
douloureux in the face may for a time be prevented from falling asleep, but if once 
asleep, his sleep is likely to be sound and uninterrupted for many hours." He says 
that though there may be exceptions to this rule, they are comparatively rare. Now 
this, you will observe, is quite analogous to what takes place in certain spasmodic '■ 
affections of the muscles also. The jactitations of chorea are almost always sus- 
pended during sleep. Jt is the same with the spasmodic wry neck, in which the 
involuntary contraction of some muscle, commonly the sterno-cleido-mastoideus, 
drags the chin round, and the head awry. Persons affected with that sort of ' 
deformity when awake, have their necks flexible enough, I believe, while they are ' \ 
sleeping. I 
I mentioned just now one character of these neuralgic pains, viz., the total ab- i 
sence in most cases, when they occupy the surface, of heat, redness, swelHng, or | 
tenderness ; and I said in most cases, because there are unquestionably exceptions i 
to this. After these pains have been long-continued and intense, they may give i 
rise even to a moderate degree of inflammation of the part; which will become i 
tender to the touch, manifestly vascular, and even swollen a little. " In a gentle- | 
man," mentioned by Sir B. Brodie, " who suffered for a great length of time what | 
was regarded as a most severe tic douloureux in the face, at first the parts to which | 
the pain was referred retained their natural appearance, but ukimately they be- • 
came swollen, from an effusion of serum into the cellular texture, and so exqui- 
sitely tender that they could not bear the slightest touch. In a patient who had i 
laboured for some time under pain in the testicle, depending on a calculus passing j 
down the ureter into the bladder, the testicle became tender and considerably | 
swelled." I 
The attacks of neuralgia may recur at intervals of a few seconds only : or they ' 
may take place daily, or every other day : or they may be separated by much longer i 
intervals, regular or irregular. Sometimes there is continual pain, but it is wonder- | 
fully exalted and aggravated by fits. It is described as being sharp, sudden, ! 
twinging, like an electric shock in its momentary duration. Sometimes it is at- ^ i 
tended by a feeling of constriction and cramp, although no muscular contraction ' 
accompanies it. I suppose that is one reason why such pain is so often spoken of 
even by medical men, and almost always by the vulgar, as spasm. Whenever a ; 
patient tells me he has spasms here or there, I am obliged to request that he will | 
explain himself further. I want to know how he construes spasm ; and nine times 



TIC DOULOUREUX. 



429 



out of ten I find that he intends a sudden and sharpish, and generally a transitory 
attack of pain: whereas the term spasm really signifies, and ought to be restricted 
to, involuntary muscular contractions. When a medical man prints a case in which 
he states that spasms occurred in such or such a part, it is impossible to tell 
what he means, unless that term is explained by the context. Pray avoid this 
inexactness. 

The most common of these neuralgic pains, as I have said, is that Avhich has been 
called, mr' ttoxriv, tic douloureux, and which is situated in the facial branches of the 
fifth pair of nerves ; nerves, as you know, of sensation ; and it is usually restricted 
to one of the three branches that emerge severally to supply the parts in their neigh- 
bourhood. Sometimes two, sometimes all of them, are implicated. The middle one 
of these branches, the infra-orbitary, is, I believe, the most commonly affected in the 
severer forms of the complaint. The torture occasioned by this dreadful malady is 
sometimes excessive. The sufferers speak of it as anguish that is scarcely endura- 
ble ; and you see, in their quivering features and restless limbs, that the acute bodily 
pang is, indeed, hard lo bear. 

When the uppermost branch of the trifacial nerv6 is the seat of the complaint, the 
pain generally shoots from the spot where the nerve issues through the supercihary 
hole ; and it involves the parts adjacent, upon which the fibrils of the nerve are dis- 
tributed ; the forehead, the brow, the upper lid, sometimes the eyeball itself. The 
eye is usually closed during the paroxysm, and the skin of the forehead on that side 
corrugated. The neighbouring arteries throb, and a copious gush of tears takes 
place. Tn some instances the eye becomes blood-shotten at each attack ; and when 
the attacks are frequently repeated, this injection of the conjunctiva may become 
permanent. 

When the pain depends upon a morbid condition, or morbid action, of the middle 
branch of the nerve, it is sometimes quite sudden in its accession, and sometimes 
comes on rather more gradually ; being preceded by a tickling or pricking sensation 
of the cheek, and by twitches of the lower eyelid. These symptoms are shortly 
followed by pain at the infra-orbitary foramen, spreading in severe flashes (so to 
speak) over the cheek, affecting the lower eyelid, ala nasi, and upper hp, and often 
terminating abruptly at the mesial fine of the face. Sometimes it extends to the 
teeth, the antrum, the hard and soft palate, and even to the base of the tongue, and 
induces spasmodic contractions of the neighbouring muscles. 

When the pain is referable to the inferior or maxillary branch of the fifth pair of 
nerves, it darts from the mental foramen, radiating to the lips, the alveolary processes, 
the teeth, the chin, and to the side of the tongue. It often stops exactly at the sym- 
phj^sis of the chin. Frequently it extends in the other direction to the whole cheek, 
and to the ear. During the paroxysm the features are liable to be distorted by spas- 
modic action of the muscles of the face, amounting sometimes to tetanic rigidity, and 
holding the jaw fixed and immovable. 

The paroxysms of suffering in this frightful disease are apt to be brought on by 
apparently trivial causes ; by a slight touch, by a current of air blowing upon the 
face, by a sudden jar or shake of the bed in v/hich the patient is lying, by a knock 
at the door, or even by directing the patient's attention to his malady by speaking 
of it, and asking him questions about it. This was remarkably manifest in a patient 
who came into the hospital under my care for another complaint ; but who had for 
some time been subject to tic douloureux. The necessary movements of the face in 
speaking, or eating, are often sufficient to provoke or renew the paroxysm. At the 
same time firm pressure made upon the painful part frequently gives rehef, and 
causes a sense of numbness to take the place of the previous agony. 

This cruel malady occurs most commonly in persons who exhibit, in other re- 
spects, the signs of an unsound, or deranged, or debilitated system. It is more apt 
to fasten upon those who are pale, and asthenic, and upon individuals whose powers 
have been broken by advancing years. It is not unfrequently attended with some 
obvious disorder of the digestive organs, and ceases or is mitigated when that disor- 
der is corrected. Sometimes it is clearly connected with a disposition to rheumatic 
affections ; coming on in persons who suffer rheumatism in other parts, and even 



430 



TIC DOULOUREUX. 



alternating with rheumatism in other textures. It is observed to be common among 
fishermen, and the inhabitants of marshy districts ; and in some of these sufferers it 
may be attributable to their habitual exposure to cold and moisture ; and this nerve, 
lying superficially, and being unprotected by any artificial covering, is more likely, 
perhaps, for that reason, to be affected by vicissitudes of temperature ; but in many 
of these cases the disease seems to be produced by the malaria^ which is prevalent 
in those situations. The paroxysms are then not only intermittent, but periodical, 
and they will frequently yield to the remedies which have been ascertained to be 
specific against ague and its various modifications. Sometimes the facial neuralgia 
is evidently dependent upon some general state of the system : for it will cease in 
the face, and fix itself in sonie other place ; and in this way it may come to occupy 
several distant parts of the body in succession. There are other cases again in 
which the disease has a local origin, and results from some diseased bone, or exosto- 
sis, in the neighbourhood of the painful spot. The late Dr. Pemberton afforded a 
well-known example of this. He was seized with tic douloureux in the very zenith 
of his reputation, and when he was in the fullest practice of his profession in this 
town. It completely ruined him : compelled him to give up business. He ulti- 
mately died of apoplexy. When his head was examined after death, the os frontis 
was found to be unusually thick ; and on the falciform process of the dura mater, at 
a little distance from the crista galli, a small osseous substance was discovered, nearly 
half an inch long, and almost as broad. Sir Henry Halford has recorded several 
other instances in which the disease was connected with some morbid condition of 
the bones of the head or face. 

Now tic douloureux is one of those complaints for the cure of which there exists 
a number of specific remedies. But what I have been stating of this disease will 
suffice to convince you that, as it depends upon different causes and different per- 
sons, it is absurd to expect that any single drug — or even any one plan of treatment 
— will always remove it. Our first care, in every example of it that comes before 
us, must be to investigate all the particulars of the case. We must not be satisfied 
with learning that the complaint is tic douloureux, and then go on prescribing, one 
after another, the reputed specifics for tic douloureux. It may happen that the ori- 
gin of the disease is plain, and the remedy obvious. We must endeavour to make 
out whatever is amiss in the system at large, or in the state of particular functions. 
Very rarely, I believe, tic douloureux is dependent upon a condition of general ple- 
thora. Mr. John Scott gives the case of a gentleman who suffered severely from it 
for some time ; at length he had an attack of apoplexy, and for this last disorder he 
was copiously bled, and the bleeding seemed to cure the neuralgia. Much more 
frequently we find evidence of a feeble or a shattered state of the system ; debility 
and paleness : and then we may expect to do good by the treatment so strongly 
recommended by Mr. Hutchinson, viz., by giving the carbonate of iron. This 
remedy has been put largely to the test, since Mr. Hutchinson wrote in commenda- 
tion of it, by Dr. ElHotson, and subsequently by others. Dr. Elliotson states it as 
the result of his experience, that, " in all cases of neuralgia, whether exquisite or 
not, unaccompanied by inflammation, or evident existing cause, iron is the best 
remedy." I have already explained the manner of administering the carbonate of 
iron, the quantity in which it may be given, and the Kmits within which I should be 
incHned to restrict the doses. Sir Benjamin Brodie thinks it probable that the car- 
bonate of iron proves beneficial by its mechanical operation on the internal surface 
of the intestines : but I should rather ascribe its good effect to the well-known pro- 
perty of preparations of iron, to give firmness to the nervous system ; apparently by 
increasing the quantity of red blood that circulates in it. However, it is of the utmost 
consequence that the state of the digestive organs should be attended to. Mr. Aber- 
nethy used to relate, in his lectures, many instances of tic which he had been suc- 
cessful in curing by measures which were solely directed to the improvement of the 
stomach and bowels. He had a notion, that in patients who suffer under this disor- 
der, there were always two functions wrong ; those of the nervous system on the 
one hand, those of the digestive system on the other. And I am sure you will com- 
monly find indications of a faulty state of both these systems. " The two," he used 



TIC DOULOUREUX. 



431 



to say, " were the common parents of a numerous progeny of very dissimilar local 
diseases. In tic douloureux, you must seek to put the digestive organs right, or to 
soothe the nervous system, according as the one or the other may seem to be the 
principal and primary cause of the disease. Take away one of the parents, and there 
will be no more propagation." 

In these cases the unhealthy state of the digestive apparatus may be marked by 
obvious signs ; a furred tongue, loss of appetite, costive bowels : or it may reveal 
itself by no other symptom than the pain. It may depend upon the mere presence 
of acid in the stomach. Dr. Rigby tells us that having suffered in his own person 
an intense attack of tic douloureux, which opium did not assuage, he swallowed, at 
the suggestion of a friend, some carbonate of soda dissolved in water. The effect 
was aJmost immediate : carbonic acid was eructed, and the pain quickly abated. 
More often the cause of offence appears to lie in some part of the intestines ; and 
purgatives do good. Sir Charles Bell — drawing a bow at a venture — achieved the. 
cure of a patient upon whom much previous treatment had been expended in vain, 
by some pills composed of cathartic extract, croton oil, and galbanum. He mixes 
one, or two, drops of the oleum tighi, with a drachm of the compound extract of colo- 
cynth ; and gives five grains of this mass with ten grains of the compound galbanum 
pill at bed-time. I mention the exact proportions and dose, because other cases have 
been since reported, both by Sir Charles and by others, in which the same prescrip- 
tion was followed by the same success. 

When the disease occurs in a rheumatic individual, and especially when, as is 
sometimes the case, it alternates with rheumatism of other tissues, the remedies which 
have been found useful in rheumatism deserve a fair trial ; guaiacum ; colchicum ; 
calomel and opium. 

When all has been done that can be done towards restoring or improving the 
general health, we may turn our thoughts to local remedies. It is plain that these 
must be inefficient when the local pain results from constitutional causes that are un- 
redressed, or perhaps incurable. Yet even then topical measures may soothe the 
pain for a while. 

One of these topical expedients, which promised, well when first thought of, is the 
division of the trunk of the painful nerve, so as to cut off the nervous communica- 
tion, through that main channel at least, between the painful part and the brain. 
This was originally proposed by Dr. Haighton, and was at first attended with some 
little success ; but in a great number of instances it has signally failed, as indeed might 
have been expected. In Dr. Pemberton's case the several branches of the fifth pair 
were cut by Sir Astley Cooper : but in vain. When there is any reason to think 
that the disease has a constitutional origin, or a local distant origin, the division, or 
even the excision, of a part of the nerve must be perfectly useless. It would be as 
reasonable (as Mr. Abernethy has observed) to expect to cure gout by cutting the 
nerve that goes to the great toe : or to perform castration with the view of remedying 
that pain in the testicle which is apt to be produced by the passage of a calculus 
through the ureter. Nevertheless there are cases, in which the division of the 
nerve, or some other surgical operation, is required. If you can make out that there 
is any tumour pressing upon or adherent to some part of the nerve — or if some 
foreign body, as a splinter, or a shot, should be ascertained to be in contact with the 
surface of the nerve, or to be entangled in its substance, the tumour or the foreign 
body may be removed by the knife, with the strong expectation that a cure will be 
thus effected. ' And if this cannot be done, or if the nerve itself be altered in struc- 
ture, either from disease or injury, (I am referring now to neuralgia in general, and 
not merely to that in which the facial branches of the fifth pair of nerves are impli- 
cated,) under those circumstances it will become a very proper subject of delibera- 
tion whether the nerve should be divided, or even the limb amputated. 

In the Medical and Physical Journal there is a case described by Mr. Jeffries, of 
a violent facial neuralgia, cured by the removal of a small fragment of china, which 
had been lodging in the cheek for fourteen years. And Mr. Descot mentions an 
instance in which a very severe affection, of ten years' standing, was removed by 
the extraction of a carious tooth. I saw, not many days ago, a young woman whose 



432 



TIC DOULOUREUX. 



finger had been amputated for very acute neuralgic pain which she had suffered in 
it ; and the amputation had been successful in Hberating her from that pain. 

Sometimes we may hope to afford relief to the suffering patient by means which 
tend to remove or lessen the exciting cause of the paroxysms. Of this I may men- 
tion one remarkable example, which fell in part under my own observation : although 
I had nothing to do with the treatment. I was asked, a few years ago, by a friend, 
to go with him to call upon a relation of his, who laboured, he said, under tic dou- 
loureux : he did not wish me to see her professionally, but was desirous that I 
should witness what he considered an extraordinary complaint. I saw a young girl, 
about twelve or thirteen years old, very pale and delicate, lying on a sofa ; and I 
learned from her and from her mother that she was subject to the most excruciating 
agony in one side of her face and neck. The pain came on whenever she swallowed 
anything : the act of deglutition proved invariably the exciting cause of the torment. 
She was at that time under the care of a practitioner who had desired that she might 
eat mutton-chops three or four times of a day. Of course this was a sentence full 
of misery to her ; but so desirous was she to get rid of her disease, that she resolved 
steadily to follow the directions enjoined her. This plan was to be tried for at least 
a month ; after that time, if she were no better, her mother had resolved to consult 
another practitioner who had been much recommended to her. I should say that 
she had already consulted a great number of medical men ; for the malady had 
existed nearly two years. At the end of the month she was worse than at the 
beginning ; and the new practitioner, Mr. Pennington, was called in. He acted, hke 
a man of sense and sagacity, upon the fact that the act of swallowing always gave 
rise to the pain ; and he advised that she should not attempt to swallow for twenty- 
four hours. That period passed without an"y return of the pain ; but it immediately 
recurred upon her eating a morsel of bread. The result of this experiment, how- 
ever, encouraged him to hope that the morbid habit might be broken through by a 
sufficiently long abstinence from swallowing. And as she had been subjected to a 
great variety of fruitless treatment, he gave her no medicine, but advised that she 
should refrain altogether from taking food or drink by the mouth. Nourishing injec- 
tions, composed of beef tea with an egg beat up in it, or of milk, were thrown into 
the rectum, two or three times a day. This plan was persisted in for a longer time 
than I should have supposed she could have endured it. No nutriment whatever 
was taken by the mouth for five weeks and three days, and no paroxysm of pain 
occurred. At the end of that period the pulse sank suddenly, from between seventy 
and eighty, to thirty-five beats in a minute ; and thereupon Mr. Pennington thought 
he had carried his experiment far enough ; and deemed it advisable to administer by 
the mouth a dessert-spoonful of beef-tea twice a day. This was continued for four 
days without producing any return of the pain. A small piece of fish was then 
allowed, and afterwards some chicken ; and proceeding thus cautiously, in the course 
of a month she was able to eat and drink anything, without the slightest inconve- 
nience. 

1 should state, however, that some time afterwards, the neuralgia returned in 
another situation, affecting the left knee : and this was remedied by a different mode 
of treatment. She is since dead. 

When other means fail, or in conjunction Vv'ith other means, local applications to 
the affected part may be tried. Belladonna will sometimes materially- palliate the 
pain : so will opium : but within the last few years a new anodyne has been brought 
into use ; and it really seems to have been of essential service in several instances 
of this most painful disorder. I allude to aconitine: the active principle of the 
monkshood. The property belonging to this plant, of benumbing sensation, has 
long been known. Sir Benjamin Brodie found many years ago that after chewing 
its leaves, a remarkable numbness of the hps was left, which lasted some hours. We 
may understand therefore the beneficial operation of the aconitine upon a part of 
which the sensibility is unduly exaked. It is only very recently that pure aconitine 
has been procured ; and consequently it has not yet been very extensively employed, 
and the less so on account of its very high price ; but what experience we have of 
it, as a benumber of pain, is highly encouraging. It has been of singular benefit to 



TIC DOULOUREUX. 



433 



a surgeon who formerly lived in Charterhouse Square, and whose case is well known, 
I believe, to the profession. Mr. Spry had suffered greatly, for eight years, under 
very acute neuralgia affecting the parts suppKed by the lowermost or mental branch 
of the fifth pair of nerves. After exhausting almost every expedient that ever has 
been recommended for tic douloureux, except that of dividing the nerve, he was 
induced to make trial of the aconitine. It was mixed with cerate, in the proportion 
of one grain to one drachm, and a small portion of this was smeared over the track 
of the painful nerve once or twice a day for six days. By that time he had entirely 
lost the pain. He states, I understand, that the application of the ointment produced 
a sense of numbness, which continued for twelve, or eighteen hours. Dr. Hue, who 
first told me of Mr. Spry's case, told me at the same time that he knew of two others 
in which the same application had been equally successful. This encouraged me to 
try it upon my patient, whom I mentioned before, and who happened at that time to 
be in the hospital. I bought, for ten shillings, five grains of the aconitine at Mr. 
Morson's, in Southampton Row, where t knew it would be genuine. One-third of a 
drachm of ointment, containing one-third of a grain of the alkaloid, was smeared 
two or three times a day over my patient's face, and the attacks presently diminished 
, in intensity, and in a few days ceased altogether. He soon after left the hospital, so 
that I cannot tell whether the cure was permanent. I presume it was so, as he did 
not return. The particulars of Mr. Spry's case have been published by Mr. Skey 
in the nineteenth volume of the Medical Gazette. It is now (1841) six years since 
the aconitine was applied, and the pain (as Mr. Skey has recently informed me) has 
never recurred. It used to be excited by gentle friction of the hand, or by a current 
of cold air, but Mr. Spry " can now face any wind or temperature with impunity."* 
In the same paper Mr. Skey relates another instance of the utility of this substance 
in facial neuralgia. It occurred in one of his patients at St. Bartholomew's Hospital. 

This is a remedy therefore which is not to be neglected. Even if it only allayed 
the pain for a time it would be highly valuable. But, judging from the instances 
now referred to, we may hope that, in some forms of tic douloureux, the aconitine 
may be found equal to their cure. It seems probable that the recurrence of the pain 
is sometimes kept up by the influence of habit ; and will cease if the habit can for 
a while be broken. You must take care, however, to obtain a genuine article. The 
manufacture of aconitine is difficult, and therefore the cost is considerable. Mr. 
Skey, in the Bartholomew case, failed with some aconitine that had been imported 
into this country, but succeeded at once when he employed the same quantity of Mr. 
Morson's preparation. 

A few years ago Mr. John Scott published a little book on the disease we are now 
considering, with the professed object of introducing to genera] notice a species of 
local treatment which he had found successful in several long-standing and previously 
obstinate cases. It is well to be aware of these things, though probably the aconitine 
ointment will beat Mr. Scott's. Mr. Spry used Mr. Scott's ointment, but without 
benefit. It consists of the iodide of mercury, mixed with lard, in the proportion of 
two scruples to the ounce : and it is rubbed into, or placed in contact with, the affected 
surface, until some degree of irritation is produced. 

[In several cases of neuralgia, of different parts of the body, which, for a number of years, 
had resisted a variety of plans of treatment, we have seen almost immediate relief, and in a 
few, a permanent removal of the disease result from acupuncturation. In other cases, how- 
ever, no benefit has resulted from the operation, — C] 

There is a kind of face-ache, which cannot properly be reckoned as a species of 
neuralgia, for it does not occur in short stabbing paroxysms, nor is the pain acute 
enough to entitle it to the name of tic douloureux ; but which is very common, very 
distressing, and under ordinary treatment sometimes very intractable. It is called 
by some a rheumatic pain ; it occupies the lower part of the face, the jaw princi- 
pally, and the patient cannot tell you exactly whereabouts it is most intense. It is 
often thought to proceed from toothache, and bad or suspected teeth are extracted, 



28 



This gentleman is since dead. 

2m 



434 



SCIATICA — HEMICRANIA. 



but with no good effect. Now I allude to this for the sake of saying that some years 
ago I was instructed by an experienced old apothecary, that this face-ache might be 
almost always and speedily cured by the muriate of ammonia ; — a medicine that we 
seldom give internally here, although it so much used in Germany. And I have 
again and again availed myself of this hint, and been much thanked by the patients 
for the good I did them with this muriate of ammonia. It does not always succeed ; 
but it often does. It should be given in half-drachm doses, dissolved in water, or in 
almost any vehicle, three or four times a-day. If the pain does not yield after four 
doses, you may cease to expect any benefit from it. In two or three instances of a 
similar kind that I have recently had to treat, I have found the iodide of potassium, 
in doses of five or six grains, work a speedy and permanent cure. This induces me 
to suppose that the pain in some of these cases is periosteal. I so judge from the 
ascertained efficacy of the iodide in other periosteal affections attended with pain. 

Tic douloureux is the principal form of severe neuralgia which you may expect 
to meet with, in regard to acuteness of suffering and difficulty of cure. Two other 
forms, more common, and luckily more tractable, are generally spoken of under the 
same head : sciatica, namely, and hemicrania. I have very little to say, in this 
place, of either of these. Sciatica, or pain radiating from the sciatic notch, and fol- 
lowing the course of the sciatic nerve, is sometimes an inflammatory complaint, and 
yields to the remedies of inflammation — bleeding and bhstering : sometimes it is 
plainly a part of rheumatism ; and then may often be relieved by calomel and opium, 
or by colchicum : sometimes, again, it results from irritation within the pelvis, affect- 
ing the nerve before it emerges externally ; this irritation may be connected with a 
disordered state of the kidney, and I suspect that it is in such cases that the oil of 
turpentine is of so much use : lastly, it is sometimes a purely nervous and neuralgic 
pain : and then the treatment applicable to facial neuralgia will, mutatis mutandis^ 
be applicable to it. I had some time ago a butler under my care at the hospital, 
whom I am afraid I did not manage well. He suffered severe sciatica, and I had 
him cupped and blistered, and gave him. a variety of medicines, for some time, to 
little purpose : at last he got what I ought, I suppose, to have given him at first, viz., 
the carbonate of iron, and was presently well. 

Hemicrania is simply headache, confined to one side, and occupying generally 
the brow and forehead, but sometimes affecting very exactly one moiety of the head. 
It is the migraine of the French, the inegrim of our vernacular language ; each of 
these terms being obviously traceable to the same Greek root. It is often attended 
with sickness ; and in many instances it is periodical, coming on every day at a 
certain hour, lasting a certain time, and then subsiding. Like the other forms of 
neuralgia, hemicrania may be produced by various causes, which are, however, 
almost all of them such as tend to debilitate the system : it sometimes occurs in con- 
nection with hysteria ; sometimes it plagues women who have suckled their infants 
too long ; sometimes it acknowledges the same cause as ague ; and sometimes also 
it occurs independently of all other disease, and when no obvious exciting cause can 
be traced. 

Whatever may be its origin, it is usually a very manageable complaint. When 
it is associated with evident anoemia, steel and the shower-bath may be expected to 
cure it. When its visits are strictly periodical, it will yield to quina. Arsenic is 
considered by many to have a specific power over the complaint ; and I believe that 
foiy: or six drops of the liquor arsenicahs, given three or four times a day, with due 
attention to the state of the bowels, will be almost sure to remove hemicrania in nine 
cases out of ten in which it occurs. But steel or bark, being milder and safer drugs, 
are, cseteris paribus, to be preferred. 

I say this disorder often acknowledges the same cause as ague; namely, the 
miasm of marshes, or malaria : and as that cause, mysterious as it is in some respects, 
exerts apparently its primary or chief influence upon the nervous system, and as 
ague has no definite seat in the human body, if it be not in the nervous system, I 
shall not find a more convenient place in these lectures for the consideration of ague 



INTERMITTENT FEVER. 



435 



than here, at the close of the remarks which I had to make respecting the diseases 
of the brain and nerves. In the next lecture, then, I shall begin to speak of Inter- 
mittent Fever. 



LECTURE XL. 

Intermittent Fever. Phenomena of an Ague Fit, Species and varieties of Inter- 
mittents. Predisposing causes. Exciting cause. Malaria ; known only by its 
effects ; places which it chiefly infests ; conditions of its production ; its effects 
upon the human body; influence of soils in evolving it. 

I AM now to enter upon the consideration of that disorder of which the trivial 
English name is ague, and which is called by nosologists intermittent fever. This 
-is one of the diseases which are known to us only in their respective group of symp- 
toms. Before we can inquire successfully into its history, it is necessary that we 
have the group of symptoms which identify it set fairJy before us. I must, there- 
fore, describe the phenomena of ague. 

You will observe that ague resembles several other maladies that essentially 
belong to the nervous system, in being paroxysmal. A certain series of symptoms 
occurs, and then the patient reverts to a state of health : but this alternation com- 
monly happens (or would happen if the disease were left to itself) a great many 
times. You may therefore look upon this succession of attacks as so many repe- 
titions of a short distemper; or you may regard the whole period during which 
the attacks continue to recur at brief intervals, as being occupied with one single 
disease. 

An ague fit is composed of three distinct stages ; and they are severally named, 
from the phenomena that characterize them, the cold, the hot, and the sweating 
stages. 

A person who is on the brink of a paroxysm of ague, experiences a sensation of 
debihty and distress about his epigastrium; becomes weak, languid, listless, and 
unable to make any bodily or mental exertion. He begins to sigh, and yawn, and 
stretch himself; and he soon feels chilly, particularly in the back along the course 
of the spine ; the blood deserts the superficial capillaries ; he grows pale, his fea- 
tures shrink, and his skin is rendered dry and rough, drawn up into little promi- 
nences, such as may at any time be produced by exposure to external cold, and 
presenting an appearance somewhat like the skin of a plucked goose : hence it is 
called goose's skin, and in Latin cutis anserina. Presently the slight and fleeting 
sensation of cold, first felt creeping along the back, becomes more decided and more 
general ; the patient feels very cold, and he acts and looks just as a man does who 
is exposed to intense cold, and subdued by it ; he trembles and shivers all over ; his 
teeth chatter, sometimes so violently that such as were loose have been shaken out ; 
his knees knock together ; his hair bristles shghtly from the constricted state of the 
integuments of the scalp ; his face, lips, ears, and nails turn blue ; rings which be- 
fore fitted closely to his fingers become loose ; his respiration is quick and anxious ; 
his pulse frequent sometimes, but feeble ; and he complains of pains in his head, 
back, and loins : all the secretions are usually diminished ; he may make water 
often, though generally he voids but httle, and it is pale and aqueous ; his bowels 
are confined, and his tongue is dry and white. 

After this state of general distress has lasted for a certain time, it is succeeded by 
another of quite an opposite kind. The cold shivering begins to alternate with 
flushes of heat, which usually commence about the face and neck. By degrees the 
coldness ceases entirely ; the skin recovers its natural colour and smoothness ; the. 
collapsed features and shrunken extremities resume their ordinary condition and bulk. 
But the reaction does not stop here ; it goes beyond the healthy line. The face 
becomes red and turgid ) the general surface hot and pungent and dry ; the temples 



436 



INTERMITTENT FEVER. 



throb; a new kind of head-ache is induced ; the pulse becomes full and strong, as 
well as rapid ; the breathing is again deep, but oppressed ; the urine is still scanty, 
but it is now high-coloured ; the patient is exceedingly uncomfortable and restless. 
At length another change comes over him : the skin, which, from being pale and 
rough had become hot and level, but harsh, now recovers its natural softness ; a 
moisture appears on the forehead and face ; presently a copious and universal sweat 
breaks forth, with great relief to the feelings of the patient ; the thirst ceases ; the 
tongue becomes moist ; the urine plentiful but turbid ; the pulse regains its natural 
force and frequency ; the pains depart ; and by and by the sweating also terminates, 
and the patient is again as well, or nearly as well, as ever. 

This is surely a very remarkable sequence of phenomena : and it would appear 
still more remarkable if it were less familiar to us. The earlier symptoms are all 
indicative of debility, and of a depressed state of the nervous system. There is the 
same sensation of exhaustion, with incapacity of exertion, which is produced by 
fatigue. The sighing, yawning, and stretching, all notify debihty. The paleness 
of the surface, and constriction of the skin, and collapse of the features, are all owing 
to the retirement of the blood from the superficial capillaries. The skin shrinks, 
but the parts containing the bulbs of the hairs cannot contract so much as the other 
parts, and therefore the surface becomes rough, and the hairs bristle up, or become 
erected in some degree. Horripilatio is the learned term for this state of the surface. 
The coldness of the skin is another consequence of the emptiness of its blood- 
vessels ; and the tremors which are always indicative of debility, seem to depend 
upon the coldness. The chattering of the jaws has been (it is said) so violent as to 
fracture the teeth. This you may believe or not as you please, but certainly the 
w^hole bed is often strongly shaken by the shivering of the patient. The necessary 
accumulation of the blood in the larger and internal vessels offers a reasonable expla- 
nation of the distressed and anxious breathing. 

In their attempts to render a " ratio symptomatum," authors have sometimes spoken 
of the hot stage as though it were a necessary consequence of the cold. But if the 
cold fit be in any sense or degree the cause of the hot fit, it can only be so partially. 
There must be some other cause for these reasons. The cold stage may occur and 
never be followed by the hot ; or the hot stage may come on without any previous 
cold stage ; and when they do both happen, they are not by any means propoi:iioned 
to each other. When we thus see that a supposed cause is not always followed by 
the effect, and that the effect is sometimes produced without the agency of the sup- 
posed cause, and also that the supposed cause and the effect are not proportioned to 
each other, we cannot but conclude that the supposed cause is at most but a partial 
and accessory cause. We can more easily conceive how the hot fit may conduce 
to bring on the sweating stage. The stronger action of the heart and the more forci- 
ble propulsion of the blood will fill the superficial vessels, and in this way the natural 
secretions may be restored. We see exactly the same thing happen when the force 
of the circulation is increased by exercise : the extreme vessels receive a larger sup- 
ply of blood, and sweat ensues. 

There are many curious facts to be observed in respect to the paroxysm of an 
intermittent, such as it has been now, in general terms, described. In the first place 
the paroxysm returns. Cullen makes this a part of his definition ; and quibbling 
objections to his statement have been made, which are scarcely deserving of men- 
tion. Thus it is said that this circumstance should not have been introduced into 
the definition, because it is not necessarily or universally true ; that the patient may 
die in the very first paroxysm ; or that he may be cured by the proper remedies of 
ague, before a second paroxysm has time to show itself. But all this is captious tri- 
fling. The paroxysms, if the disease be left to itself, will recur for a certain length 
of time ; and, unlike the paroxysms in many of the spasmodic diseases which vve 
have lately been speaking of, they recur at regular periods, and often Avith singular 
punctuahty. This is a circumstance which we should waste our time in attempting 
to account for. Dr. Cullen has tried to explain it on the principle of some diurnal 
habit of the body ; but the truth is, that no satisfactory explanation of it has ever 



INTERMITTENT FEVER. 



437 



been given, and we must be content, for the present 9.t least, to receive it as an ulti- 
mate fact ; and, doubtless, a very strange and interesting fact. 

For distinguishing some equally curious varieties of these successions and alterna- 
tions of disorder and health, certain terms have, by common consent, been adopted 
by pathologists ; which terms it is necessaiy that I should explain. The period that 
elapses between the termination of one paroxysm and the commencement of the 
next is called an intermission ; while the period that intervenes between the begin- 
ning of one paroxysm and the beginning of the next, is called an interval. As the 
paroxysms are liable to vary in length, the intermissions may be very unequal, even 
when the intervals are the same. When the intermissions are perfect and complete, 
the patient resuming the appearance and sensations of health, the disorder is an in- 
termittent fever. When the intermissions are imperfect, the patient remaining ill 
and feverish, and uncomfortable in a less degree than during the paroxysm, then the 
complaint is said to be a remittent fever. 

But, confining ourselves for the present to interraittents, it is another curious pro- 
perty of this complaint that, although the intervals are commonly constant in each 
case, and quite regular, they differ in duration in different cases. Upon this circum- 
stance is founded a division of agues into species. When the paroxysm occurs at 
the same hour every day, the patient is said to have quotidian ague. When it 
comes on at the same hour every other day, appearing and remaining absent day by 
day alternately, h%is said to labour under tertian ague. The paroxysm, strictly 
speaking, repeats itself every second day: and if the species I first mentioned be 
fitly termed quotidian, that in which the fits occur on alternate days ought to be 
styled secundan. But nosologists have chosen to reckon the day on which the pre- 
ceding fit happens as the first : and then the day on which the fit next to it will hap- 
pen, in the species now under consideration, is the third. In the same way, when 
a paroxysm absents itself for two whole days, and then recurs, the complaint is 
called a quartan ague. These are the th^ree principal species or types of intermit- 
tent fever. It follows, of course, from what I have been stating, that in the quoti- 
dian type, the interval is twenty-four hours ; in the tertian, forty-eight ; and in the 
quartan, seventy-two. 

Each of these types has some other characters pecuhar to itself. Thus, the parox- 
ysms of the quotidian ague begin in the morning ; those of the tertian, at noon ; 
those of the quartan, in t^e afternoon. These are the r?xles. You are not to expect 
to find them always or rigidly observed ; for the most part you will find that they 
are observed. It is probable that quotidian paroxysms, occurring at noon or at night, 
have sometimes been ascribed to ague, when they were merely symptoms of some 
local disease or inflammation ; or perhaps accessions of hectic fever. It is observed 
also of the paroxysms, that when the disease is about to yield, they often occur later 
day after day, before they take their final departure. This is called postponing : 
and when they occur ear her than their stated hour, the paroxysms are said to antici- 
pate. Now a postponing quotidian may be deferred till noon. But when the dis- 
ease is pursuing its regular undisturbed course, the rule is such as I have men- 
tioned. 

The three principal types differ from each other, not only in their respective inter- 
vals, and in the periods of the day at which the paroxysms severally commence, but 
also in the duration of the paroxysms ; and in the proportions which the stages of 
these paroxysms bear to each other. The average duration of the paroxysm in the 
quotidian is ten or twelve hours; and of course the average duration of the intermis- 
sion is nearly the same. The tertian paroxysm commonly begins at noon, and is 
finished the same evening ; its average duration may be estimated at six or eight 
hours. And that of the quartan does not exceed four or six hours. 

You must observe, also, that while the quartan has the longest interval and the 
shortest paroxysm, it has the longest cold stage ; w^hereas the quotidian has the 
shortest interval and the shortest cold stage, but the longest paroxysm. To express 
these facts in mathematical language, the length of the paroxysm varies inversely as 
the length of the cold stage ; inversely also as the length of the interval. 

Of these three principal types or species, the tertian is by much the most com- 

2m3 



438 



INTERMITTENT FEVER. 



mon : but the quotidian and quartan are neither of them unfrequent wherever ague 
is rife. 

I should tell you that there are other types also spoken of, as quintans and sextans : 
but they are scarcely worth our attention. It is probable that when they are ob- 
served (and that is very rarely) they are merely irregular quartans, postponing per- 
haps for a day or two. They never prevail epidemically. Galen describes one of 
these ; so does Van Swieten. Boerhaave talks of a septiman, and even octavans are 
mentioned ; or if you want still more of the marvellous, PUny, the naturahst, informs 
us that a certain Improvisatori was in the habit of having a paroxysm once a year, 
and that exactly on his birth-day ; yet he died at a good old age. 

There are, however, some curious modifications of the three principal types ; or 
rather of two of them, the tertian and the quartan. For instance, a paroxysm may 
occur daily, and yet the ague not be of the quotidian type, but of the tertian. The 
paroxysm of one day will diffd*r from the paroxysm of the next, but exactly resemble 
that of the third day ; while the paroxysm of the second day will be like that of the 
fourth ; and so on alternately. And these differences will be decidedly marked ; 
the paroxysms of two consecutive days will come on at different hours, and will differ 
in duration and severity. This form of ague is called the double tertian. One case 
of this kind, very distinctly characterized, was some time ago under my care in the 
hospital. 

There is another form of double tertian. Two fits will occur m the same day — ' 
Monday, for example, one in the morning, the other in the evening ; on Tuesday 
there shall be no fit ; on Wednesday again two ; on Thursday none ; and so on. 
The Latin nomenclature is more precise than the EngUsh in denoting these varia- 
tions. The form I have last mentioned, in which two dissimilar paroxysms occur 
every other day, is called tertiana duplicata, while the other form, in which there is 
a fit every day, but those on the alternate days resemble each other, is called tertiana 
duplex. 

In the same way you may have a double quartan. In that case, a paroxysm 
occurs on two days in succession, and leaves the third day free ; then it returns 
on the fourth day as it was on the first, and on the fifth as it was on the second, and 
leaves the sixth day free like the third, and so on. This is the quartana duplex. 
But two fits may happen in one day — say on Monday ; none on Tuesday or Wed- 
nesday ; and two again on Thursday. This is the quartana duphcata. Nay, the 

aroxysm of quartan ague may recur every day, and so far resemble a quotidian; 

ut the fit of the first day will differ from those of the second and third, and resemble 
that of the fourth : the fit of the second^day will be dissimilar from that of the first 
or that of the third, and like that of the 'fifth ; and the fit of the third will be unlike 
that of either of the two preceding days, and find its counterpart in that of the sixth. 
This is a triple quartan ; and where three paroxysms occur on the first day, which 
we will again suppose to be Monday, and none on Tuesday or Wednesday, but 
three again on Thursday, corresponding respectivel}^ to the first three, we have the 
quartana triplicata. And there are other complications still, with which I need not 
trouble you. In Dr. Cleghorn's book on the diseases of Minorca, you may find a 
very good and authentic account, evidently drawn from nature, of the irregular types 
and varieties of ague. They are well worthy of the attention of any among you who 
may be likely to practise abroad. 

Some physicians have used the words double tertian, and so on, in the hteral sense, 
and have supposed that two or more distinct agues coexisted. This savours a good 
deal of the error that I formerly warned you against, of looking upon diseases as 
separate entities, and not merely as modes of being and of acting different ft om those 
which are proper to the state of health. The vulgar always regard disorders in this 
light. A coachman by whose side I sat while travelhng from Broadstairs to Mar- 
gate, was speaking of the rarity of ague in that part of the Isle of Thanet. His 
father, he said, once had the complaint, and when he was on a visit to him, the 
coachman, at Ramsgate, a fit came on. The son administered to his suffering parent 
a glass of brandy : whereupon " he threw the agy off his stomach ; and it looked 



INTERMITTENT FEVER. 



439 



for all the world like a lump of jeily." That was the only occasion on which. he 
had ever " seen the agy." 

Besides these varieties in type, some other deviations from the normal and regular 
paroxysms require to be noticed. 

Sometimes the paroxysm is incomplete : it is shorn of one or more of its stages: 
the heat and sweating occur without any previous rigors ; or the patient shakes, but 
has no subsequent heat ; or the sweating stage is the only one of the three that 
manifests itself. These fragments of a fit are oiten noticeable when the complaint is 
about to take its departure ; but they may also occur at other periods of the disease. 
Sometimes there is no distinct stage at all : but the patient experiences frequent and 
irregular chills, is languid and uneasy, and depressed. This state is commonly 
known among the inhabitants of our fenny and aguish districts as the dumb ague, 
or dead ague ; the patient is said not to shake out. 

Again, there is often observed a tendency to a change of type in the course of the 
same disease affecting the same person. The quotidian will be transformed into a 
tertian ; a tertian into a quartan ; or, on the other hand, a quartan into either of these. 
I have already noticed the fact that the paroxysms will also alter their time of inva- 
sion, sometimes coming later and later in the day, at each recurrence, sometimes 
earlier and earlier. When the paroxysm thus postpones, the disease is growing 
milder : when it anticipates its usual period of attack, the disease is increasing in 
severity. The postponement or anticipation, therefore, of the fit, has a close relation 
to the prognosis. 

There are yet other cases, in which from first to last no determinate type or order 
of succession is observed by the paroxysms ; and these cases authors speak of as 
erratic forms of ague. 

There are also many modifications or complications observable in the symptoms 
which constitute the fits. Occasionally each paroxysm is attended by violent deli- 
rium : this is most common, I believe, in the hot stage. This symptom has been 
known to be almost constant throughout an epidemic. Sometimes the patient is 
convulsed in the paroxysm; or syncope comes on; or tetanic rigidity; or petechicB 
takes place on the skin, and disappear with the paroxysm. These deviations from 
the common and. regular kind and order of the symptoms may sometimes depend 
upon the constitutional predispositions of the person affected ; but there is another 
way also in which they may be explained. 1 shall presently have a good deal to 
say upon the one grand — 1 may say sole — exciting cause of intermittents. Now 
exposure to that cause, a residence in aguish districts, v/iil sometimes impart a periodic 
character to other diseases: and I apprehend that this explanation will apply to 
many of the instances which have been observed of hysterical, tetanic, or other 
paroxysmal complaints, occurring at perfectly regular intervals. 

The duration of ague — of the whole disease, and not merely of a separate pa- 
rox3'Sm — it is not easy to estimate. If persons who laboured under it were always 
removed at once from the influence of the exciting cause, and were always suffered 
to remain without treatment calculated to check the malady, we might then find 
materials for determining its average natural duration. But we have not these data. 
In point of fact, ague sometimes consists of a very few paroxysms only, half a 
dozen, or four, or three, or even of one fit ; and on the other hand, they may be pro- 
tracted over a space of several weeks, or inonths ; nay, of many years. 

An ague may attack a person at any time ; but they are much more common in 
spring, and in autumn, than in the other seasons of the year : so that you will hear 
and read a good deal of vernal intermiitenis, and of autumnal intermittents. The 
autumnal agues are, cfsteris paribus, the more severe and dangerous. The quotidian 
is most common in the spring ; the quartan in the autumn ; and the tertian is fre- 
quently met with both as a vernal and as an autumnal ague. You will bear in mind 
that in all this I am stating the prevailing rules ; which are hable to numerous ex- 
ceptions. 

Ague is one of those disorders of which (as of common inflammation) all persons, 
at all periods of their existence, seem to be susceptible, when submitted to the influ- 
rce of the specific exciting cause. Individuals of all ages, from sucking infants to 



440 



INTERMITTENT FEVER. 



persons of four-score, are liable to it, but they are not equally subject to it. It is 
less likely [cscteris paribus) to affect the very young, and the aged, than those of 
middle hfe. However, the very old are by no means exempt from the operation of 
the cause of ague : and with respect to the very young, some extremely curious 
statements have been made. It is said that persons have had ague before they" were 
born. We know that the period of intra-uterine hfe is obnoxious to many forms of 
disease ; for we trace the consequences of such disease, in visible changes of struc- 
ture, immediately after birth. Pulmonary tubercles constitute one malady to which 
the fcetus in utero is hable: hydrocephalus is another: acute inflammation of the 
peritoneum a third. And there can. be no doubt that various specific poisons influ- 
ence, occasionally, the included being, even although they may have no sensible 
effect upon the parent. The f(Etus may thus contract small-pox, which sometimes 
proves fatal to it, sometimes not. The daughter of my bed-maker at Cambridge had 
a child ill of hooping-cough in the house with her while she was in the last months 
of pregnancy ; and the infant in the womb must have caught the disease, for I was 
assured that he hooped the very day he came into the world. The sins of the parent 
are thus visited often upon the child, when, before its first breath is drawn, its frame 
is contaminated by the virus of syphilis. And in like manner unborn infants are 
capable of being affected by the poison that produces ague. One case in proof of 
this is recorded by Dr. Russell, in his History of Aleppo. The woman had tertian 
ague, which attacked her, of course, ever)^ other day: but on the alternate days, 
when she was well and free, she felt the child shake ; so that they both had tertian 
ague, only their paroxysms happened on alternate days. Bark was prescribed for 
her ; and it cured the little one first, and afterwards it cured the mother. 

One probable reason why ague more commonly afl^ects persons about the middle 
period of life, than those near its extremes, is that the former are much more hkely 
to be exposed to the primary exciting cause. And the same reason may be given, I 
presume, for another fact ; viz., that the complaint is much more frequently seen in 
men than in women. 

Among the circumstances which predispose to ague, debihty has a powerful in- 
fluence. It is important to be aware of this, as it concerns the prophylaxis, and the 
management of the patient after the disease has been subdued. Soldiers have been 
exposed to the exciting cause, without becoming affected by it, while strong and in 
good heakh ; and have fallen ill of intermittent fever upon being weakened by ex- 
ertion and fatigue. When I have told you that debihty, an}'^ how produced, consti- 
tutes a predisposition to intermittent fever, I need scarcely add that all the multiform 
causes of debility may also be regarded as predisposing causes of this same diease ; 
as they are of so many others. 

But the strongest predisposing cause of all is an actual occurrence of the disease 
itself. The effect of former iniermittents upon the system is such that the complaint 
may be reproduced by agencies which under any other circumstances would be quite 
inoperative in exciting ague. I have stated already my persuasion that, strictly 
speaking, there is but one exciting cause of intermittent fever : but in making that 
statement I refer to its first production. The disease leaves the body in a condition 
in which other injurious influences may, of themselves, be sufficient to renew it. 
It brings into play a new order of exciting, or rather of re-exciting causes. If a 
person were never exposed to the malaria, he would never, as I believe, have ague : 
but having once had ague, he may many times have it again, although he should 
never again be subjected to the direct influence of the malaria. The late Dr. James 
Gregory of Edinburgh, had a brother-in-law who illustrnted well in his own person 
the effects of predisposing circumstances in respect to ague. This gentleman was a 
strong, active man, and commanded a battalion in the West Indies ; and he escaped 
for a long time, while others were falling down around him in remittent fever. At 
last he was wounded by a musket-ball which passed through his shoulder. He in- 
sisted, much against the will of the surgeon of the regiment, on resuming his duties 
before his strength was completely restored ; snd the consequence was that he was 
immediately attacked by a remittent fever of such violence, that his life was for some 
lime despaired of. But this was not all, The remittent disease assumed by degrees 



INTERMITTENT FEVER. 



441 



a distinctly intermittent form, and became a tertian : and at last he got well, and 
strong, and came over to this country. Bat for a long while, though to all appear- 
ance his health was re-established, ague fits would from time to time occur ; and 
they came precisely at the day and hour on which they would have happened if the 
tertian had continued with its original type ; and shght causes were sufficient to re- 
produce them. He had marked in an almanack, the days of the expected accession; 
and on those days it recurred, for some time, whenever the east wind blew. This 
very circumstance, the east wind, is a common re-exciting cause in such cases ; ex- 
posure to cold in any way is another. 

The exciting cause of intermittent and remittent fevers — the primary exciting 
cause I mean, that without which ague would never occur at all — deserves a some- 
what particular consideration. I need scarcely say that it consists in certain invisible 
effluvia or emanations from the surface of the earth, w^hich were formerly called 
marsh miasmata, but to which it has, of late years, become fashionable to apply the 
foreign term malaria. In some respects the latter designation is the more conve- 
nient of the two. 

The malaria is a specific poison, producing specific effects upon the human body. 
In its medical sense, it is not simply bad air, or impure air, although the word is 
loosely employed by many to express any mixed kind of contamination of the at- 
mosphere. Thus we hear of the malaria of London : but ague, even when it occurs 
in London, is very seldom indeed, now-a-days, of London growth. The impure air 
incident to large and populous cities is prejudicial enough to health, as I formerly 
took occasion to show you : but it does not generate fe'-er : neither continued fever, 
nor intermittent. 

[The author certainly cannot mean to assert, as his language would seem to imply, that no 
form of fever is generated by " the impure air incident to large and populous cities," but 
that all fevers are produced by a " specific poison^''' resulting from other causes than those by 
which the atmosphere is rendered impure in the crowded, unventilated, and filthy lanes, 
courts, and alleys, which abound in suburbs of most large cities. That typhus and typhoid, 
bilious, and yellow fevers are generated in large and populous cities, no one, we presume, 
will pretend to deny, but of their dependence upon a spe^^ific aerial poison we have not as 
yet been furnished with any satisfactory evidence. — C] 

The emanations which cause ague have been called marsh miasmata, because they 
are notoriously common in marshy places. But they are not peculiar to marshy 
places. For this reason, and for brevity's sake, I prefer using the single word mcil- 
aria. In this country, thank God, we witness its milder evils only, and those not 
very often ; but it is the bane and scourge of large portions of the world. Whether 
you practise here or abroad, it is very fit that you should know the qualities, habitats, 
and habits, of this wide-spread poison. The mildest form of fever to which it gives 
birth is the intermittent fever, or ague ; but in climates and places where it exists in 
greater abundance and intensity, the fever becomes remittent, or even assumes the 
continued form. This has led to strange errors, and proved a fertile source of dif- 
ference and controversy amongst medical men: not a few of whom confound the 
severe continued fevers which spring from the malaria, and which are never conta- 
gious, with the severe continued fevers usually called typhous, which are unques- 
tionably communicable from person to person. 

The effluvia which thus form the sole exciting cause of intermittent and remittent 
fevers proceed from the surface of the earth, and are, probably, gaseous, or aeriform : 
at any rate they are involved in the atmosphere. But they are imperceptible by 
any of our senses. Of their physical or chemical qualities we really know nothing. 
We are made aware of their existence only by their noxious effects ; and the 
inference that they exist was not made till within the last century and a half. — Time 
out of mind, indeed, it had been matter of common observation that the inhabitants 
of wet and marshy situations were especially subject to these definite and unequi- 
vocal forms of disease. But the Italian physician, Lancisi, was the first, so far 
as I know, to put forth distinct ideas concerning malaria, in his book, published 
about 1695, De noxiis pallidum effluviis. This is the great original work upon * 
the subject. 



442 



INTERMITTENT FEVER. 



To the production of this deleterious agent, a certain degree of temperature seems 
necessary. It does not appear to exist within the arctic circle : nor does it manifest 
itself during the colder seasons of more temperate climates. It is very seldom 
traceable beyond the 56th degree of north latitude ; and it is supposed to require for 
its development a continuous temperature higher than 60° of Fahrenheit's thermo- 
meter. The nearer we approach the equator, the more abundant, virulent, and per- 
nicious does the poison become, wherever it is evolved at all. — ^In this climate it gives 
rise to intermittents, and principally to tertians. As we go south, in Spain, and 
along the shores of the Mediterranean, the remittent becomes the predominant form ; 
and (what is very instructive) remittents there contracted often improve into inter- 
mittents upon the removal of the patient to a colder climate. Under the tropical 
heats, in the West Indies, for example, the fevers very frequently assume the conti- 
nued form. 

And another condition of the development of the poison soon becomes apparent. 
It requires a certain degree of moisture. Of all these regions, malaria, showing 
itself always by its effects alone, infests certain parts only ; which parts are, most 
generally, remarkable for their humid and swampy character. Thus, in this island, 
intermittents are produced chiefly, I may say almost exclusively, along the eastern 
coast ; in parts of Kent, Essex, Cambridgeshire, Norfolk, Lincolnshire, and the East 
Riding of Yorkshire : and in each of these counties there are marshes, or fens, or low 
grounds and lands that are occasionally overflowed. Many of these spots have, 
within the last fifty years, been drained, and brought under cultivation ; and agues 
are consequently much more rare in England than they formerly were. In Syden- 
ham's time they were very frequent, and very fatal indeed, in this metropohs. James 
I. and Oliver Cromwell both died of ague contracted in London. At present (as I 
said before) we seldom meet with them. — Except in the year 1827, 1 have never, 
since I have been in practice, known ague to be at all common here. This compa- 
rative freedom from malaria is mainly owing, no doubt, to the improved character of 
the draining and sewerage. 

Agues, or aguish fevers, are endemic along every part of the low and level coast 
of Holland. In Italy, the Pontine marshes, near Rome, have possessed for ages an 
infamous celebrity of the same kind. The whole of the district called the Maremna, 
which stretches for about thirty leagues along the shores of the Mediterranean, and 
which in some places is ten or twelve leagues broad, is rendered dangerous, and 
almost uninhabitable, by the vast quantity of malaria annually evolved from its soil. 
In x4.merica large districts are, for the same reason, prohfic of disease. The late 
Bishop Heber, in his Narrative of a Journey through the Upper Provinces of In- 
dia, gives the following striking picture of the influence of the malaria in that part 
of the world. It seems to be alike pestiferous to man and beast. 

"I asked Mr. Boulderson if it were true that the monkeys forsook these woods 
during the unwholesome months. He answered that not the monkeys only, but 
every thing which has the breath of life, instinctively deserts them from the begin- 
ning of April to October. The tigers go up to the hills; the antelopes and wild 
hogs make incursions into the cultivated plain ; and those persons, such as dak- 
bearers, or military officers, who are obliged to traverse the forest in the intervening 
months, agree that not so much as a bird can be heard or seen in the frightful soli- 
tude. Yet during the time of the heaviest rains, while the water falls in torrents, 
and the cloudy sky tends to prevent evaporation from the ground, the forest may be 
passed with tolerable safety. It is in the extreme heat, and immediately after the 
rains have ceased, in May, the latter end of August, and the early part of Septem- 
ber, that it is most deadly. In October the animals return. By the latter end of 
that month the wood-cutters and the cow-men again venture, though cautiously. 
From the middle of November to March troops pass and repass, and with common 
precaution no risk is usually apprehended." 

Persons who live in England might perhaps be disposed to think lightly of the 
malaria, had not such fearful evidence of its appalling power been brought home to 
the experience of our countrymen, in the early part of the present century, by the 
resuk of the unfortunate expedition to Walcheren. Sir Gilbert Biane has given an 



INTERMITTENT FEVER. 



443 



account of the ravages it there committed among our troops. You may see his 
paper, to which I shall presently again refer, in the third volume of the Medico-Chi- 
rurgical Transactions. 

Not only a certain degree of heat, and a certain quantity of moisture, but the pre- 
sence of ail the four elements of the ancients, would appear to be requisite for the 
production of this poison. Air of course there must be ; and earth also is essential. 
If heat and moisture were alone adequate, we should find the fever prevailing among 
sailors when out at sea : but it is not so, whatever may be the temperature under 
which they cruise. It is when they approach the coast, or land upon it, that they 
are attacked. The water of marshes has been examined under the microscope, and 
analyzed again and again, with a view to the discovery of the nature of this pesti- 
lential agent ; but in vain. A more likely way to detect the noxious material would 
seem to be by examining the air of malarious districts ; and this has been done 
carefully and repeatedly by expert chemists ; and with the same want of success. 
The poisonous principle eludes the test of the most delicate chemical agents. 

Where there are are much heat, and much moisture, there we usually find also 
much and rank vegetation, and much vegetable dissolution and decay. The belief 
was as natural, therefore, as it has been general, that the putrefaction of vegetable 
matters was somehow or other requisite to the formation of the poison that exists so 
commonly in swampy situations. This behef has descended, almost unquestioned, 
from the time of Lancisi ; and it obtains almost universal acceptance, I fancy, among 
physicians of the present day. Yet very strong facts have been adduced to show 
that the decomposition of vegetable substances is only an accidental, though a fre- 
quent, accompaniment of the miasm ; and not by any means an essential condition of 
its evolution. 

In the first place, the decomposition of vegetable matter goes on abundantly with- 
out the production of malaria. The rotting cabbage-leaves of Covent Garden, and 
those which taint the air of the streets from the neglected dust-holes of London, 
during the hot weather of summer give rise to no ague. The same may be said of 
the putrefying and offensive sea-weed, which is deposited in large quantities upon 
some very healthy parts of our sea-coast. But the converse facts are the most 
remarkable and conclusive. I have stated that marshes are not necessary to pro- 
duce malaria ; but Dr. William Ferguson — a physician who has had, and who has 
well used, very sufficient opportunities of investigating the question — shows that 
vegetation is not necessary : that the peculiar poison may abound where there is no 
decaying vegetable matter, and no vegetable matter to decay. As the prevailing 
behef is, in my opinion, an erroneous one, and as it is really of great importance that 
correct views of this subject should be taken and disseminated by medical men, I 
will mention a few of the most striking of the facts detailed by Dr. Ferguson. They 
are contained in a very interesting paper " On the Nature and History of the Marsh 
Poison,'''' published in the Edinburgh Philosophical Transactions. 

In August, 1794, after a very hot and dry summer, our army in Holland encamped 
at Rosendaal and Oosterhout. The soil, in both places, was a level plain of sand, 
with a perfectly dry surface, where no vegetation existed, or could exist, but stunted 
heath plants.^ It was universally percolated to within a few inches of the surface, 
with water which, so far from being putrid, was perfectly potable. Here fevers of 
the intermittent and remittent type appeared among the troops in great abundance. 
It is interesting to observe that the soil in Walcheren is precisely similar. Sir Gil- 
bert Blane describes it as consisting " of a fine white sand, known in the eastern 
counties of England by the name of sik, and about a third part of clay." Jt was 
after a hot and dry summer, also, that the British army suffered in that island from 
the endemic fever, to a degree which Dr. Ferguson speaks of as "being almost un- 
precedented in the annals of warfare." 

In the year 1809, several regiment^ of our army in Spain took up an encamp- 
ment in a hilly ravine which had lately been a water-course. Pools of water still 
remained here and there among the rocks, so pure that the soldiers were anxious to 
bivouack near them for the sake of using the water. Several of the men were seized 
v;ith violent remitting fever before they could move from the bivouack the next morn 



444 INTERMITTENT FEVER. 

ing. " Till then (says Dr. Ferguson) it had always been believed amongst us that 
vegetable putrefaction (the humid decay of vegetables) was essential to the produc- 
tion of pestiferous miasmata ; but in the instance of the half-dried ravine before us, 
from the stony bed of which (as soil never could he for the torrents) the very exist- 
ence even of vegetation was impossible ; it proved as pestiferous as the bed of a 
fen." 

After the battle of Talavera, the army retreated along the course of the Guadiana 
river, into the plains of Estremadura. The country was so arid and dry for want 
of rain, that the Guadiana itself, and all the smaller streams, had in fact ceased to be 
streams, and were no more than hnes of detached pools in the courses that had for- 
merly been rivers. The troops there " suffered from remittent fevers of such destruc- 
tive malignity, that the enemy, and all Europe, believed that the British host was 
extirpated." 

Cividad Rodrigo is situated on a rocky bank of the river Agueda, a remarkably 
clear stream ; but the approach to it on the side of Portugal is through a bare, open, 
hollow country, that has been likened to the dried-up bed of an extensive lake ; and 
upon more than one occasion, when this low land, after having been flooded in the 
rainy season, had become as dry as a brick-ground, with the vegetation utterly 
burned up, there arose to our troops fevers which, for malignity of type, could only 
be matched by those before mentioned on the Guadiana. 

Many more facts to the same purpose are related in Dr. Ferguson's paper, which 
is in every way well worth your perusal. He tells us " that in the most unhealthy 
parts of Spain, w^e may in vain, towards the close of the summer, look for lakes, 
marshes, ditches, pools, or even vegetation. Spain, generally speaking, is then, 
though as prohfic of endemic fever as Walcheren, beyond all doubt one of the driest 
^ countries of Europe ; and it is not till it has again been made one of the wettest, by 
the periodical rains, with its vegetation and aquatic weeds restored, that it can be 
called healthy, or even habitable with any degree of safety." 

Our time will not allow of my extracting any further evidence on this point ; one 
circumstance of contrast, however, I am unwilling to omit. i 

The river Tagus is, at Lisbon, about two miles broad ; and it separates a healthy i 
from a very unhealthy region. On the one side is a bare hilly country; the founda- 
tion of the soil, and of the beds of the streams, being rock, with free open water- . 
courses among the hills. This is the heakhy side. But the Alentejo land, on the 
other side, though as dry superficially, being perfectly flat and sandy, is most pesti- j 
ferous. Moreover, in and near Lisbon there are numerous gardens, where they keep \ 
water, durins^ the three months' absolute drought of the summer season, in stone i 
reservoirs. These reservoirs, containing water in the most concentrated state of foul- I 
ness and putridity, are placed close to the houses and sleeping rooms : the inhabitants I 
literally live and breathe in their atmosphere. " Yet no one ever heard or dreamt; | 
of fever being generated amongst them from such a source ; though the most igno- | 
rant native is well aware that were he only to cross the river, and sleep on the sandy I 
shores of the Alentejo, where a particle of water at that season had not been seen 
for months, and where water, being absorbed into the sand as soon as it fell, was 
never known to be putrid, he would run the greatest risk of being seized with re- 
mittent fever." j 

Now these facts, and facts hke these, seem to prove that the malaria, and the pro- | 
duct of vegetable decomposition, are two distinct things. They are often in company 
with each other, but they have no necessary connection. Whoever, in a malarious 
country, waits for the evidence of putrefaction, will wait, says Dr. Ferguson, too long. 
For producing malaria it appears to be requisite that there should be a surface capa- j 
ble of absorbing moisture, and that this surface should be flooded and soaked with 
water, and then dried : and the higher the temperature, and the quicker the drying 
process, the more plentiful and the more virulent (more virulent probably because 
more plentiful) is the poison that is evolved. 

The putrefaction of animal matter is sometimes spoken of as an element in the 
formation of the malarious poison. But the evidence I have just set before you re- 
futes this supposition as completely as it excludes the alleged necessity of vegetable 



INTERMITTENT FEVER. 



445 



decay. I hope to prove to you, in a future part of the course, that neither animal 
nor vegetable decomposition is sufficient to generate fever of any kind. 

Dr. Ferguson's facts are generally in accordance with the observations which 
others have made upon the same subject : and his views will be found to account for 
some phenomena which the ordinary theory of vegetable putrefaction did not cleverly 
explain. 

There is good reason for believing that in all cases the poisonous emanations pro- 
ceed from parts of the surface that have been flooded and then dried, rather than 
fi-om parts that are still wet, or putrid. And this elucidates a circumstance very 
often noticed, viz., that neighbouring places — especially high and low lands lying 
near each other — change iheir character in respect to salubrity upon the occurrence 
of rains. The low grounds, which had previously been very dangerous, become 
healthy when they are flooded over : and the higher lands, which are made wet, 
and which rapidly dry again, produce the malaria abundantly. For the same reason, 
the edges or borders of swamps, which of course expand or contract according to 
^the wetness or dryness of the season, are more unsafe than their centres. The 
drying and half-dried margins of the purest streams may be prolific of the evil, when, 
from the want of confining banks, those margins have been flooded by the rising of 
the waters. ^ 

There is no observation more general than that, in malarious places, agues and 
remittent fevers abound more in hot and dry years than in those which are cold and 
moist. And this influence of temperature it is which mainly determines the differ- 
ences observable in regard to these fevers at different elevations, and in different 
seasons of the year. In the higher grounds of the West Indies agues occur as in 
this country: as you descend, and the mean atmospheric temperature increases, 
remittents are met with : and in the lowest and hottest parts the fever becomes con- 
tinued. The following instructive facts are stated by Dr. Ferguson. In 18 1(5, the 
British garrison of English Harbour, in Antigua, was disposed in three separate 
barracks, on fortified hills surrounding, the dock-yard. One of the barracks was on 
ah eminence named Monk's Hill, six hundred feet above the level of the marshes. 
The other two were situate on an eminence called the ridge, one at the height of five 
hundred, and the other at the height of three hundred feet. So pestiferous were the 
marshes among which the dock-yard was placed, that it often happened to a well- 
seasoned soldier, coming down from Monk's flill, and mounting the night-guard in 
perfect heakh, to be seized with furious delirium while standing sentry, and to ex- 
pire within less than thirty hours after being carried up to his barracks, with a yellow 
skin, and having had black vomiting. Those in the barracks on Monk's Hill who 
did not come down, the superior officers, the women, children, and drummers, had 
no fever of any kind. Seventeen artillerymen, in the barrack at the height of three 
hundred feet, did not come down to the night-guards. (We shall see hereafter that 
malarious places are always most dangerous at night.) Every one of these men 
was attacked with remittent fever, of which one of them died. At the barrack on 
the top of the ridge, at the height of five hundred feet, there scarcely occurred any 
fever worthy of notice. Thus, in the same place, the malaria, in the level plain, 
caused continued fever, resemhling, and I believe identical with, yellow fever : at the 
elevation of three hundred feet it gave rise to remittent fever ; and at the height of 
five hundred or six hundred feet its influence was scarcely felt at all. In the neigh- 
bourhood of the Pontine marshes you see the villages perched curiously on the inter- 
vening hills ; the Itahans having been taught by experience that these elevated spots 
afforded comparative security against the effects of the miasmata. 

Wherever the malaria prevails, it produces its peculiar consequences chiefly in 
certain seasons : and it is in the autumn especially that agues and aguish fevers occur; 
that is to say, after the heats of summer : and the hotter and drier the preceding 
summer, the more frequent and fatal are the autumnal fevers. The Pontine marshes 
lie to the southward of Rome ; and Horace, yo-u know, says or sings, 

Frustra per autmnnos nocentetn 
Corporibus metuemus austrum. 

3n 



446 



INTERMITTENT FEVER. 



The effects of these morbific effluvia upon the human body vary much under dif- 
ferent circumstances. Where they are most concentrated and deadly, their opera- 
tion may be almost immediate. Witness their speedy influence upon the soldiers 
who descended at night from Monk's Hill. So also sailors, who have gone on shore 
for a single night only, have been attacked by the fever before they could return to 
the ship. On the other hand, when the emanations are less copious, or Jess virulent, 
there is sometimes a long and uncertain period of incubation. The disease remains 
latent, or the poison lies dormant, for a considerable space of time. Many of the 
soldiers who were exposed to the malaria at Walcheren did not experience its bad 
effects until after they had returned, and had even resided several months in England. 
In the same way, labourers, especially the itinerant Irish, will go down in the 
autumn for harvest work into Lincolnshire, and bring back the seeds of the disorder 
within them, and yet may not be attacked with ague for weeks or months ; upon 
the occurrence of an east wind perhaps, or after unusual exposure to cold and wet. 
We trace in all this some analogy with the animal contagions ; but the period of 
incubation is more irregular and accidental ; and it is probable that in many instances 
the ague would not happen at all, but for the concurrent operation of some other 
mahgn influence. 

Another fact worthy of notice in respect to the agency of the malaria upon the 
human frame, is that it aflects strangers much more readily and decidedly than the 
natives of the place. In other words, habit mitigates the injurious effects of the 
poison. Persons become seasoned to it. At Walcheren, though almost every adult 
among the lower classes had laboured, in the course of his life, under the endemic 
intermittent, yet they were infinitely less subject to it than strangers : and they will 
not believe that their beloved birth-place is unhealthy. Sir Gilbert Blane says that 
persons of education, and even medical men, denied indignantly that their country 
was less healthy than any other ; and attributed the sickness which raged among our 
troops to some trivial circumstances of diet or habits, and not to any insalubrity of 
the air. This is a curious moral feature ; but a very general one. In the pestilen- 
tial plains of Estremadura the superstitious natives, unable or unwilling to account 
for a disease of a type so uncommon, among the soldiers, from any unwholesomeness 
of the air, declared that they had all been poisoned by eating mushrooms. 

It was found, also, at Walcheren, that the strangers who survived the first attacks 
became thereafter much less liable to the endemic fevers. The French general, 
Monnet, who had held the command at Flushing for seven years, had acquired a 
knowledge of this fact, and endeavoured to turn it to practical account. He recom- 
mended that troops should not be frequently changed ; for when it was the custom 
to send battahons from Bergen op Zoom every fourth night in succession, to work on 
the lines of Flushing, these men never failed, upon their return, to be taken ill in 
great numbers. General Monnet therefore advised, however displeasing it might be 
to the officers, that a stationary garrison should be retained at Walcheren, in order 
that the men might be habituated or seasoned to the air {acclimates,) and he adduced i 
the instance of a French regiment which suffered in the second year of its being i 
stationed there only one-half the sickness and mortality which it suffered during the 
first year ; and hardly suffered at all in the third year. , 

But although the natives and residents in malarious places are not so liable as new j 
comers to the violent and distinct forms of fever, they are chronically affected by | 
the insalubrity of the atmosphere. They are spoken of by travellers as being puny, ; 
sallow, and sickly ; feeble in body and spiritless in mind ; as having yellow faces, 
swelled bellies, and wasted limbs ; as being subject to dropsies and fluxes ; phleg- \ 
matic, melancholy, and short-lived. j 

One remarkable exception is mentioned by Dr. Ferguson. From some peculiarity ! 
or idiosyncrasy (which he conjectures may be somehow connected with the texture 
of the skin) the negro appears to be proof against endemic fevers. " To him marsh ' 
miasmata are in fact no poison ; and hence his incalculable value as a soldier, for 
field service, in the West Indies. The warm, moist, low, and leeward situations ; 
where these pernicious exhalations are generated and concentrated, prove to Mm \ 
congenial. He delights in them, for there he enjoys life and health, as much as his j 



INTERMITTENT FEVER. 



447 



feelings are abhorrent to the currents of wind that sweep the mountain tops, where 
alone the whites find security against endemic fevers." 

No very certain or extensive observations have yet been made in respect to the 
kind of soil from which the miasmata are most apt to be extricated. Such as is 
loose, penetrable, porous, and sandy, appears highly favourable to their formation. 
So are soils which, containing much clay, are very retentive of moisture. One 
curious fact, however, bearing upon Ihis question, seems to have been made out: 
viz., that what is termed peat-bog, or peat-moss, is not productive of malaria. Many 
parts of Scotland and of Ireland, that are occupied by large tracts of marsh in which 
the peat-moss abounds, are completely free from these fevers. Dr. Bisset affirms 
that the exhalations from black peat-moss do not occasion intermittents, " at least in 
high moors under a clear sharp air." Now in the cHmate of Virginia, this counter- 
acting influence of a sharp air can scarcely be looked for : yet it is a remarkable fact, 
that though the provinces of North America, especially North and South Carohna 
and Virginia, are full of ague, that disease is never seen among the inhabitants near 
the country of the Dismal Swamp, a moist tract of 150,000 acres on the frontiers 
of Virginia and North Carolina. Weld, the traveller, informs us, that this immense 
tract is covered with trees and abounds with water, which appears the moment the 
shallowest trench is dug. The water is brown, like brandy, but quite clear, and not 
unpalatable. Its colour is ascribed by the inhabitants to the roots of juniper; and 
it is said to be diuretic. (Craigie.) 



LECTUHE XLI. 

^gue, continued. Speculations respecting its periodicity. Habits and properties 
of the malaria ; most noxious at night ; lies near the ground ; is carried along 
by winds ; cannot pass across water ; attaches itself to trees ; is diminished by 
the increase of cultivation and of population. Ultimate effects of the poison on 
the body. Ague formerly thought salutary. Prognosis. Propriety of stopping 
the disease. , 

You will remember the progress we made, at our last meeting, in the subject of 
intermittent fever. I described the ordinary phenomena of a paroxysm of ague ; 
and afterwards mentioned certain unusual symptoms with which it is sometimes 
complicated. The three principal types of ague were also delineated ; the quotidian, 
the tertian and the quartan : as well as their respective characters, and intervals, and 
varieties, and changes of type. I spoke, too, of the predisposing causes of inter- 
mittent fever, which may all be briefly included under the head of circumstances 
that tend to debihtate the body: the strongest predisposing cause of all being a 
former attack of the disease. And I began to consider the great exciting cause of 
agues and aguish fevers — the malaria. I first directed your attention to the circum- 
stances under which the malaria appears to be evolved. Since the time of Lancisi 
it had been very generally supposed that the humid putrefaction of vegetable sub- 
stances was necessary to the production of this pecuhar and wide-spread poison ; and 
that heat accelerated the putrefactive process. That was Dr. Bancroft's opinion. 
That also is (I believe) the opinion held, and stated in lectures, by many pathologists 
at the present time. I showed you, from facts which rest upon Dr. Ferguson's 
authority, that this notion is founded in mistake : that the products of the vegetable 
decay and decomposition may and do often coexist with malaria, but are distinct and 
separable from it, and by no means essential to its formation. There is reason to 
beheve that the flooding of a porous earthy surface with water, and a subsequent 
drying of that surface , under a certain degree of heat, constitute the sole or main 
conditions of the generation of the poison. ' We found that the effects of the malaria 
are modified by the temperature of the place : that in low and hot situations it may 



448 



INTERMITTENT FEVER. 



give rise to an affection not distinguishable in its symptoms from yellow fever; and 
that in proportion as the locality is higher and cooler, the fever tends to assume first 
the remittent, and then the intermittent type : that the period of incubation — the 
period which intervenes between exposure to the malaria and the invasion of the 
fever — is extremely variable in duration : that the poisonous effluvia affect strangers 
more certainly and more severely than natives of the place : that persons may be- 
come in some sort seasoned to the malarious districts : but that, with the exception 
of the negroes in the West Indies, the inhabitants of places much infested with the 
peculiar miasmata, are feeble, and sickly, and short-lived. 

There was one point which I briefly adverted to, and dismissed perhaps too un- 
ceremoniously : I mean the very curious fact of the regular periodic recurrence of 
the paroxysms of intermittent fever. I ought, I think, to have informed you of the 
views which pathologists have entertained respecting the explanation of that singular 
circumstance ; although it must be confessed that the solution of the phenomenon is 
still to be sought for. A great number of persons have tried their hands, however, 
upon this question. Many of the earher attempts at explanation are either quite hy- 
pothetical, or totally insufficient and illogical. WilKs ascribed the intermission to a 
periodic development of the fermentable matter in the blood. But if any such de- 
velopment took place (of which we have no evidence) we should be no nearer the 
mark : the question would still recur, why the development of this matter should 
happen periodically : and the same remarks apply to various other so-called expla- 
nations brought forward by different writers of considerable reputation. Reil referred 
the intermittence of fevers to some general law of the universe ; by which he meant, 
I believe, some vague generalization of such facts as the alternation of light and 
darkness, the periodic recurrence of the seasons, the ebbing and flowing of the tides, 
the succession of appetite and satiety, of the states of sleeping and waking, and so 
on: but this evidently is no explanation at all. M. Bailly offers a very singular 
conjecture upon the subject : he attributes the periodic phenomena to the modifi- 
cation necessarily induced in the human system, and particularly in the function of 
circulation, by the akernate change of position from the upright to the recumbent, 
and from the recumbent to the upright, every twenty-four hours ; and he adduces in 
corroboration of this notion the alleged fact that animals, which undergo no such os- 
cillation of posture, are not subject to intermittent fevers ; but this is said not to be a 
fact. Rodet and Charpentier affirm that horses are liable to such complaints. Dr. 
MaccuUoch refers to the case of a dog which laboured under a regular tertian ague 
for some years; the cfeld paroxysms taking place always at three o'clock in the 
afternoon. Even if this were not so, M. Bailly's theory fails to account for the oc- 
currence of continued fevers. If his views were correct, then we might avoid 
having ague by refraining from these changes of position from the vertical to the 
horizontal during sleep, and back again upon awaking. Recently M. Roche has 
put forth the opinion that the attacks of ague are periodic, because the causes of 
them are periodic. And if this could be made out, the conjecture would carry with 
it some show of reason. He observes that the spring and the autumn are the 
seasons in which intermittent fevers chiefly break out, especially the autumn : and 
that during those periods there is a very sensible difference in the temperature and 
humidity of the atmosphere by day and by night, and even within the space of three 
or four hours ; that a consequent alternation of action and reaction is thus produced 
in the human body, and soon becomes an established habit. Throughout a part of 
the twenty-four hours, the operation of the miasmata is shght, or not manifest at all ; 
while during another part of that period it is in full energy, and at about the same 
time daily.. The emenations (which he conceives to proceed from putrefying vege- 
ble matter) are inost abundantly disengaged during the hottest part of the day ; these 
watery effluvia are dissolved by the warm air to a certain amount ; but after sunset, 
they are again deposited, and deposited the more copiously in proportion to the cold- 
ness of the atmosphere at that time ; and coming in contact with the surface of the 
body, with the mucous membrane of the air-passages, and perhaps also with that of 
the digestive organs, and being absorbed by those surfaces, it occasions the phe- 



MALARIA. 



449 



nomena which constitute an ague fit. The influence of the miasmata being inter- 
mittent, we need not wonder, he says, that their effects should be intermittent too : 
and then he goes on to ascribe the repetition of the paroxysms, after the cause has 
ceased to be apphed, to that tendency observable in the animal system to reproduce 
certain actions, simply because they have been produced before ; in one word, to 
the effect of Imbit. At length the habit wears out ; which accounts for the sponta- 
neous recovery of those who are removed from the malarious district. 

It seems to be a very serious objection to M. Roche's theory, that the disease does 
not show itself, sometimes, for weeks or months after the patient has been ex- 
posed to the miasmata. His theory fails altogether also to account for the dif- 
ferent types of intermittent fever. The differences of type are indeed opposed to the 
theory. 

After .all it is most probable that CuUen had discovered a part though not the 
whole of the truth respecting the periodicity of intermittent fevers, when he 
ascribed it to some law of the animal economy whereby it is subjected in many 
respects to a diurnal revolution. " Whether this depends," he says, " upon the 
original conformation of the body, or upon certain powers constantly applied to it, 
and inducing a habit, I cannot positively determine ; but the returns of sleep and 
watching, of appetites and excretions, and the changes wliich regularly occur in the 
state of the pulse, show sufficiently that in the human body a diurnal revolution takes 
place." But he also is much perplexed with the differences of type ; and all that 
he can say on that point amounts to this — that as the three principal types observe, 
severally, a particular time of day for their accession, and as quartans and tertians 
are apt to become quotidians, these to pass into the state of remittents, and these 
last to become continued ; and that as even in the continued form daily exacerba- 
tions and remissions are generally to be observed — all this marks the power of di- 
urnal revolution. 

A most interesting experiment, as it appears to me, performed by M. Brachet 
upon himself, shows in a strong hght the influence of acquired habit in continuing 
certain imnatural states of the system when once they have been originated : the ex- 
periment connects itself also with the pecuHar phenomena of intermittent fever. 
Towards the end of the month of October, in the year 1822, M. Brachet took a cold 
bath at midnight, for seven nights in succession, in the river Saone. On the first oc- 
casion he remained a quarter of an hour in the river; on the second, half an hour; 
till at length he was able to stay in the water a full hour at a time. After each bath 
he betook himself to a warm bed, and in a short time became affected with consider- 
able heat, followed by copious perspiration, in the midst of which he fell asleep. 
At the end of the seven days iVI. Brachet ceased to repeat this experiment ; but what 
was his surprise at finding, on the following nights, between twelve and one 
o'clock, that all the phenomena of a true ague fit appeared in due order and suc- 
cession ! As, however, this artificial paroxysm was not very severe, and as he felt 
quite well during the day, M. Brachet determined not to interfere Avith it ; but to 
observe the result. Six times it recurred with great regularity. On the seventh 
night after he had omitted the baths, he was summoned, towards midnight, to a 

woman in labour : the ride to her house heated him, and on his arrival he kept up 

the heat by placing himself before a large fire, and from that time the febrile phe- 
nomena ceased to recur. 

The facts and theories which I havfi thus brought roughly together, in respect to 
the periodicity of agues, are not without interest, but they show that we. have yet 
much to learn on this subject. Granting that habit may have its share in continuing 
the regular recurrences, we want some explanation of the return of the second and 
third fit, after certain determinate intervals, to give a beginning to the habit. In 
respect to the quotidian. Dr. Cullen's diurnal revolution might come to the rescue : 
but this principle evidently will not apply to the tertian type. I know of no two- 
day, or bidual habit. And the objection holds still more strongly in regard to quar- 
tans. Indeed in quotidians themselves there is much difficulty in applying the ex- 
planation, for though by anticipating, or postponing, they may come on at different 
hours of the day, yet their usual and natural paroxysms occur, not in the evening, 
39 3n3 



450 



INTERMITTENT FEVER. 



but in the morning, when, on the principle of diurnal habit, there should be the least 
tendency to exacerbation of febrile action.* 

In yesterday's lecture, I pointed out the favourite habitats^ if I may so speak, of 
the malarious poison. I have still a few observations to make respecting its ascer- 
tained habits and properties. Some of the laws to which it is subject are of great 
practical importance, and ought to be popularly known ; much more ought every 
medical man to be familiar with them. 

\n the first place, all malarious districts are (as I have already hinted) much more 
dangerous at night than in the day-time. Whether the poison be then more copi- 
ously evolved, or whether it be merely condensed and concentrated by the dimi- 
nished temperature, or whether the body be at that time more susceptible of its influ- 
ence, it certainly is most active and pernicious during the hours of darkness. To 
sleep at night in the open air in such places is almost to ensure an attapk of the 
fever. Lancisi was quite aware of this, and devotes a chapter to the question, "Cur 
juxta paludes noctu prsesertim indormientes magis quam vigilantes Isedantur ?" It 
has repeatedly been observed among the crews of ships, when off a malarious coast, 
that the sailors could go on shore in the day to cut wood, or for other purposes, with 
impunity ; while the men who remained on shore through the night, guarding the 
water-casks, were many or all of them seized with the fever. Take one instance as 
a sample of many. It is recorded by Dr. Lind. In 1766 the Phcenix ship of war 
was returning from the coast of Guinea. The officers and ship's company were 
perfectly healthy till they touched at the island of St. Thomas. Here nearly all of 
them went on shore. Sixteen of the number remained for several nights on the 
island. Every one of these contracted the disorder, and thirteen of the sixteen died. 
The rest of the crew, consisting of 280 men, went in parties of twenty or thirty on 
shore in the day, and rambled about the island, hunting, shooting, and so on : but 
they returned to the ship at night ; and not one of those who so returned suffered 
the slightest indisposition. Exactly similar events occurred the following year, with 
the same ship, at the same place, where " she lost eight men out of ten, who had 
imprudently remained all the night on shore while the rest of the ship's com- 
pany, " who, after spending the greatest part of the day on shore, always returned 
to their vessel before night, continued in perfect health." Many more examples of 
the same kind are stated or referred to by Dr. Bancroft in his book on the Yellow 
Fever : a book which is rich in information respecting the malaria. 

The reapers in the "Campo Morto" — a well-named part of the Maremna which 
I yesterday mentioned — are permitted to sleep for two hours about noon. They 
do so at that time without danger : but when the dews of evening have fallen down 
upon the earth, which serves them for their bed, it is then that the poison puts forth 
its most deadly power. Upon this principle Lancisi admonishes those who in sum- 
mer travel through the Pontine marshes, not to do so by night, as many had been 
accustomed to do, in order to avoid the greater heat of the day : and similar advice 
is still given at Rome to all strangers. Though the passage requires but. six or eight 
hours, there are numerous instances of travellers who, in consequence of their having 
crossed these fens during the night, have been attacked with violent and mortal 
fevers. 

The practical lesson to be derived from a knowledge of this fact is too obvious to 
dwell upon. In malarious countries the open air at night must be avoided. — "Early 
to bed" is always a good and wholesome mle ; but the other half of the proverb, 
" early to rise," becomes, in such countries, an vmsafe precept. At least it is hazard- 
ous to leave the house early. 

Secondly, the malaria loves the ground. It tends downwards. Whether this 
results from its specific gravity, or from its adhering to the moisture suspended in 
the lower strata of the atmosphere, or from some peculiar attraction for the earth's 
surface, I cannot tell you. There is reason to suppose that the poison combines 
somehow, or becomes entangled, with fog : and fogs usually brood and settle, at 

* I would beg to refer the reader to Dr. Holland's interesting chapter (in his Medical Notes 
and Reflections, imhlishecl since these lectures were delivered) "On Morbid Actions of Intei' 
injttent kind." — T. W. 



MALARIA. 



451 



night especially, upon the surface. This ma.j be one reason why Imnsi; down to 
sleep in the open air at night is so very perilous. The lower rooms of the same 
house may contain the noxious effluvia, while the upper are free. "In all malari- 
ous seasons and countries," says Dr. Ferguson, " the inhabitants of ground Jloors 
are uniformly affected in a greater proportion than those of the upper stories. Ac- 
cording to official returns during the last sickly season at Barbadoes, the proportion 
of those taken ill with fever in the lower apartments of the barracks exceeded that 
of the upper by one-third, throughout the whole course of the epidemic. At the 
same time it was observed that the deep ditches of the forts, even though they con- 
tained no water — and still more the deep ravines of rivers and water-courses — 
abounded with the malarious poison." Dr. Hunter, in his work on the diseases of 
the army in Jamaica, says,' " The barracks of Spanish Town consist of two floors, 
the first upon the ground, the second on the first. The difference in the health of 
the men on the two floors was so striking as to engage the attention of the Assembly 
of the island : and upon investigation it appeared that three were taken ill on the 
ground floor, for one on the other. The ground floor was not therefore used as a 
barrack afterwards." Mr. Ealph, in a table printed as an appendix to a paper of 
Dr. Ferguson's in the eighth volume of the Medico- Chirurgical Transactions, states 
the results of an inquiry into the comparative healthfulness of the upp'er and lower 
apartments of barracks in Barbadoes, to have been that the individuals residing in 
the lower apartments were attacked in the proportion of two to one of those living in 
the upper: and with certain apparent exceptions, which I shall notice presently, 
experience is uniformly in favour of the proposition that the poison is most preva- 
lent and destructive near the surface of the earth, and does not rise high into the 
atmosphere. 

To specify the sanatory precautions dictated by an acquaintance with this pro- 
perty of the malaria, must be quite superfluous. 

Thirdly, the malaria is movable by the wind. It is capable, therefore, of being 
carried from the spot where it was generated, and to other places which might else 
be free from it and healthy. In this respect it is analogous to a heavy fog or vapour: 
and, in some cases, it is accompanied by a palpable mist ; to which, perhaps, it may 
chng. The following passage relative to this subject occurs in Bishop Heber's 
Journal. " From Cheeta Talao our road lay through a deep and close forest, in the 
lower parts of which, even in the present season, the same thick milky vapour was 
hovering as that which I saw in the Terrai, and which is called essence of owL^^ 
This Terrai is the region which I mentioned in the last lecture as being so pestife- 
rous, that it is deserted, during certain parts of the year, by every living creature. 

This conveyance of the poison, like a cloud or fog, from one part of the surface 
of the ground to another, it is very important to attend to in all places ; and espe- 
cially so in tropical climates, where the wind blows for a long time together from 
the same quarter. We are thus enabled to account for the apparent exceptions to 
the last-mentioned property of the malaria, viz., its preference of low to elevated 
situations. You will readily understand how the miasmata may roll up, and hang 
accumulated upon, the side of a hill towards which a current of air sets steadily from 
or across a neighbouring marsh. Nay, the poison may be thus blown over a hill^ 
and deposited on the other side of it. In this way, I presume, are to be explained 
the following curious facts, related in Dr. Ferguson's paper. 

The beautiful port of Prince Rupert's, in the island of Dominica, is a peninsula 
which comprehends two hills of a remarkable form, joined to the main land by a flat 
and very marshy square isthmus to ivindward, of about three-quarters of a mile in 
extent. The two hills jut right out on the same line into the sea, by which they 
are on three sides encompassed. The inner hill of a slender pyramidal form, rises 
from a narrow base nearly perpendicular, above and across the marsh from sea to 
sea, so as completely to shut it out from the port. The outer hill is a round-backed 
bluff pronaontory, which breaks off abruptly, in the manner of a precipice above the 
sea. Between the hills runs a very narrow clean valley, where all the estabhsh- 
ments of the garrison were originally plf;ced; the whole space within the peninsula 
being the driest, the cleanest, and the healthiest surface conceivable. It was speedily 



452 



INTERMITTENT FEVER. 



found that the barracks in the valley were very unhealthy ; and to remedy this fault, 
advantage was taken of a recess or platform near the top of the inner hill, to con- 
struct a barrack which was completely concealed by the crest of the hill from the 
view of the marsh on the outside, and at least three hundred feet above it : but it 
proved to be pestiferous beyond belief In fact no white man could possibly live 
there, and it was obliged to be abandoned. At the time this was going on, it was 
discovered that a quarter which had been built on the outer hill, on nearly the same 
line of elevation, and exactly five hundred yards further removed from the swamp, 
was perfectly healthy ; not a single case of fever having occurred in it from the time 
it was built." 

There is a striking anecdote given by Lancisi, showing, on a small scale, the effect 
of the wind in carrying the malaria with it. Thirty ladies and gentlemen had sailed 
to the mouth of the Tiber on an excursion of pleasure. Suddenly the breeze shifted 
to the south, and began to blow over a marshy tract of land situated to windward of 
them. Twenty-nine of the thirty were immediately after attacked with tertian 
ague. So also Humboldt informs us that the town of Cariaco is afflicted with inter- 
mittents by the north-west wind conveying across it the miasmatic emanations of the 
Laguna of Campona. 

And as the wind may thus transport the malaria to a distance, and thereby render 
a spot unheakhy which naturally would not be so : so also it is often of service in 
clearing the poison from other places, and preventing its concentration. ■ 

A knowledge of these facts ought to be valuable in determining the choice of 
encampments, and of sites for dwelling-houses in aguish districts. Settlers in hot 
climates, especially where trade-winds prevail, would do well to avoid founding towns 
on the lee side of any swampy or suspicious ground. The outlets of rivers are 
commonly selected, for the convenience of commerce : and there is often a right and 
a wrong bank. I believe that most of the principal towns in the West Indies are 
bulk, for the advantage of the outward-bound vessels, upon the western, or lee side 
of the island. 

Fourthly, it is a singular, but well-ascertained fact, that the miasmata lose their 
noxious properties by passing over even a small surface of ivater. Probably they 
are absorbed by it. And this is another proof of their tendency downwards. Many 
instances have already been referred to, where some of the crew of a ship have 
landed on a malarious coast, and have all been attacked by the fever; while the rest 
of the sailors, who remained on board, continued all healthy and well, though the 
ship was close to the shore. You could not have a better or more striking example 
of this than what took place at VValcheren. "Not only the crews of the ships in 
the road of Flushing were entirely free from the endemic; but also the guard-shijs 
which were stationed in the narrow channel between this island (Walcheren) ai d 
Beveland. The width of this channel is about six thousand feet, yet, though some 
of the ships lay much nearer to one shore than to the other, there was no instance of 
any of the men or officers being taken ill with the same disorder as that with vc^hich 
the troops on shore were affected." This Sir Gilbert Blane has told us ; and it is 
curious that Sir John Pringle made the very same remark in the very same place in 
1747. He is speaking of the diseases of the campaign in Dutch Brabant; espe- 
cially in reference to four battahons which had remained for some time in Zealand : 
and "he says, " But Commodore Mitchell's squadron, which lay all this time at anchor 
in the channel between South Beveland and the island of Walcheren, in both which 
places the distemper raged, was neither afflicted with the fever nor the flux, but 
amidst all that sickness enjoyed perfect health ; a proof that the moist and putrid air 
of the marshes was dissipated, or corrected, before it could reach them." 

It is probable that this peculiarity has led to an erroneous and contracted estimate 
of the space through which the poisonous effluvia can be carried upon land, by the 
wind. Although the distance to which they are capable of being so conveyed, 
without losing their morbific power, has never been precisely defined, there can be 
no doubt that it is considerable. In Italy, according to Dr. Macculioch, the poisonous 
exhalations of the lake Agnano have been ascertained to reach as far as the convent 
of CamaldoU, situated on a high hill three miles distant. 



MALARIA. 



453 



Fifthly, another remarkable property of the marsh poison, is its attraction towards, 
and its adherence to, the foliage of lofty umbrageous trees: so that it is very danger- 
ous, in malarious places, to go under large thick trees, and still more dangerous 
to sleep under them. But this property, thus a source of peril to those who are 
ignorant of it, affords when known and rightly made use of, a mode of protection 
and remedy against the influence of the miasmata. In the territory of Guiana, 
where large trees abound, the settlers live fearlessly, and unhurt, close to the most 
pestiferous marshes, and to leeward of them, provided that a screen or belt of trees 
be interposed. New Amsterdam, in Berbice, hes on the lee side of an immense 
swampy forest, in the direct tract of a strong trade-wind that blows night and day, 
and pollutes even the sleeping apartments of the town with the stench of the marshes ; 
yet it brings no fevers. The inhabitants are well aware that it would be almost 
certain death for an European to sleep, or even to remain after nightfall, within the 
verge of the forest. To cut down the trees would not only be a perilous operation 
in itself ; but would let in pestilence to the town. 

This property also of the malaria, as well as the use to which it may be turned, 
was known to Lancisi. He describes the vast increase of agues and remittent fevers 
in Rome during the summer of 1695, after a great overflowing of the Tiber, by 
which the lower part of the city, and the fields adjacent, had been inundated in the 
preceding winter. The bad effects of this flood were felt throughout the whole of 
Rome, with the exception of one particular quarter, which was protected by a belt 
of trees around it. Lancisi even addressed a remonstrance to the Pope against a 
project which was entertained of feUing some wood near the Pontine marslies, be- 
tween them and the city. He endeavours to show that woods and groves were first 
made sacred on account of their conservative influence in this way, to prevent their 
ever being cut down. 

It would appear, from the facts I have just been detailing, that dwellings unfortu- 
nately built in the vicinity of marshes, might sometimes be rendered safe and salu- 
brious by encircling them at a httle distance by a hedge of trees — or (perhaps) even 
by drawing round them a broad moat of water. Such experiments deserve, at least, 
a fair trial. 

Sixthly, the production and consequently the effects, of the malaria are prevented, 
or lessened, by cultivation. It is to this, that the diminution of agues in this country 
is mainly attributable. The fenny lands have been drained ; and many of them 
brought under the plough. Dr. Craigie states that East Lothian, in Scotland, was 
at one time so productive of malaria, that it was quite an expected thing that the 
reapers in harvest should be attacked with ague ; but that nov/, in consequence of 
the perfect tillage, and the numerous tracts of wood with which the country is 
cohered, that disorder is quite unknown there. Conversely, in regions which have 
been suffered to fall out of cuhivation, intermittent and remittent fevers multiply. 
The more thoroughly any country is cultivated, the more fully, in general, it is 
peopled also : and in many places the prevalence of these fevers has been observed 
to diminish and increase wath the increase and diminution of the population. Cdeteris 
paribus, agues are much less common in large towns than in country villages. This 
has been oddly enough accounted for by saying that populous cities are so full that 
there is no room for the malaria. A much more rational and probable explanation is 
that which ascribes the freedom of crowded towns, and thickly inhabited districts, to 
the number of fires burned in them. 

Many instances might be adduced to show that the more any place naturally pro- 
ductive of malaria, is depopulated, the more evident does the power of the poison 
become. The Italians date the introduction of the malaria into the Maremna, from 
the great plague in the sixteenth century, since which period the inhabitants of that 
district have never been sufficiently numerous to counteract the bad air which in- 
creases as population and agriculture diminish. 

Bishop Heber, in the narrative I quoted before, bears testimony to facts of the 
same kind with those I have now been stating. He says, " At the foot of the lowest 
hills, a long black level line extends, so black and level, that it might seem to have 
been drawn with ink and a ruler. This is the forest, from which we are still re- 



454 



INTERMITTENT FEVER. 



moved several coss, though the country aheady begins to partake of its insalubrity. 
It is remarkable that this insalubrity is said to have greatly increased in the last 
fifteen years. Before that time, Ruderpoor, where now the soldiers and servants 
of the Police Thanna die off so fast that they can scarcely keep up the estabhshment, 
was a large and wealthy place, inhabited all the year through, without danger or 
disease. The unfavourable change is imputed by the natives themselves to depopu- 
lation. The depopulation of these countries arose from the invasion of Meer Khan, 
in 1805. He then laid waste all these Pergunnahs, and the population, once so 
checked, has never recovered itself." 

When persons having intermittent fever are unable to leave the unhealthy situa- 
tion in which they have been exposed to the influence of the malaria — and espe- 
cially when they are placed under unfavourable circumstances in respect to food, 
and clothing, and shelter — the disease is apt to become exceedingly serious, leading 
to disorder of the sensorium, and great disturbance of the abdominal viscem, even 
in the intermissions ; sickness, diarrhoea, dysentery, diseases of the liver. 

[Dr. S. A. Cartwright, of Natchez, asserts, that ilie jussieiia grandiflora, or floating plant of 
the bayous and lakes of lower Louisiana, has the power of preventing the development of 
malaria in regions particularly adapted to its generation. He affirms, also, that "it purifies 
all stagnant water in which it grows — that of the lakes and bayous inhabited by it, being as 
pure to the sight, taste, and smell, as if it had just fallen from the clouds." He ascribes to 
the presence of and the peculiar "hygienic or health-preserving properties of this plant," the 
remarkable exemption of the inhabitants of lower Louisiana from "malarious or miasmatic 
diseases." ■ "The fact," he remarks, "that the region of country in which this aquatic plant 
abounds, is exceedingly healthy, can be established beyond cavil or dispute ; it nevertheless 
contains more stagnant water and swamps than any other inhabited district, of the same 
extent, in the United States." — C] 

In Zealand, the biliary functions suffer so much during the complaint, that it is com- 
monly known among the inhabitants of that country under the name of the gall fever. 
The frequent unnatural concentration of the blood in the internal parts may afford 
a reasonable explanation of these phenomena. When death takes place, morbid 
appearances present themselves such as might be expected : hepatic alterations ; 
inflammation and ulceration of the mucous membrane of the alimentary canal : but 
the most characteristic morbid condition produced by repeated attacks of, intermittent 
fever consists in enlargement of the spleen ; with or without induration of its sub- 
stance. That viscus is sometimes enormously increased in bulk, so as to be felt, 
and even its outhne seen through the integuments of the abdomen. It has been 
known to weigh nearly eleven pounds. So common is this state of the spleen, that 
it is famihar to the observation of the vulgar, who have even given it a name : it is 
called among the inhabitants of the fenny parts of this country, the ague cake. I 
believe that whenever the abdominal circulation is much embarrassed, and the 
abdominal veins gorged, as they must be during the cold stage of an intermittent, 
the spleen in particular becomes distended with blood. Constantly we see this 
happen when the passage of the blood through the portal vessels is impeded by 
disease of the liver. Now this distension may not thoroughly subside perhaps at 
once. If the paroxysms of ague be frequently repeated, we may understand how 
the spleen may become fuller of blood on each successive occasion. It may be that 
a portion of the blood coagulates; or that inflammation of a slow kind is set up in 
the stretched covering of that organ. At all events, this is a very common sequel 
of ague ; and it can scarcely be doubted that the repeated congestions of the internal 
vessels and viscera are the determining causes of the ague cake. 

Independently of the paroxysm of ague, there is ample evidence to show the 
injurious influence of the malarious districts upon the general health. In this 
country such effects are not much seen ; but in places where the malaria is more 
constantly and abundantly present, the race of inhabitants deteriorates. Their 
stature is small; their complexion sallow and 3^ellowish ; they are prematurely old 
and wrinkled ; even the children early acquire an aged aspect ; and the spirits and 
intellects of those who dwell in these unhealthy spots are low and feeble, and par- 
take of the degeneration of their bodily quahlies. 



MALARIA. 



455 



It is therefore strange that a notion should ever have prevailed, of the salufiferous 
effects of an attack of ague. But such a notion may be traced from very nearly 
our own times up to the earliest records of physic. "The late Dr. James Sims, 
who v^^as a physician of some note in this town, felt convinced, at the commencement 
of the illness which terminated his life, that he should recover if he could catch an 
ague : and he went down into one of the marshy districts expressly for that purpose ; 
but returned to London without having succeeded, complaining that the country had 
been spoiled by draining, and that there were no agues to catch. The superstitious 
Louis XL entertained a similar opinion, and prayed to the Lady of Selles that she 
would confer upon him a quartan ague. Our monarch, James the First, had more 
sensible notions on that score. There is an old English proverb which says, 'An 
ague in the spring, is physic for a king ;' and when this was repeated to him by his 
courtiers, he, being then ill of that disease, answered that the adage might be appli- 
cable to a young man, but that it would not do for an old one hke him. In fact, as 
I mentioned before, he died of his ague. The same doctrine has, however, been 
handed down to us by the father of physic himself. Hippocrates says, in the fifty- 
seventh Aphorism of his fourth Section, vrto ^xasuov, ^ tstavov svoz'^iovfi^voi, Ttvpsto^ 
sitiysvofisvo^ xvsL to vovGrjy.a. And Celsus, in his capital digest of the medical know- 
ledge of his time, preserves the same opinion, with some apparent astonishment 
that it should be true. ' Denique ipsa febris, quod maxime mirum videri potest, 
ssepe preesidio est.' I recollect hearing Dr. Graham, the professor of botany in 
Edinburgh, relate the following anecdote in one of his clinical lectures. — His brother 
was intimate with the professor of natural history at Cremona; and this gentleman 
was resolved to put the truth of the aphorism that I have quoted from Hippocrates 
to the test. Accordingly he sent a patient afflicted with epilepsy, to pass a night or 
two in a marshy place, where the malaria was known to be so abundant and so 
powerful that fev/ escaped ague, who were there exposed to its influence, and the 
twofold design succeeded admirably. The patient got an ague, and lost his epilepsy. 
The worthy professor contented himself with moderating and keeping in check the 
new complaint, thus intentionally produced, for a period of six months, when he 
administered its coup de grace in a few doses of Peruvian bark ; and the epilepsy 
never returned. If I had believed that this could have been any thing more than a 
mere coincidence, I should have told you of it before, when I was speaking of the 
treatment of epilepsy. I should rather imagine the notion thus prevalent for so long 
a time, that ague had a salutary tendency, and that it was wrong to stop it too soon, 
to have originated in the difficulty which physicians found in stopping it, before its 
cause was so well understood, and the specific for it was discovered. They found 
it obstinate under the feeble and inert methods then employed, and therefore they 
endeavoured to persuade their patients, and perhaps themselves, also, that the disease 
had better proceed a certain length. 

I have very little to say, in addition to vv^hat you must have inferred from what I 
have already said, as to ihe prognosis in intermittent fevers. In cold countries, such 
as ours, it is almost always favourable. Of course it will be modified by the pre- 
vious condition of the patient : if he was beforehand the subject of serious organic 
visceral disease, or if he be very old or infirm, the supervention of ague may destroy 
him. But to persons of tolerable heakh and strength prior to the setting in of the 
ague, we may confidently promise a cure. In warm countries intermittent fevers 
are much more dangerous : and are sometimes very rapidly fatal. They are often 
accompanied by most severe affections of the head, stupor, dehrium, convulsions ; 
and of the ahmentary canal, diarrhoea, sickness, and not un frequently the black 
vomit. They are prone, also, in those climates, to run into the remittent or conti- 
nued form ; and this tendency is shown by long protracted paroxysms, or by the 
anticipation or doubling of the paroxysms. In all countries quartans are cured with 
more difficulty than either tertians or quotidians. And quartans are most common 
in the autumn : and accordingly autumnal intermittents are more pernicious and in- 
tractable than the vernal. This fact has passed into a proverb in Italy ; which 
proverb has been thus translated into Latin, " Febris autumnaHs — vel est longa, vel 
lethalis.'^ The longer intermittents have lasted, the more difficult also are they to 



456 



INTERMITTENT FEVER. 



cure : and certainly there is much more danger of visceral disease in those that are 
of long standing. 

It is probable that agues, such as we see in this country, would generally, under 
favourable circumstances, terminate in spontaneous recovery, provided that the 
patient could be put beyond the further operation of the malaria, protected from 
exposure to Avet and cold, and suitably nourished. But possessing as we do a spe- 
cific cure for ague, if there be such a thing as a specific, there would be no sense in 
our allowing the spontaneous recovery to be made : or rather we should be inex- 
cusable, knowing as we. do that the complaint is the more obstinate the longer it has 
lasted, and that it tends to, the establishment of organic visceral disease, we should 
be inexcusable if we did not stop it as quickly as we can. The disease is always 
distressing to the patient, and always debilitating. It may be dangerous, even in 
these climates, to weak or old persons : and it is dangerous to all persons in hot cli- 
mates. " If the first fit (says the wise and observant Heberden) has been marked 
so clearly as to leave no doubt of its being a genuine intermittent, the remedy should 
be immediately given in such a manner as to prevent, if possible, a second." There 
needs very little preparation of the patient before administering the specific substance 
which is to cure him ; and which every one here knows before he hears me say so, 
is the celebrated Peruvian bark, or its active principle as presented by the salts of 
quina. The old practice was to wait a few returns of the fits, either till some hypo- 
thetical ferment had taken place, or until supposed morbid matter had been expelled 
by vomiting or purging. There is, however, one very simple and short preparative 
which I am in the habit of using, and which I learned at Cambridge. You are 
aware that Cambridge is situated on the very edge of the fenny country which ex- 
tends along that part of the east coast of the island. Numerous patients afilicted with 
ague come in from the surrounding villages ; and Dr. Haviland found that many of 
these had taken quina before they applied for assistance as out-patients at the hospi- 
tal ; but with very poor success. Now these cases readily gave way — the patient 
remaining in all other circumstances as before — after the operation of a calomel 
purge. I have adopted this practice, therefore, upon his recommendation ; but it 
does not delay the specific treatment. I generally prescribe three grains of calomel 
with six or eight grains of rhubarb at bed-time, and commence with the quina the 
next morning. Very lately, in perusing the late Dr. Baillie's posthumous volume, I 
met with the following passage : — " i have known a good many cases in which bark 
alone would not cure an ague. In all these cases, as far as I now recollect, when a 
grain of calomel was given every night for eight or ten nights, bark cured the ague 
in the course of a few days. This practice I learned from my frtend Dr. David 
Pitcairn." 

I believe that calomel given once in a purgative dose is enough. 

But first of all what'is to be done for the patient while he \s in the fit ? I confess 
to you that I seldom give myself much concern on that head. In ague, as we see it 
in this country, nature generally prompts the patient what to ; to cover himself 
up in bed, and apply warmth to his feet, and to take some hot drink' during the 
rigors ; to adopt a cooler regimen during the hot stage ; to wipe his skin dry, if the 
sweating should be very profuse or protracted. But in hot countries, and in severer 
forms of intermittent, the patient really requires some help; and -therefore I must 
consider shortly in the next lecture the management of the paroxysm ; and I am the 
more bound to do so, because certain measures which I do not think necessary or 
judicious, at any rate for the complaint as we see it here, have lately been strongly 
recommended during the ague-fit. 



TREATMENT. 



457 



LECTURE XLII. 

Treatment of Intermittent Fever ; during the paroxysm ; during the intermis- 
sions. Prophylaxis. 

I WAS about, when we ]ast separated, to consider the treatment of a^e : first, 
during the paroxysm ; secondly, during the intermissions. 

In this chmate we need not, I say, encumber a patient in an ague-fit with too 
much help. But in hot countries, where the disorder is apt to run into the remit- 
tent, or even the continu-; d form, and where, during its violent and rapid course, 
internal organs are liable ta sustain serious damage, the best, and indeed almost the 
only time for the effectual interference of the physician is in the first assault or pa- 
roxysm of the disease. 

The objects of treatment during the paroxysm are, to alleviate the uneas)^ sensa- 
tions of the patient : to abridge, if possible, their duration, by shortening the fit ; and 
to avert the danger which, under certain circumstances, may arise from intense inter- 
nal congestion long continued, or from the severity of particular symptoms. 

Now in the cold stage of ague, diluent drinks have been recommended, and cor- 
dials, and external warmth, and opium, and emetics, and blood-letting. One would 
suppose that if some of these expedients were useful, others could scarcely be so too. 
The diluent drinks are very proper : and 1 should allow the patient to use his own 
discretion in the choice of them. It was custom.ary, formerly, to prescribe medicated 
drinks of this kind ; and one pleasant, but neglected ptisan still lingers in our Phar- 
macopoeia, the decoctum hordei compositum. Now-a-days we are contented with 
the simple barley- water, toast and water, weak tea, gruel, and the like. These dilu- 
ents should be taken warm, and for persons who are very feeble or exhausted, they 
ma}^ be made gently cordial ; weak negus, for example, or white wine whey, may 
be given. 

Externcd warmth, being what nature and common sense would suggest, is cer- 
tainly advisable and beneficial in the cold fit ; even the warm bath, if it can be pro- 
cured. In some places it is the custom to await an expected fit in the warm bath. 
When this cannot so conveniently be obtained, the pediluvium may be employed ; 
or the patient may be put into a warmed bed, and have bags of hot salt or bran ap- 
phed to his epigastrium; and a hot bottle, or a hot brick, wrapped up in fi_anne], to 
his feet. Or, what perhaps is best of all, he may have a hot air bath applied to him, 
as he lies in bed. This' may be very easily done, by means of a semi-cylinder or 
cradle of wicker work, closed at one extremity by a board. This is laid over the 
patient, and then covered with blankets. Through a hole in the centre of the board 
one end of a curved iron tube is passed ; the other end, expanded into a bell, looks 
dow'nwards : and a spirit lamp being placed beneath it, the air between the wicker 
work and the sick person is soon made very hot. This apparatus was constructed 
many years ago, by Dr. Gower, when he was physician to the Middlesex Hospital ; 
where its utility has been fully proved. External warmth applied in some one of 
these ways, affords singular comfort oftentimes, and contributes to shorten the cold 
stage. And the same may be said of friction, with stimulating liniments, along the 
course of the spine. Lind found that, in children, rubbing the spine with an embro- 
cation composed of equal parts of soap liniment and laudanum, at the approach of 
the cold stage, often prevented the paroxysm. 

Opium, has often been exhibited in the cold stage, with the view of cutting short 
the fit; and not without some success. The strongest evidence of its usefulness in 
that stage of the paroxysm is furnished by Dr. Trotter, in his Medicini Nautica. 
Agues being very frequent amongr the crew of the Vengeance, he resolved to try the 
full effect of opium in preventing the fit. At its first approach a dose of laudanum 
(never less than thirty drops) was given; if this did not bring on some warmth 
within ten or fifteen minutes, from twelve to twenty drops more were administered. 
In most cases, "in a few minutes an exhilaration of spirits was perceived ; the pulse. 



INTERMITTENT FEVER. 



from being weak, quick, and sometimes irregular, became less frequent, full, and 
equal ; an agreeable warmth was diffused over the whole frame, and every unplea- 
sant feeling vanished, sometimes in a quarter of an hour. The patients were them- 
selves surprised at the sudden change m their sensations." Dr. Trotter speaks of 
these as being the completest cures that ever came under his observation. If, at the 
next period, the paroxysm threatened to recur, the opiate was repeated always with 
the same success. " Few instances were met with where any indisposition indi- 
cated a third attack, at the expected period of accession." Notwithstanding this 
testimony, it appears that opium is still better adapted to another stage of the 
paroxysm. 

Emetics were formerly much prescribed in the cold stage, at its earliest approach. 
Cullen recommends them ; and they may sometimes be useful, in spite of Chomel's 
assertion that they are always hurtful. That they have gone so much out of fashion 
is, however, a proof that they cannot be depended upon for cutting short the parox- 
ysm. Vomiting is itself no small distress to many persons ; and for my own part, 
I should not think of giving an emetic unless some indications of a loaded and op- 
pressed state of the stomach were present ; such as nausea, an ill taste in the mouth, 
a coated tongue, and foul breath. A scruple of ipecacuanha will, even then, be 
sufficient. The object is to empty the stomach effectually, but mildly. I would not 
give antimony. Irritability of the stomach, in the more violent of these fevers, is 
too apt to arise spontaneously. Sir Gilbert Blane tells us that the greatest impedi- 
ment to the cure of the severer intermittents at Walcheren, in their early stages, 
proceeded from the extreme irritability of stomach, which made it difficult to admi- 
nister the requisite medicines. In hotter climates nausea and vomiting are still more 
common and more urgent ; and we have to guard against the risk of inducing or 
aggravating these symptoms. " Emetics (says Dr. Mackintosh, in his Practice of 
Physic) have been often extolled, but I believe every experienced tropical physician 
will agree with me in cautioning young practitioners against their indiscriminate em- 
ployment. Irritability of the stomach is one of the most frequent and troublesome 
symptoms; and once excited, it is always difficuk, and in many cases impossible to 
restrain it. I have seen emetics exhibited, and the vomiting has continued till death, 
in spite of every remedy." 

[We have repeatedly prevented the accession of the chill by administering to the patient, 
just before the period when it was expected, an emetic of ipecacuanha, and after this had 
ceased operating, immersing his feet in hot water, and, as soon as he is placed in bed, giving 
him from 30 to 40 drops of laudanum, or a teaspoonful of the camphorated tincture of opium. 
By this treatment not only is the chill prevented or shortened, but the whole paroxysm is 
often rendered milder. — C] 

Lately, the practice of blood-leUing in the cold stage has been revived (for it is 
not a new practice), and strongly recommended by the physician whose name I have 
just mentioned ; and whose opinion carries with it the more weight from its having 
been founded on much personal experience in the treatment of these fevers. Dr. 
Mackintosh affirms that bleeding, performed in the cold stage, will often stop at once 
the paroxysm, and with it the disease : that even when its curative effects are less 
decisive, it will generally stop the cold stage and shorten the paroxysm, and mitigate 
its severity, and afford speedy and great ease to the distressful sensations of the 
patient ; and that any subsequent paroxysms which may occur will be mild and few. 
One bleeding, he says, is commonly sufficient ; sometimes two are required : seldom 
more than two. The blood is to be suffered to flow till the patient feels rehef : which 
usually consists in liberation from pain of the head and loins ; freedom of respira- 
tion ; the departure of the painful sensation of cold ; and the cessation of the tremors 
and of the debility. Most of the patients fall asleep after the operation. These 
effects have been produced by the abstraction of an ounce and a half of blood ; they 
haye sometimes (but rarely) required for their production twenty ounces. 

Now this is the piece of practice to which I adverted at the close of yesterday's 
lecture, as being, in my humble opinion, inexpedient and not to be recommended ; 
at least in the agues of this country. I have seen a good many cases, first and last, 
and certainly I have never seen one in which I could have thought such an heroic 



TREATMENT. 



459 



remedy necessary, in the cold stage ; if indeed it be, in that stage, a remedy at alL 
But I do not desire to oppose my experience alone, or my judgment, to that of Dr. 
Mackintosh. His method has been tried, since he first made it public, by various 
practitioners in this country. Drs. Townsend and Law, of Dublin, found it fail in 
I the majority of cases. In Dr. Stokes's hands, the most usual effect of blood-letting 
in the cold stage was, to check the shivering ; and, next to this, to mitigate its severity, 
without abridging its duration. In most instances, no modification was produced of 
i the hot and of the sweating stages. In Dr. Kelly's experience, the general effect 
was, to shorten the cold stage, and to render the hot one milder; but in some cases 
it seemed to aggravate the symptoms. Mr. Gill found that, although the blood-letting 
j might cut short the cold stage, it appeared to lengthen the period of febrile disturb- 
!| ance. Confining myself, then, to intermittents, as they show themselves in this cli- 
I mate, I cannot advise you to adopt the practice introduced by Dr. Mackintosh — of 
I bleeding in the cold stage. I object to it because it appears to me quite unnecessary; 

because it is not such as the nature of the symptoms would suggest; because it 
I tends to produce subsequent debiHty, which we should not needlessly inflict ; and 
: because the experience of other sober-minded men, who have given the method a 
fair trial, does not bear out the statements made by Dr. Mackintosh in respect to its 
I usefulness. 

' At the same time, after a careful perusal of nearly a hundred cases adduced by ' 
' Dr. Mackintosh to illustrate the efficacy of this measure, I think it highly probable 
j that blood-letting may constitute the most important part of the treatment, in the 
! very outset of the severer malarious fevers of hot climates ; attended as they are 
( with a degree of internal congestion and disturbance which is dangerous to the integ- 
' rity of vital organs. 

[Mr. Twining, ia his work on the Diseases of Bengal, bears strong testimony in favour 
of bleeding in the cold stage of intermittents. In the greater number of cases he has found 
it to arrest the paroxysm ; that is, the occurrence of the hot and sweating stages is pre- 
vented. In the majority of patients, when the bleeding has been preceded by a course of 
mild purgatives, there will be no return of the disease, provided attention is paid to keep 
I the body properly clad and to guard against exposure to atmospherical vicissitudes. In this 
' manner, he remarks, we cut short the fever, and guard against those ulterior visceral engorge- 
ments and indurations, by which it is too often prolonged, until the constitution is completely 
ruined. 

The only period of the cold stage at which bleeding is proper, Mr. Twining states to be, 
at the very commencement of the rigor, or just when the coldness and shivering are com- 
pletely established. He has found that, in general, it is sufficient to take from an adult 
twelve or fifteen ounces of blood, and in the ^jpst robust European he would limit the 
quantity to be taken at one bleeding to twenty ounces. After the arm is tied up the patient 
should be permitted to lie quiet in bed for an hour or two — but not heated by being , covered 
with too many bed-clothes ; he should be immediately supplied with a cup of warm tea, 
gruel or thin sago. 

According to Mr. Twining, " the requisites to ensure success from bleeding in the rigor, 
are, 1st, the preliminary course of moderate purging; 2d, that the blood be taken, from a 
large orifice, quite as soon as the coldness and rigor are fairly established ; and 3d, that the 
patient be bled in a recumbent posture, and no more blood be taken than is sufficient to 
arrest the paroxysm." 

In robust plethoric patients, who, during the intervals of the paroxysm, complain of head- 
ache, and morbid tenderness on pressure over the abdomen, and pain or uneasiness in the 
chest, the disease will seldom be arrested by the first bleeding; in many cases, they will 
have repeated paroxysms in each of which the use of the lancet will be required. Patients, 
also, in whom the paroxysm, more especially the cold stage, is attended with vomiting, Mr. 

I Twining has found to require the repeated abstractions of small quantities of blood during 

j the rigors. — C] 

1 If, in this country, bleeding be requisite at all, it is in the hot stage. But it is not 
I requisite at all, except when there appears to be danger of some internal inflamma- 
j tion. The best remedy of the hot stage is undoubtedly opium. Dr. Lind, who 
j wrote after large experience, says that he never saw a person die in the cold fit, but 
I had known several carried off in the hot one, with strong convulsions and delirium„ 
I He happened to notice the beneficial effect of an opiate given while the patient was 
very hot and feverish. He determined, therefore, to make further trial of opium in 



460 



INTERMITTENT FEVER. 



the paroxysm. " Having at that time (says he) twenty-five patients labouring under 
intermitting fevers, I prescribed an opiate for each of them, to be taken immediately 
after the hot fit, provided the patient had then any inquietude, headache, or any 
such symptom usually subsequent to the fever. The consequence was, that nine- 
teen in twenty-two received immediate relief ; the other three had no occasion to 
take it. 

" Encouraged by this surprising success, I next day ordered the opium to be given 
during the hot fit. In eleven patients out of twelve to whom it was thus adminis- 
tered it removed the headache, abated the fever, and produced a profuse sweat; 
which was soon followed by a perfect intermission. Since that time 1 have pre- 
scribed an opiate to upwards of three hundred patients labouring under this disease: 
and I observed, that if taken during the intermission, it had not the least efiect either 
in preventing or mitigating the succeeding fit ; when given in the cold fit, it once or 
twice seemed to remove it ; but when given half an hour after the commencement 
of the hot fit, it generally gave immediate relief." 

Dr. Lind goes on to slate that he found the influence of opium more uniform and 
constant in intermitting fever than in any other disease ; and more quick and sensible 
than that of any other medicine. 

Very little need be said in regard to the sweating stage. Up to a certain pomt the 
perspiration is to be promoted and encouraged. When the uneasy feelings of the 
patient have abated, it should be restrained ; not suddenly but with caution. Now 
the sweating may be promoted by diluents ; by keeping the patient in bed, and 
covered with moderately warm clothes ; by sippings of hot gruel or of hot chicken 
broth. On the other hand, when the sweating has continued long enough, it may 
be stopped by drying the patient with towels, changing his linen, and getting him up 
out of bed. 

It is well to bear all this in mind ; but I repeat once more that in agues, such as 
3^ou are likely to meet with in this country, it is unnecessary, and therefore objection- 
able, to be over-busy during the paroxysm. Wherever the disorder assumes a dis- 
tinctly intermittent form, the most important part of the practice is that to be employed 
during the intermissions. Now there are certain general remedies advised for 
adoption in this period ; and there are certain specific remedies. The general reme- 
dies are bleeding, emetics, and purgatives. They need not detain us a moment. 
Blood-letting may be used if there be any apparent tendency to local inflammation, 
or any marks of severe topical congestion ; especially in young and robust subjects. 
Barring such circumstances, there can be no occasion to bleed your patient in the 
intermissions. 

An emetic given a short time before the expected paroxysm has been known to 
prevent its accession ; and even ha§ sometimes cured the disease. But we can stop 
the paroxysms by gentler and better means ; so that I should not prescribe an emetic 
unless I saw symptoms of a foul and loaded stomach. 

Purgatives should always be given at the outset. They clear the stomach and 
intestines of hurtful accumulations, which are apt to impede the beneficial operation 
of the quina, or of other drugs given to check the disorder. I mentioned in the last 
lecture my own custom in this matter ; viz., to give a couple or three grains of 
calomel with eight or ten of rhubarb at bed-time ; and to commence with the specific 
remedies the next day. 

Of these specific remedies, bark and arsenic are by far the most certain and im- 
portant ; but a multitude of others have been highly praised for possessing similar 
virtues. 1 shall by and by say a word or two about some of these, because bark is 
dear, and arsenic is scarcely a safe drug to be entrusted to the hands of unprofessional 
persons ; and yet it is often expedient, in country places, where agues are rife, to 
provide the poor with remedies which they may have at hand ; and which should 
both be reasonably cheap, and perfectly safe. 

I shall not detain you with any account of the difliculties and objections which 
were thrown in the way of the Peruvian bark, upon its introduction into the materia 
medica about the middle of the seventeenth century. Its use met with the most 
violent opposition, even from physicians of the highest authority. It was resisted by 



TREATMENT. 



461 



Stahi and Hoffman ; and Boerhaave was never quite reconciled to it. Sydenham, 
by his example and recommendation, greatly promoted its adoption in this country. 
All this history is sufficiently curious and interesting, but I have no time for it : and 
you will doubtless hear it from one of my colleagues. I will merely say that in the 
Peruvian bark we have one of the very few specifics that we can boast of possessing; 
and that, unhke most other highly vaunted substances, so far from falhng off from the 
accounts first given of its virtue:s, it has acquired in the lapse of time an increase and 
stability of reputation. 

Neither shaU I enter at all into the consideration of the qualities of the several 
species of cinchona ; nor of the several principles that may be educed from them ; 
nor of the modes in which the quina even may be best procured. This would not 
belong legitimately to my province. I must suppose that the professors of chemistry 
and of materia medica have furnished you with the sulphate of quina which is the 
only preparation of the bark I intend particularly to notice: and my business is to 
tell you what f knov7 in respect to its employment as a remedy for ague. 

I may observe, however, that this is a remedy to which we could never have been 
led by any process of reasoning. It is a matter of pure empiricism. We know 
nothing of the seat or of the essential nature of the disease ; we are equally in the 
dark as to the modus operandi of the quina in curing it ; yet our knowledge of ague, 
upon the whole, estimated in reference to its precision and practical bearing, is more 
satisfactory than of many other complaints, with the seat and nature of which we 
are much betier acquainted. The group of symptoms is so "distinct, that we have no 
trouble or doubt as to the diagnosis ; and experience has tauglit us a remedy which 
is all but infalhble. 

Tli*^ discovery of quina and its salts formed a great era in the history of the materia 
medica. As far as my own experience goes, the sulphate of quina has quite super- 
seded the necessity for exhibiting any other form of cinchona for the cure of ague. 
Before quina was unshrouded by the chemist, the bark in substance was the only 
form in which the remedy could be confidently relied upon : and I am old enough 
to be aware of the infinite superiority of the salt, over the actual bark. To obtain 
the desired effect, it was often necessary to give it in such quantities as almost justi- 
fied Mr. Abernethy's sarcastic way of speaking of it and of physicians. He said the 
doctors talked of throwing in the bark, as if it were to be pitched into the stomach 
with a shovel. The sulphate of quina lies in a much smaller compass, and a more 
commodious form ; and it does not cause that insupportable nausea which the woody 
mass of the powdered bark was so apt to occasion. 

I am in the habit of giving two, and sometimes three, grains of the sulphate of 
quina every four or six hours during the intermissions, to those patients whom 1 have 
occasion to treat for ague. This plan has succeeded so well, that I have never been 
tempted to try any other. I may, indeed, say that T have never known it fail to 
stop an ague ; and to stop it speedily : so that very few paroxysms have occurred 
after the patient has begun to take the medicine. You may give it in the infusion 
of roses, which contains a convenient quantity of sulphuric acid, to ensure the solu- 
tion of the sulphate of quina. It changes the colour of the infusion, however, and 
renders it pinker and opaque. Whether the draught be more or less elegant on that 
account, I will not take upon me to say ; I know that the virtue of the quina is not 
much interfered with by the change. In private practice, I commonly prescribe 
as many drops of dilute sulphuric acid as there are grains of the quina, with a drachm 
of the tincture of orange-peel, and a drachm of the syrup of the same; completing 
the draught with water. This I find my patients commonly approve of, except in its 
bitterness, which, in solution, nothing can disguise. Or that salt may be administered 
in the shape of a pill : it is best, however, and surest in solution. 

A question has been raised, whether this remedy should be given in repeated 
doses during the intermissions, or whether one very large dose should be given a 
short time before the paroxysm is expected. Dr. Home made some experiments 
on that point in the clinical wards of the Edinburgh Infirmary, some time ago; and 
he thought that the result was in favour of the plan of giving the bark regularly at 
short intervals. I have told you the amount of my own experience, which, how- 

2o2 



462 



INTERMITTENT FEVER. 



ever, is not very great ; nor have I had any severe cases to deal with. I think it 
not improbable that my patients would have been cured quite as soon if I had given 
the remedy in half the strength. Dr. Barker, of Dublin, has found small doses 
equally effectual with large ones ; and this is very likely to be the case with specific 
remedies. It would appear, however, that in some quartans it is better to give large 
doses before the return of the paroxysm. Dr. EUiotson gives large doses just after 
the paroxysm ; and then smaller doses during the remainder of the intermission, at 
regular periods. A great majority of those who suffer ague are poor persons. Of 
course, the first object is to make the cure as speedy as possible ; the next to make it 
as cheap as possible. So that it is not a matter of indifference, or mere speculative 
curiosity, to ascertain with how little quina you may cure an ague. I repeat that it 
has not happened to me to be disappointed, when I have given the medicine in small 
doses, as already described : vi^hich amount to abont twelve grains in twenty-four 
hours ; but, then, I suppose my cases have been well behaved and submissive. 
Dr. Elliotson states that he is continually obliged to give twenty or thirty grains 
in the twenty-four hours, before he can cure the complaint; sometimes m ob- 
stinate quartans, forty-five grains ; and he mentions one case in which a scruple 
of the sulphate of quina, with ten minims of the liquor arsenicalis, were given every 
eight hours in vain, but succeeded perfectly when given every six hours. 

It appears also, upon the testimony of careful observers, that in warm climates 
larger doses are required ; and that it takes a larger quantity, upon the whole, to 
repel the complaint. In the aguish tracts of Italy, in the Maremna, small doses are 
said to be inadequate ; and the physicians there are in the habit of giving twelve, 
twenty-four, or even thirty grains at a time : and in one recorded instance, the dose, in 
seven days, was got up to 108 grains, before the ague was arrested. The medium 
dose, in many parts of America, seems to be eight grains. 

It sometimes happens that the irritabihty of the stomach is so great as to make it 
difficult to introduce a sufficient quantity of the remedy into the system. This diffi- 
culty was very much felt at Walcheren : it is in a great measure removed since the 
discovery of quina. But even the quina sometimes sits ill on the stomach ; and it 
is often very difficult to get children to swallow any preparation of bark, on account 
of its bitter taste. It is "an important thing to know, therefore, that it has been found 
scarcely less effectual, in curing the disease, when thrown into the rectum. The 
menstruum in which it is dissolved should not exceed two or three ounces, lest the 
bowel should reject it. Its expulsion may sometimes be prevented by adding a 
few drops of laudanum to the enema. 

[The quinia may also be administered endermically ; from 4 to 10 grains being sprinkled 
upon a blistered surface, once, twice or oftener, according to circumstances, in the course of 
the day. That the remedy will produce its specific efiects when thus exhibited we know 
from experience. — C] 

It is said that bark in substance will sometimes cure the disease when quina 
fails. I have never witnessed this : but in obstinate cases I would give the quina in 
the decoction of bark. 

[It is very certain that the quinia, even when given freely and in large doses, will occa- 
sionally fail in arresting the disease, and that the majority of such cases will be promptly 
cured by the bark in substance. This we have seen repeatedly to occur. — C] 

You must not be satisfied with merely stopping the paroxysms. Patients will 
often be too ready to give up their medicine, as soon as the paroxysm has once 
missed. But the disease is very apt to recur ; and it will always be right and pru- 
dent to go on with the quina for ten days or a fortnight after the patient seems cured, 
gradually diminishing, after the first week, the amount and the frequency of the 
doses. 

There have been some curious facts observed in regard to the relapses that are apt 
to take place after the bark or the quina has been omitted. Clark, of Dominica, 
states that if no more of the remedy be taken, in the West Indian ague, than is 
barely sufficient to stop a fit, and then the bark is suspended, a relapse may take 
place on the eighth day, in the case of a quotidian ; on the fourteenth or fifteenth 



TREATMENT. 



463 



in the case of a tertian or double tertian ; and on the twenty-first or twenty-second 
in the case of a quartan : thus making (you see) in each type, seven periodi- 
cal revolutions from the time the fit was suppressed to the next attack ; and the 
fit was found to return on the proper day, at the same hour at which it would have 
returned if its course had not been interrupted by the administration of the remedy. 
All this is very curious, and inexplicable : but it points clearly to the propriety 
of continuing the remedy for some time after the disease appears to have vanished. 

[The Quinine Sulphas Impurus of the United States Pharmacopceia, known in Philadelphia 
under the name of Extract of Bark, given in pills of from 3 to 5 grains every four hours, will 
seldom fail in preventing the paroxysm of the disease. — C] 

Arsenic is another substance which has great and unquestionable power over ague. 
It carries with it these marked advantages : it is efficacious ; it is cheap ; and it is 
tasteless. It is well adapted by these qualities for the poor, and for children, and for 
patients of every age and rank in whom there is much irritability of stomach present; 
but then it has also the serious disadvantage of being an active poison. One over- 
dose may be fatal : and even its long-continued use m minute doses leads some- 
times to evident and lasting disorder of the health. Arsenic, therefore, is an unsafe 
remedy to be trusted in the hands of the ignorant. It should never be administered 
except under the immediate supervision of a medical eye ; and even then it requires 
to be given with much caution. Its bad effects may be very certainly prevented, 
however, by care and attention : and it becomes a valuable instrument of cure, and 
should be adopted without scruple, in cases where its operation can be watched, and 
where the quina does not agree with the stomach, or fails to stop the disease. I 
often prescribe arsenic for other complaints ; but, as I said before, I do not recollect 
ever having been foiled in removing ague by the sulphate of quina. Some persons 
are of opinion that relapses are less frequent after the cure by arsenic than after the 
cure by bark. It would require a large induction of particular facts to make that 
point clearly out. 

When substances, which even in small quantities prove active poisons, are used 
as remedial agents, it is convenient to have some definite form in which they may be 
administered at all times, and in all places. The liquor potassse arsenitis of the 
London Pharmacopceia supphes such a form. This is the form in which arsenic 
was recommended to the public by Dr. Fowler : and it is therefore sometimes called 
Fowler^s solution. It was founded upon an analysis of the tasteless ague drop, 
which had been in considerable repute in some parts of England. The pharmaco- 
pcsial preparation is an arsenite of potass in solution. There are eighty grains of 
arsenic in the new or imperial pint, and therefore four grains in an ounce of the so- 
lution. Ten minims two or three times a day are a full dose for an adult : and you 
had better commence with not more than five minims. Ten minims contain one- 
twelfth of a grain. Twice that quantity has been administered at once ; but this 
ought not to be done except when the system has been gradually inured to the 
arsenic, and thereby enabled to bear such a dose. It is a good precaution not to give 
this corrosive substance on an empty stomach. 

The poisonous or hurtful effects that we have to look out for, when arsenic has 
been prescribed, are loss of appetite, nausea, and sometimes vomiting; griping pain 
of the stomach and bowels, and diarrhoea ; and if the medicine be continued, faint- 
ing is often added. Other symptoms, less constant, perhaps, and less important, are 
painful and hot tumefaction and stiffness of the face and eyelids, or even a tingling 
eruption something like nettle-rash. These effects may, I believe, be controlled by 
adding a few drops of laudanum to each dose ; but I would rather advise you to sus- 
pend the use of the arsenic ; or to leave it off altogether. When this is done, the 
unpleasant symptoms will readily yield to mild laxatives, followed by opiates. 

[The arsenical solution is a remedy admirably adapted for the cure of intermittent fever 
when it occurs in children, to induce whom to take the quinia in any form will be found 
often impossible. When cautiously administered, and its effects are carefully watched, we 
have never known any disagreeable eflects to result from the arsenic, and we have em- 
ployed it somewhat extensively. — C] 



464 



INTERMITTENT FEVER. 



When the paroxysms continue to recur in spite of the bark, it has been recom- 
mended (and I think the plan a good one), to try to stop them by arsenic ; and 
then, the periodic recurrence having been broken^ to employ sulphate of quina to 
prevent a relapse. 

These, then, quina and arsenic, are the two sheet-anchors to which we trust in 
the cure of ague. A host of other remedies, I say, have had their praises sung. I 
do not intend to enumerate them. But there are a few which I think it right to 
mention, for reasons already assigned. There is strong evidence of the efficacy of 
some of them ; they are cheap, and easily accessible, and above all, safe ; and, there- 
fore, in aguish districts, they may with much propriety and benefit be recommended 
to the poorer classes, or distributed by Lady Bountifuls. 

[The ferrocyanuret of iron is certainly a very valuable remedy in cases of intermittent 
fever. Stokes places it in efficacy after qninia and the arsenical solution, and perhaps he is 
right in so doing; it will, however, often succeed in preventing the recurrence of the pa- 
roxysms, given in the dose of six grains every three hoiirs. — C] 

One of these is 2vilJmv-bark ; in substance, or in decoction. If this does cure 
agues, as it is affirmed to do, it would seem as if Providence had placed the anti- 
dote alongside of the poison ; for these trees, as you know, abound and flourish in 
marshy places. The bark of the willow furnishes an alkaloid substance called sali- 
cine, in which the febrifuge propert}^ is believed to reside. Holly-leaves, and ilicine 
derived from them, stand in much the same repute in France, as willow-bark and 
salicine here. 

Another curious remedy, said to be very successful, is the iveh of the black spider, 
which inhabits barns, stables and cellars. This substance has been tried on a tolera- 
bly large scale, and the testimony to its influence in curing agues is very strong. 
Dr. Craige has given this account of it. In the year 1760, a number of prisoners 
from the vanquished squadron of Thurot having "been landed in the Isle of Man, 
Dr. Gillespie, who was practising there, found that many of the agues which came 
to prevail both among these prisoners and the inhabitants of the island, obstinately 
resisted bark and such other remedies as he had recourse to. He was informed, by 
an old French physician belonging to the squadron, of the alleged efficacy of cob- 
web, in certain forms of the disease. He therefore made trial of cobweb, and found 
it to answer admirably. He was successful v/ith it in more than sixty cases of dif- 
ferent types, in the Isle of Man, and he had further experience of its utility subse- 
quently in Ayrshire. 

After this, the same remedy was tested in the West Indies, by Dr. Jackson, to 
whom Dr. Gillespie had recommended it. Dr. Jackson's observations were made 
in the hospital of the army depot, in the West Indies, in 1801. Several cases of 
ague, on which bark, arsenic, or mercury, singly or alternately, had made either a 
very temporary impression or none at all, were selected for experiment. In four of 
these cases, two pills, containing each five grains of cobweb, were given at intervals 
of two hours, commencing six hours before the expected time of recurrence of the 
paroxysm. The fit did not return. 

[We have employed the spider's web in this manner in a number of cases, and in many 
of them found it very promptly to suspend the paroxysms — as effectually, certainly, as th.tf 
quinia ; in a few cases, however, it failed. — C] 

On subsequent trials it was found not only to arrest the course of agues, but to 
remove various symptoms, such as pain, delirium, vomiting, griping, in ague, and 
in continued fever, when these symptoms were unconnected with inflammation. 

Charcoal is another substance which has been found effectual for the cure of 
intermittent fevers. You may find an account of it in the tenth volume of the Edin- 
burgh Medical and Surgical Journal. It would seem to be especially useful in 
those cases in which there is a marked disturbance of the digestive organs; nausea, 
flatulence, hiccup, diarrhcea, or dysentery. It is said generally to cure the complaint 
by the time two drachms of it have been taken. It may be given in doses of ten or 
twenty grains, in arrow-root ; or with a few grains of rhubarb. If the power of this 
substance should be confirm.ed by future observations, a cheap remedy would thus 



TREATMENT. 



465 



be open to the poor. A clergyman of my acquaintance assures me that he seldom 
fails to cure agues among his parishioners by administering to them the snuffs of 
candies, which he takes care to have collected. He does not inform them of what 
his black powder consists. I presume that its virtue may proceed from the char- 
coal it contains ; unless it is derived from the confidence his flock is accustomed to 
place in his specific. The very same remedy, the snutf of a candle, is mentioned 
by Lind. 

Fiperine, the crystalhne salt of pepper, has obtained a considerable reputation, of 
late years, as a remedy for intermittent fever. It was largely tried by an Italian 
physician, Meh ; and Dr. Gordini has repeated Meh's experiments at the hospital 
at Leghorn. The following are the general conclusions at which these physicians 
have arrived : — 1. Piperine, in doses of six or eight grains, cures intermittents. 2. 
It is more efficient in powder than in pills. 3. It succeeds in certain cases in which 
the sulphate of quina fails. And 4. It is more effectual in preventing relapses. I 
have seen letters from some practitioners in this country, bearing testimony to the 
power of the piperine. That pepper will cure ague, has long been the vulgar 
belief ; and a very popular remedy for the disease is a teaspoonful of pepper in a 
glass of gin. 

I presume that the efficacy of chamomile flowers in the removal of intermittent 
fever is to be attributed to the piperine which they have been ascertained to contain. 
These flowers had been long in use for the treatment of ague, before the Peruvian 
bark was discovered ; and they are said to have accomphshed a cure, since that 
time, after the bark had failed ; but this was before the quina had been educed from 
it. Heberden advises us to have recourse to chamomile flowers, if the bark should 
disappoint us. I am always willing to embrace an opportunity of referring to his 
commentaries, for the exact observations they contain, but above all for the beautiful 
Latinity of which the whole book is an example. I recommend it strongly to you, 
as being, next to Celsus, the best model you can study for good medical Latin. In 
reference to the point before us he says, "Cortex, quanquam rite sumtus, interdum 
parum efficax est; quo in casu suspicio erit ventriculum sordibus onustum vin 
remedii impedire. Itaque vom.ere oportet ; quo facto, febris raro non cedit. Quod 
si redire perseveret, confugiendum est ad flores chamsemeli, quorum contriorum scru- 
pulus dandus est loco drachmas cinchonse, et ad idem prasscriptum repetendus. Hos 
flores, sic sumtos, semel atque iterum profecisse expertus sum." 

Several mineral substitutes for the bark, or for arsenic, have been tried and found 
useful. Preparations of iron and of zinc. From 5 to 10 grains of the sulphate of 
zinc have been given several times a day ; or 3 grains of the oxide of zinc every 
three hours. Sir Gilbert Blane says that both in the West Indies and in London, 
intermittents have been cured by the use of this oxide, when they had previously 
resisted the bark. Sir James Mac Grigor speaks of it also in terms of praise ; from 
what he saw of its effects in the agues of the Peninsula during the war. 

Some of the remedies of this mysterious disorder operate upon the mind, or lather 
upon the nervous system, through the mind. Hence it becomes probable that the 
drugs which have such power over the disease, act also on the nervous system, 
through the body. And hence also Ave derive a confirmation of the opinion, that 
the disease itself is essentially a disease of the same nervous system. Ague has 
often been cured by the agency of strong mental emotion, such as sudden and great 
joy, anger, terror, or eager expectation. Thus we read that Gluintus Fabius Maxi- 
mus was cured of an old quartan on the day of a great battle. Strong impressions 
upon the imagination, producing feelings of disgust and horror, have had the same 
effect : such as those caused by drinking blood, swallowing a spider gently bruised, 
and wrapped up in a raisin, or spread upon bread and butter ; keeping a spider sus- 
pended from the patient's neck in a nutshell, till it dies; and the like. The un- 
doubted success, in many cases, of charms, must be referred to the principle faith. 
The patient recovers, because he firmly believes in your power to cure him. Dr. 
Gregory used to relate the case of a patient in the clinical wards in Edinburgh, 
who, with sundry ceremonies, swallowed some word, written on a shp of paper : the 
result was, that he had not another paroxysm. And I perfectly recollect having a 



INTERMITTENT FEVER. 



great awe, when I was quite a child, of my maternal grandmother, because she was 
reputed to have the power of curing agues by means of some charm. I believe all 
that she did was to assure the poor people who came to be reheved from their ague, 
that they shou Id have no more of it after such a day ; and their implicit reliance 
upon this prophecy brought about its fulfilment. There seems to be this general 
principle observable in respect to agues, and to most other diseases which occur in 
paroxysms, viz., that after they have continued for some time, their further continu- 
ance depends more upon the effect of habit than any thing else : and this habit 
may be broken by strong impressions made upon the nervous system; and the cure 
of one paroxysm is often thus the cure of the disease. We have seen examples of 
the existence of this morbid habit in hysteria, and in some cases of epilepsy. Cseteris 
paribus, that physician will be the most successful in these disorders, who is best 
able to acquire the confidence of his patient, and to gain a pow^erful influence over 
his mind. 

There is no disease in which the prophylaxis is of more importance ; but this you 
will have gathered from the facts which were stated in the two preceding lectures. 
The disposition to relapse is strongest soon after the disease has been removed ; but 
it generally continues long, perhaps even for life. The late Dr. Macmichael caught 
an ague many years before his death, by sleeping on a rock somewhere in Greece ; 
and he was ever after subject to occasional attacks of periodic headache, and other 
aguish symptoms, for which he was obliged to have recourse to bark or arsenic. Of 
course one essential point in the prophylaxis is the withdrawal of the patient from 
the influence of the exciting cause ; taking him away from the malarious locality. 
But this cannot always be done ; and when it cannot, we must impress upon him 
those cautions w'hich arise out of the facts ascertained in regard to the operation of 
the malaria upon the human body. Persons who have been exposed to the exciting 
cause, or who have once had the fever, should, in whatever place they may happen 
to be, avoid over-fatigue, and exhaustion of all kinds ; sudden exposure to- cold or 
heat ; and the neglect of changing wet clothes ; v/et shoes and stockings, for instance. 
In a malarious district persons should bear in mind the facts, that the miasmata are 
much more virulent in the night-time than in the day ; and close to the surface of 
the earth, than in a higher part of the atmosphere. They should refrain, therefore, 
from going out late in the evening, or early in the morning; and they should rather 
select the attic than any other floor for their bed-chamber. They w^ho are obliged | 
to go out in the morning in countries where agues are rife, should take care not to 
go out fasting ; a good hot breakfast should be first taken, or at any rate some mode- 
rate stimulus. A crust of bread and a glass of wine, or a small quantity of ardent 
spirit, will fortify the system against the pestilential miasma. Measures of this kind 
have been found extremely beneficial in the navy : the giving, for instance, the men 
a warm breakfast before going out in the morning on malarious shores in boats, 
whatever the hour of starting might be. Generous diet, and a fair allowance of fer- 
mented liquor, are proper also for all persons in aguish countries. The late Dr. 
James Gregory used to mention in his lectures an anecdote in point, told him by his 
father. The elder Dr. Gregory studied at Leyden, under Boerhaave ; and twenty- 
four other EngHsh students were living there at the same time : that is, they were 
called English, on account of their common language, but they were in fact composed 
of English, Irish, Scotch, West Indians, and Americans. The celebrated John 
Wilkes and Charles Townsend were among the number. These twenty-five students 
lived a good deal together ; in truth they were cut, as the phrase is, by the Dutch, 
for some raffish behaviour on their parts. However, of the twenty-five, only one 
was a water-drinker. The other twenty-four drank each a bottle of claret daily ; 
and the water-drinker, and he alone, fell ill of ague there. 

Persons who have recently become residents in aguish districts, or who even hap- 
pen to be travelling through them, would do well to take moderate doses of quina by 
way of safeguard. And in regulating the bow^eis, which, of course, is of much im- 
portance, warm stomachic laxatives should be made use of, rather than cold aperi- 
ents, such as Dhe neutral salts. 



I 



EPISTAXIS. 



467 



There is just one more expedient which I would suggest as not unHkely to affoi^: 
complete protection to those who are of necessity exposed to the malaria ; and it is, 
that they should wear an orinasal respirator. It is impossible that as a breeze is 
filtered of the poison which was mingled with it, by passing through a dense mass 
of foliage, so, on a smaller scale, the air inspired in breathing may be strained and 
purified, and rendered harmless, in its transit through the sieve-hke structure of Mr. 
Jeffreys' ingenious instrument. The principle of the suggestion is not new ; but 
this mode of applying it has not, so far as I know, hitherto been tried. It is said 
that by surrounding the head with a gauze veil, or conopeum, the action of malaria 
is prevented ; and that thus it is possible even to sleep in the most pernicious parts 
of Italy without hazard of fever. Dr. Macculloch says that in Malta, and elsewhere, 
this belief is universal : and hence the popular practice of covering the mouth and 
nose with a handkerchief in the morning on going out, or in other suspicious circum- 
stances : a practice (he observes) the efficacy of which is attested, as far as popular 
belief can attest any thing. Can it be the moisture which accumulates upon the 
handkerchief from the breath, that confers the protection ? 



i 

I LECTUHE XLIII. 

I Epistaxis. Bronchocele ; Cretinism: their Phenomena and probable Causes. 
Medical and Surgical Treatment of Bronchocele. 

I YESTERDAY finished what I had to say respecting intermittent fever ; its symp- 
toms ; its cause ; and its cure. The subtle poison which produces it is thickly dis- 
tributed over the fairest portions of the habitable globe : blighting human health, and 
shortening human life, more often, and to a far greater numerical amount than any 
I other single cause whatever. Known only by its noxious effects, holding out no 
i signal of its presence, this unseen and treacherous enemy of our race has yet been 
' tracked to its haunts and lurking places, and detected in some of its habits. It was 
necessary, therefore, that I should enter somewhat fully into the history of the mal- 
aria, and show how it may sometimes be shunned, sometimes be averted ; how, also, 
in this climate at least, the effects it has already produced upon the human body 
may be successfully combated. But I shall not pursue in further detail, the ravages 
committed by this invisible agent, and the remedies they require, in hotter and 
less favoured regions than our own. Of these personally, I know nothing ; and I 
must refer you, for information on such diseases, to authors who have seen and 
I treated them : particularly to Drs, Lind, Jackson, Bancroft, Johnson, and Sir William 
Burnett. 

It is customary, with writers and lecturers, to pass from the consideration of ague 
to that of continued fever. A paroxysm of ague has been regarded as exhibiting a 
paradigm or sample of fever in general.. But this has always appeared to me rather 
an ingenious refinement than a useful matter of fact. Practically, I see nothing to 
be gained by the association. Intermittent fever, it is true, does often run, in hot 
chmates, into the remittent, and the remittent into the continued form. But these 
are very different disorders from the continued fever with which, in these climates, 
■ and in this country, we have to do. Intermittent fever, and continued fever, as we 
see them, differ in their phenomena, in their course, and in their treatment. They 
1 are alike, inasmuch as they are both called fever, and both are attended, in some part 
1 or other of their course, with pyrexia ; but, in essential symptoms, I have known 
I many a compound fracture more like continued fever than any ague we are likely 
to witness. I shall take up the subject of continued fever, then, in connection with 
the eruptive febrile diseases, with which it has many strong links of analogy ; and 
I resume the consideration of the disorders that come within the province of the 
physician, according to their anatomical seat. 



I 



468 



EPISTAXIS. 



After what was stated c/ ,^-emorrhage in general, in an earlier part of the coarse, 
I hardly know whether epistaxis needs or deserves any formal notice. There are, 
however, some points relating to this simple, and commonly harmless hemorrhage, 
which it may be worth while very briefly to touch upon. Sometimes it is a remedy ; 
sometimes a warning ; sometimes really in itself a disease. The readiness w^ith 
which the mucous hning of the nasal passage pours forth blood is familiar to the 
experience of every schoolbo}-, who " often wipes a bloody nose." A slight blow, 
brisk exercise, a strong bodily effort, a fit of sneezing, or the summer heat, is suffi- 
cient, in many boys, to make the nose bleed ; and this facility of hemorrhage furnishes, 
often, an index of some unnatural state of the circulation : and especially of undue 
fullness of the vessels of the head. But the import of this symptom is not always 
the same. Epistaxis may, indeed, be taken as affording an epitome of the various 
forms of hemorrhage by exhalation. In childhood and early youth it is idiopathic, 
dependent upon active congestion, and probably arterial. It is nature's favourite 
mode of blood-letting at that period of life. In old age it is symptomatic, the result 
of passive or mechanical congestion, and probably venous. In somd adult persons 
it happens periodically, and is habitual : and its suspension, rather than its occur- 
rence, becomes a token of disease or of danger. In young women it is not seldom 
vicarious of suspended menstruation : in men it is apt to take the place of hemor- 
rhois. Lastly, it may proceed from disease in the nares themselves ; or form a part 
of a more general hemorrhagic disorder. 

It is unnecessary to go at length into the phenomena of epistaxis. The main 
phenomenon becomes obvious at once both to the patient and to those around him : 
and the accessory and incidental circumstances are easily discoverable when the 
attention is aroused to them by the sight of the blood. Usually the blood flows 
guitatim; in a succession of drops: but these may follow each other so fast as to 
constitute a little stream. Sometimes a few drops only fall ; sometimes several pints 
are lost. A moderate hemorrhage of this kind is generally succeeded by a sense of 
relief and refreshment. A large efflux of blood may cause pallor, faintness, debility, 
exhaustion, even death. 

. Active idiopathic epistaxis, as it occurs in children, is almost alv/ays salutary, and 
may be left to work its own cure. When it runs into excess, or is too often repeated, 
it may be checked by applying cold water to the forehead and to the bridge of the 
nose. The sudden contact of some cold substance with a distant part of the surface 
of the body will often have the effect of restraining the hemorrhage : apparenuy by 
producing a general and sympathetic constriction of the superficial blood-vessels. 
This is doubtless a reflex phenomenon. The nursery remedy is to shp a cold key 
down the child's neck, between its back and its clothes. The aspersion of cold water 
is still better. Besides these external appliances, cooling laxatives should be given : 
and if the bleeding proves obstinate, some astringent internal remedy may be thought 
proper. I have, myself, hitherto found none so efficacious as the acetate of lead. 
But I have been recently informed by Dr. Latham that his experience has led him 
to trust much to mercury in the management of epistaxis ; and that the same indica- 
tions have governed him, in adapting its use to this form of hemorrhage, as serve to 
guide him in cases of inflammation. Thus, when the hemorrhage has been profuse 
and frequent, and moderate depletion by blood-letting, or by purgatives, has not 
arrested it, he has brought the constitution rapidly under the influence of mercury; 
and as soon as the mouth became sore, the hemorrhage has ceased, not a drop more 
of blood has been lost. Again, when the epistaxis has been, not copious, but habitual 
or frequently recurring, without any excess of vascular action, or any other apparent 
ailmenc in the constitution at large. Dr. Latham has often cured his patient by a 
moderate salivation, gradually induced, and continued for a few weeks. 

In conversing with Dr. Southey on the same subject, I find that he also has been 
taught by experience to rely upon mercury as almost a specific remedy for obstinate 
hemorrhage, occurring under similar conditions, from whatever organ of the body it 
may proceed. 

This plan of treatment it is therefore my purpose to prove, as future opportunity 
may permit. 



EPISTAXIS. 



469 



When epistaxis begins to show itself in advanced Hfe, it is a symptom which 
cannot safely be neglected : for it indicates that the veins of the head are loaded. It 
imphes a morbid condition that requires to be redressed. You will look for disease 
of the heart — or for threatenings of apoplexy — and take your measures accordingly. 
The blood-vessels which ramify upon and beneath the pituitary membrane, commu- 
nicate by indirect inosculation with the veins and sinuses of the skull, as well as 
with the jugular veins. You see, therefore, how it is that hemorrhage from this 
membrane may perform the office of a safety-valve, and protect the important organ 
within the cranium from impending mischief. 

On the other hand, when epistaxis, which is known to have been habitual, fails to 
recur at or about the usaal periods, you will look, with a jealous care, into your 
patient's state, and watch for and obviate any t^dency to plethora capitis. 

When epistaxis forms a part of more general hemorrhagic disease — as when it 
occurs among other symptoms of purpura — its treatment merges in that of the whole 
malady. 

In any case, if the flow of blood be excessive, and cannot be restrained by the 
ordinary remedies, but is exhausting the patient's strength, it becomes an absolute 
disease : and it will be requisite to staunch the blood by manual expedients. 

These consist in stopping the bleeding orifices mechanically : which is most effec- 
tually to be done by plugging the cavity. A dossil of lint must be carefully inserted 
into the bleeding nostril. Its mechanical effect, which is pressure, may be chemi- 
cally aided by first wetting the lint with a saturated solution of alum. The mode 
of introducing these plugs it is the business of the surgeon — and not mine — to teach. 
The operation is not a very comforfable one either to bear or to perform. 

A very simple mechanical remedy has been lately announced by Dr. Negrier, of 
Anglers ; who discovered it (he says) by mere accident. The patient is to raise one 
or both of his arms above his head, and to hold them for some little time in that 
position. Dr. Negrier declares that during an experience of three years he has 
never known this method fail to arrest the bleeding. His explanation of its modus 
operandi is not very satisfactory. The expedient itself is however so easy, so prompt, 
and even if unsuccessful so harmless, that its real value deserves to be tested — 
and will soon probably be settled — by an ampler trial. 

[In cases of frequently recurring or iong-continued epistaxis, blisters to the nape of the 
neck will be found, in general, a very effectual remedy. — C] 

Before we trace this mucous membrane downwards, through the mouth, to the 
inside of the throat, let me turn your attention to a singular disorder which may be 
deemed external, for it is scarcely more than skin-deep : I mean that enlarged state 
of the thyreoid gland to which the name of broncliocele has been given. This word 
is not merely derived from the Greek, but was used by the Greek writers in the 
same sense in which we now employ it. In Switzerland, where it is very common, 
and in France, the complaint is called goitre ; a corruption, it is believed, of the 
Latin "guttur," the throat. It is known in England as the Derbyshire neck; from 
its frequent occurrence in that country. 

The term bronchocele has been sometimes apphed indiscriminately to all protu- 
berances or swellings in front of the throat ; or at any rate, to all enlargements of 
the thyreoid gland ; whereas it should be restricted to hypertrophy of that part : an 
exaggeration of its natural structure, with augmentation of its volume. The texture 
of the gland becomes coarser; its blood-vessels grow larger and more numerous ; its 
cells are magnified, and filled with a thick, viscid secretion. It usually presents a 
soft, smooth, elastic tumour, which is neither painful, nor tender, nor discoloured. 
The lobes of the gland become more obvious. Sometimes the whole tumour is 
irregularly lobulated : sometimes the exact form and relative proportions of the gland 
are preserved, each lobe and portion being equally increased in size. Occasionally 
there is a soft uniform or irregular sweUing, without much distinction of parts. 
Alibert states that the right lobe is more frequently enlarged than the left. Mr. 
Rickwood found it so in every instance of bronchocele that came under his notice 
in the neighbourhood of Horsham. 

2p 



470 



BRONCHOCELE. 



Unless the tumour be very large, it follows all the motions of the larj^nx : and this 
is a point of considerable importance whenever the diagnosis is at all doubtful. It 
is just possible that an enlarged lymphatic gland, or an encysted tumour in the 
neighbourhood of the larj^nx, or even a collection of pus thereabouts, might, in some 
degree, embarrass the diagnosis. But, by placing the head and neck in different 
successive positions, swelHngs of this accidental kind may, in general, be ascertained 
to be unconnected with the larynx : and they do not follow its up and down move- 
ments when the act of deglutition is performed. 

It is of importance to know, also, that the gland itself is subject to different kinds 
of enlargement. It may swell from inflammation, chronic or acute : and then it 
will be hard, and tender, and painful. But it does not seem Yerj prone to inflame ; 
and probably Dr. Copland is right in his opinion that inflammation occurs sponta- 
neously in this organ in scrofulous persons only. Baillie and Alibert speak of it as 
being occasionally ihe seat of cancer : but that must be very rare. Sqmetimes carti- 
laginous or ossific deposits take place in the gland. It is necessary, I say, to be 
aware of these circumstances, and to distinguish one kind of thyreoid tumour from 
another : for some of the morbid changes just referred to are clearly beyond the 
power of any inedicine to remove ; and if all forms of enlargement incidental to this 
part are lumped together under one common name of bronchocele, we shall be 
liable to arrive at false conclusions concerning the power of remedies over that 
disease. 

Bronchocele is not, in itself, a painful disorder: nor does it taint the system, or 
affect the constitution in any way. It has no character of malignancy about it. It 
is always, however, a deformity ; and, by its mechanical effects, that is, by its weight 
when large, and by the pressure it exercises on contiguous parts, it may occasion 
great distress, and suffering, and even death itself. The size, and the effects, of the 
tumour both vary much in different cases ; but its injurious effects are not always, 
though they are generally, in proportion to its bulk. Sometimes there is no more 
than a slight fullness of the throat, which some persons, I beheve, think rather 
graceful than otherwise. Now and then, the swelling, after its first commencement, 
develops itself with great rapidity; but its ordinary progress is slow. It often con- 
tinues for months, or years, without reaching any extreme or very troublesome mag- 
nitude. Sometimes it remains stationary for a considerable time, and then suddenly 
increases without any apparent cause. The worst effects of bronchocele are its 
interference with the circulation, and with respiration. By its pressure it may 
obstruct the free descent of the blood through the veins of the neck, and give rise to 
headache, giddiness, noises in the ears, confusion of thought, and a turgid condition 
of the head and face. Or, by pressing upon the wind-pipe, it miay cause hoarse- 
ness, wheezing, and d3^spnGea. It may even impede deglutition. But these effects, 
I say, do not depend altogether on the actual size of the tumour. A very large 
goitre may produce no other inconvenience than what results from its weight and 
its unseemly appearance. It may surround all the front and sides of the neck hke 
a thick collar, and rise as high as the ears ; or it may hang down, in a pendulous 
lump, and be supported upon the chest. Nay, the tumour is said to descend, in 
some rare instances, so low as to be in contact with the abdomen : and AHbert 
mentions one case in which the sweUing was of a tapering cyhndrical shape, and 
reached to the middle of the thigh. On the other hand, a small tumour, not bigger 
than one's fist, especially if it happens to occupy the central portion, cr what is 
called the isthmus, of the gland, may so press inwards upon the trachea as mate- 
rially to hinder the breathing, and even to threaten suffocation. A pupil now 
attending the hospital has informed me of a case, which he himself saw, of death 
produced by the encroachment of a bronchocele ; not so much, however, from suffo- 
cation as from starvation : for the sweUing encircled the trachea, and came at last to 
press so much upon the woman's oesophagus, that she could not get food into her 
stomach. T suppose that the reason of these differences may be sometimes found in 
the manner in which the tumour gro\vs, and in its relative situations. When it is 
bound down by the muscles of the neck, it presses, as it continues to enlarge, upon 



BRONCHOCELE. 



471 



the parts behind it. When it is not so confined, the skin readily yields, and the 
entire growth of the tumour takes place anteriorly. 

This disease is much more common in women than in men. Indeed we seldom 
see it, in this country, except in females. Yet I happen to have an example of it 
now, (December, 1837) in a male among my patients in the hospital. Dr. Andrew 
Crawford states that forty-nine cases were admitted into the JBampshire County 
Hospital, in ten years, and forty-eight of these were in women. Of seventy patients 
treated in the Chichester Infirmary in nine years, two only were males, and they 
were boys of a very feeble and feminine habit, and backward for their years. 
Among one hundred and sixteen patients of Dr. Manson, fifteen were men. Taking 
an average from these three lists, we have one male for twelve females. It is well 
to bear in mind that our fashion of dress renders a small bronchocele much more 
noticeable, much less easily concealed, in women than in men. In the former the 
swelhng has been known to come: on, or at any rate to increase rapidly, during their 
confinement in child-bed : and it is frequently observed to undergo a temporary en- 
largement at the menstrual period. Dr. Copland has seldom met with an instance 
in the female, unconnected with some kind of irregularity in the catamenial discharge, 
or disorder of the uterine functions ; and he never saw a case in which the disease 
made its appearance before the period of commencing puberty. In Switzerland, 
and in some parts of India, where the complaint is much more prevalent than here, 
the proportion of males afiected is greater; and it begins, often, prior to the age of 
puberty, in both sexes. It seldom shows itself earher than the age of eight or ten. 
Dr. Elliotson states, indeed, that he himself, when in Switzerland, saw goitre in a 
little boy only four years old ; and the naiives told him that it rarely made its appear- 
ance before the age of six. But children have been born goitrous. M. Godelle, 
physician to the hospital at Soissons, had a preparation of the body of an infant, 
which only hved a few hours, and which came into the world with a goitre ; the 
raother being affected with the same disease. A case is mentioned in the London 
Medical Repository of a child born in Derbyshire with bronchocele of considerable 
size. The disease, therefore, undoubtedly may be congenital ; and one of the 
facts I have just mentioned points to the question of its being hereditary. It is said' 
to be so ; and there is much probability in favour of that opinion. Children born 
of goitrous parents often have goitre. But that, you will say, may depend upon 
their being in the same place, and exposed to the same causes, w^hich produced bron- 
chocele in the mother or father. Dr. Crawford states, however, that he knew a 
woman, with goitre, whose grandmother, father, paternal aunt, and cousins, also had 
it, although the}.' did not all live in the same place, and no other person in their 
respective neighbourhoods was affected by the disease. 

Admitting what seems -probable, that the disease may sometimes be hereditary in 
the sense in which I formerly explained that term, there can be no doubt that it is 
often acquired. 

In the first place, bronchocele is e?if/ewic— prevalent in certain localities, and 
scarcely occurring elsewhere. And persons who, being previously well, go to live 
in those localities, often become affected with the complaint : and persons who mi- 
grate /rom those localities, having the complaint upon them, sometimes get rid of it 
by the mere change of residence. The physical circumstances of the places thus 
selected b}^ the disease have been studied with the natural hope of discovering what 
the cause may be of an effect so singular. Some morbific quahty of the air was long 
suspected. The habitats of the unknown cause of bronchocele appeared at first 
sight to be very much like those of the malaria. Goitre abounds in the hollows of 
many mountainous districts ; among the Alps, for example, and in the Pyrenees. 
This was notorious to the ancients. Juvenal asks — ■ 

Quis turnidum guttur miratur in Alpibus ? 

And it is in the deep, close, and humid valleys of Switzerland, which lie at the 
feet of, and between, high mountains, that bronchocele is most common. Several 
writers, who have personally investigated this subject in places where goitre is rife, 
concur in the belief that it depends upon insalubrity of the air, arising from the pe- 



472 



CRETINISM. 



culiarities of the situation. They affirm that it is most frequent in low, damp, con- 
fined spots, v.'here the stagnant atmosphere is seldom stirred by wholesome breezes ; 
and where the sun, in summer, has great power. Dr. James Johnson rem.arks, " We 
find in the Valai-s (one of the Swiss cantons) and in the lower gorges or ravines that 
open on its sides, both cretinism and bronchocele in the most intense degrees. As we 
ascend the neighbouring mountains, cretinism disappears, and goitre only is observed. 
And when we get to a certain altitude, both maladies vanish." Dr. Reeve, again, 
states that all the cretins he saw were in adjoining houses in the^ little village called 
La Batia, situated in a narrow corner of the valley, the houses being built up under 
ledges of the rocks, and all of them very filthy, very close, very hot and miserable 
habitations. In villages situated higher up the mountains, no cretins are to be 
seen. 

The cretinism mentioned in these quotations is a strange and melancholy disease : 
a sort of idiocy, accompanied by (and doubtless dependent upon) deformity and im- 
perfection of the bodily organs. The mental affection exists in all degrees, from 
mere obtuseness of thought and purpose, to the complete obliteration of intelligence. 
Many of the cretins are incapable of articulate speech ; some are blind, some deaf, 
and others labour under all these privations. They are mostly dwarfish in stature, 
with large heads, wide vacant features, and goggle eyes, short crooked limbs, flabby 
muscles, and tumid bellies. The worst of them are insensible to the decencies of 
nature, and obey, without shame or self-restraint, every animal impulse. In nO 
other class of mortals is the impress of humanity so pitiably defaced. 

More recent and extensive observation of the localities infested by goitre have ren- 
dered it improbable that the disease derives its origin from any deleterious properties 
of the air. Certainly it is not owing to any thing that is common to all mountain- 
ous countries. Some parts of Switzerland are free from it. So are the Highlands 
of Scotland. It is met with also in flat situations — as in Norfolk. I have seen 
several cases of it in Cambridgeshire, which is a very flat country. In one village 
in particular, about five miles from Cambridge, it is extremely common. There are 
some striking facts collected by the celebrated and philosophic Humboldt, which go 
to show that the prevalence of bronchocele does not depend on any particular 
configuration of the surface of the earth, nor on any peculiar condition of the 
atmosphere. He tells us that in South America bronchocele is met with, both in 
the upper and the lower course of the Magdalen river ; and in the flat high country 
of Bogota, 6000 feet above the bed of the stream. The first of these regions is a 
thick forest ; while the second and third present a soil destitute of vegetation. The 
first and third are exceedingly damp ; the second peculiarly dry. In the first the 
air is stagnant : in the second and third the winds are impetuous. In the first two 
the thermometer keeps up all the year at 22 or 23 degrees of the Centrigrade scale : 
in the third it ranges between 4 degrees and 17. 

The researches of Mr. M'Clelland, in India, lead to the same conclusion. He found 
goitre extremely frequent in one portion of the district which he surveyed, while the 
other portion was almost exempt from the complaint, "although an equality of 
moral as well as physical circumstances appeared to afiect the whole. The external 
Alpine characters of the province are the same in every part ; the inhabitants all 
belong to the same tribes of Hindoos, and are subject to fewer irregularities in their 
mode of hfe than any other people in the world." 

The different localities of the viflages, in the portion where goitre was not preva- 
lent, he describes as being as diverse as can well be imagined. " Some are erected 
on narrow Vidges, others in deep valleys, surrounded by abrupt and lofty mountains ; 
others on rugged declivities between lofty peaks on one side, and deep ravines on the 
other, into some of which the sun can scarcely penetrate. The different altitudes of 
these villages vary from 2000 to 6000 feet." 

Facts of this kind have turned the attention of scientific inquirers towards the only 
other obvious source to which the disorder could, with probabihty, be attributed, viz., 
the quality of the water "use^i for drinking. Wherever goitre prevails, the popular 
belief assigns it to the water, as a cause : and the more accurately the search is pro- 
secuted, the more strength and likeUhood does this supposition acquire. Its very 



CRETINISM. 



473 



universality is a presumption in its favour. The disease was formerly ascribed to 
the use of snoiu water : a notion which originated, I imagine, in its frequent occur- 
rence in Alpine regions. But the people in almost all the valleys of Switzerland 
drink the water that comes from the Glaciers ; while bronchocele is known in some 
of the valleys only. It prevails also in certain spots where pump water is used, and 
there the people accuse the pump water of producing it. Besides, goitre occurs in 
other countries, where the snow never lies long, as in Derbyshire ; and even in Su- 
matra, where there is 720 snow. Dr. Bally, a native of a goitrous district in Switzer- 
land, beheves that bronchocele is caused by certain waters, which issue from the 
hollows of rocks, trickle along crevices of the mountains, or rise from the bowels of 
the earth. And in support of that opinion he refers to some fountains in his own 
neighbourhood, the drinking of the waters of which will produce, or augment, goi- 
trous swellings, in eight or ten days. Such of the inhabitants as avoid these waters 
are free, he says, from goitre and cretinism. In Captain Franklin's narrative of his 
expedition to the shores of the Polar sea, there is the following statement, made by 
his fellow-traveller Dr. Richardson : — " Bronchocele or goitre is a common disorder 
at Edmonton. I examined several of the inhabitants afflicted with it, and endeavoured 
to obtain ev^ery information on the subject from the most authentic sources. The 
following facts may be depended upon : — The disorder attacks those only who 
drink from the water of the (Saskatchanan) river. It is, indeed, in its worst state, 
confined almost entirely to the half-bred women and children who reside constantly 
at the fort, and make use of river water, drawn in winter, through a hole made in 
the ice. The men, from being often from home on their journeys through the plain, 
where their drink is melted snow, are less affected : and if any of them exhibit during 
the winter some incipient symptoms of the complaint, the annual summer voyage to 
the sea-coast generally effects a cure. The natives who confine themselves to snow 
water in the winter, and drink of the small rivulets which flow through the plains 
in the summer, are exempt from attacks of this disease. A residence of a single year 
at Edmonton is sufficient to render a family bronchocelous. Many of the goitres 
acquire great size. Burnt sponge has been tried, and found to remove the dis- 
ease : but an exposure to the same cause immediately reproduces it. A great 
proportion of the children of the women who have goitres are born idiots, with 
large heads, and the other distinguishing marks of cretins. I could not learn 
whether it was necessary that both parents should have goitres to produce cretin 
children." 

We are able even to go a step further, and to announce a probable conjecture as 
to the specific quality of the suspected water. Bronchocele is very prevalent in 
Nottingham and its neighbourhood ; and the vulgar there ascribe it (so Dr. Manson 
informs us) to the hardness of the water. You know that the rough practical dis- 
tinction between soft and hard water' is that the former dissolves soap, while the 
latter decomposes it. The hardness is generally occasioned by the presence either 
of sulphate of lime, or of carbonate of lime. In the one case the remedy is to mix 
the carbonate of an alkali with the water ; in the other you simply boil it. Now the 
well water in and about Nottingham is more or less hard, and unfit for the purpose 
of washing. Dr. Coindet, of Geneva, declares that the use of hard or pump water 
in the lower streets of that town brings on the goitre very speedily. At CI uses, on 
the Arve, numerous cretins and goitrous persons are seen in the streets : lofty chfts 
of limestone tower over the town, and through its caverns copious streams of water 
fin^ a passage. The soil in the neighbourhood of Edmonton was found by Dr. 
Richardson to be calcareous, and to contain numerous fragments of magnesian lime- 
stone. In a JVealise on English Bronchocele, very recently published. Dr. Inghs 
states his belief that the presence of magnesian limestone always implies the co- 
existence of the disease, "Take (he says) that ridge of magnesian limestone run- 
ning from north to south through the centre of Yorkshire, and margining the shires 
of Derby and Nottingham. All along that line we have goitre to a very great 
extent; whereas, on our diverging to either side, the disease is found to diminish." 

These scattered indications that the hurtful quahty of the water is somehow de- 
rived from its contact with hmestone rocks, receive a powerful corroboration from tha 

ap2 



474 



CRETINISM. 



result of Mr. M'CleJland's minute and valuable inquiries, which were carried on in 
the province of Kemaon, south of the Himalaj^an mountains. I have not been able 
to obtain his book ; what I am about to tell you I take from a full and instructive 
notice of it in the fifteenth number of the British and Foreign Medical Review. 
Mr. M'Cleiland finding goitre very abundant (as I mentioned before) in one great 
section of a district, and almost entirely absent from another section, set himself to 
find out in what other particulars these sections were distinguished from each other. 
He ascertained that they completely agreed " in external aspect, altitude, and cli- 
matology," but differed remarkably "in their geognostic relations; and this distinc- 
tion was even traced down to the very villages in which the disease is found, with 
such perfect nicety, as to enable one almost to predict, a priori, on examining the 
rocks of a neighbourhood, whether the inhabitants are affected with goitre or not." 

It would be impossible for me to give you even an abstract of Mr. M'Clelland's 
numerous observations ; but I select one or two striking instances in favour of his 
opinion that the endemic prevalence of goitre is connected with the use of water in*- 
pregnated with calcareous salts. 

One extremity of the long village Deota, which occupies half a mile of the foot 
of Durge mountain, is inhabited by Brahmins ; the other by Rajpoots and Domes. 
Of the first caste there are about twenty persons, all of whom are free from goitre. 
There are forty of the second, and two-thirds are affected, more or less. Of the third 
caste, forty-six in number, nearly the whole are goitrous. " To what cause can we 
ascribe the immunity of one caste of the inhabitants of this village, and the almost 
universal affection of the other two castes ? They are all alike well fed, and have 
little toil ; their land producing the requisites of hfe almost without labour. Differ- 
ence of caste does not here imply a difference of pecuniary circumstances, and con- 
sequently of the comforts of life. In these respects the three castes in this village 
are on perfect equahty. Nor will hereditary predisposition acquired by intermar- 
riages be sufficient to explain the interesting fact : for the affected parties are con- 
fined to the Rajpoots and Domes, who cannot intermarry, while the Brahmins and 
Rajpoots may. The village is raised about one hundred feet above the level of the 
valley ; and the mountain, at the foot of which it is situated, rises with a gentle 
slope, and is not in this vicinity at all rugged. It is chiefly composed of transition 
limestone, and the village is erected on a conglomerated rock, composed of calcare- 
ous tuff, inclosing fragments of other rocks. There is a spring in the valley, about 
one hundred yards from the village, bearing on its first appearance the character of 
a mineral spring. The w^ater bursts forth with strong ebulhtion, in the quantity of 
at least forty gallons in a minute, and agglutinates the sand and gravel b}' Avhich it 
is surrounded, b)^ the deposition of calcareous tuff. The temperature and quantity 
of the water are the same at all seasons. The former inhabitants of the village, 
aware perhaps of the noxious effects of this spring, had an aqueduct formed, by which 
water is conveyed into the Brahmin portion of the village from a distant source. 
The aqueduct having been suffered to get out of repair, the quantity of water it 
transmits is reserved exclusively for the Brahmins ; except during the rainy season, 
when, the water being plentiful, the Rajpoots also use that of the aqueduct; but the 
Domes have no alternative at any season but to use the water from the spring." 

The valley of Baribice is elevated 4000 feet above the sea. Its eastern extremity 
IS composed of clay slate, and in five villages, containing 152 inhabitants, there is 
not one goitre. The other extremity of the vallej^ is partly composed of hmestone ; 
and of 192 inhabitants, distributed in six villages, 70 are affected with goitre : but 
Ducygong, one of these villages, supplied with water from clayslate, has not a single 
case of the disease ; while Agar, only half a mile distant, and containing 50 inha- 
bitants, has no less than 40 ; and of that number 20 are cretins. They use the water 
which issues from an old copper-mine in hmestone, and which contains carbonate 
of lime, and of soda, but no sulphate. 

Mr. M'Cleiland affirms that in the course of his personal inquiries, which extended 
over 1000 square miles, and which were prosecuted without regard to any theory, 
no instance occurred in which goitre prevailed to any extent where the villages 
were not situated on or close to hmestone rock. 



CRETINISM. 



475 



[In the United States the disease is prevalent in many of the valleys situated in the moun- 
tainous regions of New Hampshire, Vermont, New York, Pennsylvania and Virginia ; many 
of these regions abound in limestone rocks. — C.J 

Cretirdsm has a close, but an ill-understood, connection with goitre. Wherever 
cretinism is endemic, bronchocele never fails to be abundant. But bronchocele may 
prevail in a place where there are no cretins. With but few exceptions, cretins are 
goitrous ; whereas many of those who have bronchocele are not affected with cre- 
tinism. The two disorders either spring from the same cause, requiring for their 
joint production that this cause should be in active operation : or, if they have sepa- 
rate causes, these frequently co-exist and act in combination. It is said, I know not 
with what accuracy, that when both parents are goitrous for two generations in suc- 
cession, the offspring, being in the third generation, are sure to be cretins. Cer- 
tainly cretinism is most common where bronchocele is most common, and especially 
in mountainous places. It occurs in the Pyrenees as well as in the Alps, in the 
mountains of Syria, in the hilly parts of China, and in the Himala3^an regions. Yet 
cretinism is confined within much more limited bounds than goitre. Saussure, Fo- 
dere, and Dr. Reeve, agree entirely as to the circumstances under which cretinism 
appears to be most commonly engendered in Switzerland. They say that the dis- 
ease is usually met with in valleys which are nearly surrounded by high and steep 
rocks, where there is but little circulation of air, and where the inhabitants are ex- 
posed to the direct rays of the sun, and to the reflection of them from the rocks ; and 
also to effluvia from marshes. It is in the filthy habitations built in these close, hot 
and humid situations, that cretinism abounds most. The children that aie taken 
away from the low valleys, and carried up, when young, into the high grounds, 
escape the disease ; or even get the better of it if removed soon enough. And the 
amendment is said to be perceptible even in a very few days. These facts have led 
many persons to conclude that cretinism, if not bronchocele, depends on some condi- 
tion of the air. It appears to me probable that the exciting cause of both is the 
same, and that the local circumstances just now mentioned operate as predisposing 
causes only. Cretinism, as well as goitre, was observed, by Ramond, in the " open, 
well- watered, and well- ventilated valleys of the Pyrenees." 

There are some difficulties opposed to the implicit reception of the opinions formed 
by ]Mr. M'Clelland and by others, respecting the origin of these diseases. And the 
facts upon which those opinions are grounded, are not without apparent exceptions. 
Moreover, the actual substance which exercises or confers the noxious power, has 
yet to be ascertained. This etiological problem, so full of interest, is not solved. 
One step more, and probably one step only, remains to be taken. We look to the 
medical geologist, for its complete solution ; and I trust that, now, we have not long 
to look. The deleterious agent has been traced, with tolerable certainty, to water : 
and hence to some element of the soil washed by that water. And if what at present 
is probable only, shall hereafter be proved, — namely, that the hidden cause of goitre 
and of cretinism lurks in some chemical quality of man's natural beverage — it can 
scarcely be doubted that chemistry will be found ready to supply a simple and effec- 
tual corrective of the evil. This hope it is which makes it so important that medical 
men should be accurately possessed of the present state and bearings of the ques- 
tion ; and prepared to take advantage of every opportunity that may arise from its 
practical determination. For surely it would be a noble achievement of our art, and 
a signal blessing provided for hundreds of human beings yet unborn, thus to prevent 
the deformity, the discomfort, and sometimes the danger, of bronchocele ; and to 
forbid, in its very source and fountain, the more hideous and loathsome disfigurement 
of mind as well as of body that distinguishes the wretched cretin. 

I ought, perhaps, to tell you, that other causes, many of them very vague and un- 
satisfactory, have, at different times, been assigned. Thus Valentin supposes the 
disease to be more common in women than in men, simply because women more 
frequently have the neck uncovered. It has been affirmed that young females who 
have taken the veil in Catholic countries have lost their goitres in consequence of the 
change then made in their costume ; and a medical man in Guatimala asserts that 



476 



CRETINISM. 



the same infirmity has sensibly, diminished among the men in that part of the world, 
since cravats became fashionable there. These views of the matter accord with some 
whimsical notions entertained by the late Sir Anthony Carlisle. He held that the 
chief purpose of the thyreoid gland was to protect the delicate organ of the voice 
from the injurious influence of cold ; and he consequently regarded the tumour of 
bronchoceie as being rather of a sanative than of a morbid nature. He looked upon it 
as an additional greatcoat thrown over the important instrument of speech, in circum- 
stances of extraordinary need. His theory agrees with some of the facts on which 
other theories, not perhaps more plausible, have been founded. Thus, although 
snow water may not be, indeed I may say certainly is not, the cause of bronchoceie 
from any peculiar quahty that belongs to it, yet the disorder is confessedly frequent 
in many places where snow water is habitually drunk ; i. e., as Sir Anthony would 
have reasoned, where very cold water is frequently drunk ; the swelling being a 
provision of nature to obviate the hurtful effects which might else be produced on 
the larynx by these cold potations. The summer change for the better, described 
by Dr. Richardson, consists also with the same theory ; which would suggest the 
covering an incipient bronchoceie continually with warm clothing, such as flannel, 
to check its growth, to obviate its necessity, and so gradually to occasion its subsi- 
dence. And this plan is mentioned, I see, by Bouiliaud, among the curative indi- 
cations. 

I mention these theories, not because I have any faith in them myself, but as being 
curious specimens of the manner in which the human mind strives to account for 
obscure phenomena; and as showing how readily facts may be called and pressed 
into the service of very slender and infirm hypotheses. 

One very important point in the treatment of bronchoceie is obvious ; the removal 
of the patient, if that can be done, from the infected locality. When this has been 
effected, or when the disorder occurs sporadically, as it sometimes does, we may 
administer drugs with better hope and advantage. Now a great variety of empirical 
remedies have been recommended for the cure of bronchoceie, concerning most of 
which it would be a waste of time for me to speak at all. The remedy which, as 
an internal medicine, has of late years superseded ah others, and acquired the repu- 
tation of a specific against goitre, is iodine : and it certainly has a remarkable influ- 
ence over the genuine unmixed form of the disease, whether endemic or sporadic — ■ 
the hypertrophied gland ; yet it does not, perhaps, merit the title of specific in the 
same absolute sense as that in which we say that bark is a specific for the ague, or 
sulphur for the itch. Dr. Coindet, of Geneva, was the first who made this remedy 
extensively known. Dr. Straub, however, of Hofwyl, has laid claim to the priority 
of its use. Probably that happened in this matter, which has often happened in 
others, viz., that the state of knowledge was ripe for such a discovery, and it was 
made by each of these physicians independently of the other. Dr. Coindet's name, 
however, has been inseparably connected with the application of iodine to the cure 
of bronchoceie, in a work which, if he had no other claim to be remembered, would 
immortalize his memory ; — I mean Sir J. Herschel's profound and beautiful Dis- 
course on the Study of Natural Philosophy ; — a book which I should advise those 
among you who have not already read it, to make themselves master of as soon as 
they have leisure to do so. He thus strikingly illustrates an observation of his own, 
that mighty benefits often accrue to science from the casual experience of even un- 
scientific or iUiterate persons. "A soap manufacturer remarks that the residuum of 
his ley, when exhausted of the alkah for which he employs it, produces a corrosion 
of the copper boiler, for which he cannot account. He puts it . into the hands of a 
scientific chemist for analysis : and the result is the discovery of one of the most 
singular and important chemical elements — iodine. The properties of this being 
studied, are found to occur most appositely in illustration and support of a variety of 
new, curious, and instructive views then gaining ground in chemistry ; and thus 
exercise a marked influence over the whole body of that science. Curiosity is 
excited ; the origin of the new substance is traced to the sea plants from whose 
ashes the principal ingredient of soap is obtained ; and ultimately to the sea-water 
itself. It is thence hunted through nature, discovered in salt-mines and springs, and 



TREATMENT. 



477 



pursued into all bodies which have a marine origin : among the rest into sponge. A 
medical practitioner, Dr. Coindet, of Geneva, then calls to mind a reputed remedy 
for the cure of one of the most grievous and unsightly disorders to which the human 
species is subject, the goitre ; which infests the inhabitants of mountainous districts 
to an extent that, in this favoured land, we have happily no experience of, and which 
was said to have been originally cured by the ashes of burnt sponge. Led by this 
indication, he tries the effect of iodine on that complaint, and tlie result establishes 
the extraordinary fact that this singular substance, taken as a medicine, acts ^ith the 
utmost promptitude and energy on goitre, dissipating the largest and most inveterate 
in a short time, and acting (of course, hke all medicines, even the most approved, 
with occasional failures) as a specific, or natural antagonist, against that odious 
deformity." 

It is curious enough, and marks the accuracy with which the effects of remedies 
may be observed, that not only had burnt sponge been found efficacious in removing 
bronchocele, but the biadderwrack also, the fucus vesiculosus, the plant that, with 
others of the same family, yields the soda wherewith the iodine was found combined. 
Dr. Gairdner, who was the first I believe in this country to write on the effects of 
iodine, accounts for the frequent failure of even large doses of the burnt sponge, by 
showing that it was much adulterated with charcoal. Dr. Manson, of Nottingham, 
has published the following tabular statement of the results of the employment of 
iodine by himself. He had treated one hundred and sixteen patients, of whom fif- 
teen were men, and the rest women. Of the fifteen men, ten were cured, three 
were improving and under treatment at the time of his publication, one was dismissed 
for irregular attendance, and one was much reheved. Of the one hundred and one 
women, sixty-six were cured, nine much relieved, two received no benefit, ten were 
discharged for irregular attendance, and fourteen were improving under treatment. 
Of the whole one hundred and sixteen, therefore, there were seventy-six positive 
cures, or two-thirds of the entire number; and only two positive failures. Dr. Coin- 
det was successful in about the same proportion of cases. This is strong evidence 
of the power of the remedy. Dr. Manson found that in some, but not in all indivi- 
duals, after the preparations of iodine had been given internally for a certain time, 
they were apt to occasion headache, giddiness, sickness of stomach, with some degree 
of languor, and inaptitude for exertion. His plan in such cases was to suspend the 
use of the medicine, or to reduce the dose. The following effects of the iodine are 
stated by Dr. Coindet as having occurred in his practice : — Acceleration of the 
pulse, palpitation, dry cough, watchfulness, marasmus, and prostration of strength. 
Sometimes swelling of the legs, tremors, painful hardness of the bronchocele, dimi- 
nution of the breasts, or a remarkable increase of appetite supervened ; and he adds, 
that in almost all the instances which he had observed, a very rapid diminution, or a 
disappearance more or less complete, took place, during these symptoms, of even 
hard, bulky, and old bronchoceles. His doses varied from somewhat less than a 
grain to somew^hat more than a grain and a half. This was certainly, as Dr. Manson 
has suggested, too large a quantity of this powerful drug for the generality of patients. 
The management of the remedy is now belter understood. I have never seen any 
of the unpleasant consequences enumerated by Dr. Coindet. These practitioners 
gave the iodine in the form of a tincture. But this is a bad mode of exhibiting it: 
for the tincture is decomposed in any aqueous menstruum, and the iodine thrown down 
to the bottom. Under such circumstances the patient may at one time get no iodine 
at all, and at another time a dangerous dose : for you are aware that iodine is an ac- 
tive irritant poison. But if you mix iodine with iodide of potassium, it is then held 
in solution: and this. is the form in which it is now commonly given. Tn the last 
edition of the Pharmacoposia there is a Liquor Potassii lodidi composite, made 
by dissolving five grains of iodine, and ten of the iodide of potassium, in a pint of 
distilled water. This will doubtless, in future, be much prescribed. It is a dilute 
preparation. There is one grain of iodine in four ounces of the hquor. An ounce 
would, therefore, be a very safe dose, but you may begin with a couple of drachms, 
and iiiicrease the quantity, if need be, gradually : for not only Dr. Manson, but Dr. 
Copland also, who states that the remedy has been very successful in his hands, 



478 



BRONCHOCELE. 



advocates small, unirritating, what are sometimes called alterative doses. Simple 
friction is said to have had the effect of diminishing the tumour ; and friction with 
some ointment or liniment containing iodine should be employed whenever the inter- 
nal exhibition of the remedy is contra-indicated : or in addition to its internal use. 
There is an authorized form for that purpose also in the PharmacopcEia — the Un- 
guentiim lodini Compositum. A small portion of this may be rubbed upon the 
tumour night and morning. I need not add that besides great care in watching 
for the 1?pecific ill effects of the iodine upon the system, no less care is to be taken 
in correcting the state of any other function which may be faulty, and in improving 
the general health. 

Such is the best jnedical treatment of bronchocele ; and such is the plan which 
you will always do well to make cautious trial of in the first instance : and with re- 
spect to surgical treatment I may observe, that so long as the disease is merely a 
deformity, so long as it does not interfere with any of the important functions of the 
body, nor produce serious discomfort — does not distress the respiration by pressing 
upon the trachea, nor impede deglutition by pressing upon the (psophagus, nor de- 
range to any great degree the circulation through the head by pressing upon the 
great blood-vessels of the neck, nor grievously encumber the patient by its weight — 
we should not be justified (in my opinion) in performing or advising any surgical 
operation for the removal or the diminution of the tumour. Of such operations the 
three principal are, extirpation of the whole gland ; the passing a seton through the 
tumour, and so exciting suppuration in it, whereby its substance is broken down and 
destroyed ; and, tying the arteries which supply it with blood. The first of these 
methods, extirpation, has been performed when the wen was small ; but few patients 
under such circumstances would consent to the operation ; and few surgeons would 
now^-a-days, I presume, advise or undertake it; and in cases where it might seem 
more expedient, that is, where the swelling is large, and suffocation is threatened by 
its pressure on the trachea, the execution of this measure would be exceedingly difii- 
cuk and dangerous ; for the arteries are so much dilated in these cases that perilous 
hemorrhage might be expected from their division, especially when their close vicinity 
to the carotids is considered. Such large goitres come to involve also, by their lateral 
extension, very important nerves there situated. In one case where excision was 
attempted, the hemorrhage was so alarming that the surgeon was obliged to desist in 
the middle of his task ; and the patient actually died of hemorrhage a few days 
afterwards. I believe that this operation may be considered as wholly abandoned 
by surgeons in the present day. 

The introduction of a seton into the tumour has been more successful. This prac- 
tice was revived somewhat more than twenty years ago by Dr. Quadri, of Naples ; 
who supposed, indeed, that he had been the first to devise it. You will find an 
account of his mode of proceeding in the tenth volume of the Medico- Chirurgical 
Transactions, by Dr. Somerville. The seton is passed through the substance of the 
gland, and retained there a considerable time ; the chief caution necessary is to 
avoid the enlarged blood-vessels. Dr. Gluadri affirms that the larger trunks of the 
thyreoid arteries will not be endangered unless the seton needle be passed so deeply 
as almost to touch the thyreoid cartilage ; and that hemorrhage from any of the 
branches of those arteries that may be wounded when the seton is inserted more 
superficially, will not be attended with hazard. This plan was followed in one case 
by ulceration and sloughing, and the patient died. An example of the success of 
this treatment occurred in the practice of Mr. James, of Exeter ; the tumour was 
almost entirely removed, and the patient was for some time in London for the pur- 
pose of showing himself to the medical men here. But he also had passed through 
a good deal of suffering and peril. 

The expedient of tying one or more of the thyreoideal arteries, and so starving 
the tumour, has been attended with varied success. It has been done on the conti- 
nent ; and several times in this country : there is a case of it by Mr. Coates, of Sahs- 
bury, in the same volume of the Medico-Chirurgical Transactions. His patient 
was much relieved for a time, and supposed herself cured. But the tumour gradually 
returned, and caused her death by suffocation. Sir B. Brodie has also performed a 



CYNANCHE PAROTID^A. 



479 



similar operation ; and I have myself seen one very satisfactory instance of the same 
thing, the operation having been done by the late Mr. Earle, in St. Bartholomew's 
Hospital. The patient was a young woman with an immense bronchocele, which 
for some time previously had obstructed her breathing, and of which the effect on 
the trachea seemed to be every day increasing. There was loud wheezing, and great 
difficulty of respiration, and cough, and extreme emaciation : and it was plain that 
the girl must soon die suffocated if nothing were done for her relief. One of the 
arteries, I think the superior thyreoidal, was tied, without much difficulty, on one side. 
After the operation, the tumour on that side shrunk considerably ; the distress of 
breathing was removed ; and the patient presently recovered so much of her former 
strength, and flesh, and comfort, that she was unwilling to have any thing more 
attempted, and left the hospital. After some time, however, she came back again of 
her own accord, and requested that the artery on the other side might be tied also. 
This was accordingly done, and a further reduction of the tumour took place. The 
shrinking, however, if I remember rightly, was not so striking or complete after the 
second operation as after the first : but the patient was certainly rescued, upon the 
whole, from imminent death, and put into a condition of ease and at least temporary 
safety ; the tumour that remained constituting merely a deformity. I never heard 
of her afterwards. In a case very similar to this, related by Mr. Crawford in the 
Cydopxdia of Practical Medicine, Mr. Wickham, of Winchester, tied one of the 
arteries, with much immediate, but no ultimate benefit. The goitre gradually dimin- 
ished for about six weeks, and then (in consequence, I presume, of the establish- 
ment of a collateral arterial circulation) it as gradually enlarged again till it was as 
big as ever. 

Of these surgical expedients there is not one, of which the average results have 
been sufficiently prosperous to warrant its repetition, except in cases where life is 
put in jeopardy or made miserable by the swelling ; and where other methods, and 
particularly the treatment by iodine, have been tried, and have failed. One excep- 
tion, perhaps, I should here make. The tumour sometimes evidently contains a 
quantity of fluid, either in one of its enlarged cells, or in a distinct cyst. Now the 
cell, or cyst, may in such cases be punctured, and the contained fluid let out, w^ith- 
out much risk. This was done in one instance by my colleague, Mr. Arnott. He 
kept the orifice open ; and the cyst shrank, and was at last obliterated, and the wo- 
man was much gratified by this diminution of her load. 



LECTURE XLIV. 

Cyncmche Paroticlsea. Spontaneous Salivation. Aphthse, Cynanche Tonsillaris, 

The Greek writers on medicine apply the terms awayxyj and xvmyxt] to inflamma- 
tory affections occurring about the throat, and more or less interfering with the func- 
tions of respiration and deglutition : and the Latins employed the word angina in 
nearly the same sense. CuUen, in his Nosology, has made a genus of Cynanche, 
although the diseases which he has included in that genus have but little connection, 
except that the parts they occupy lie 7iear to each other. Some of them, indeed, 
have their seat in different, though almost contiguous, portions of the same memr 
brane ; and are apt, sometimes, on that account, to pass one into the other. In 
general the}^ are allied rather by proximity of situation than by com^munity of 
symptoms. 

I mention these things, because there being a great disposition in the present day 
to re-name diseases, and to affect a more precise and scientific nomenclature than 
sufficed for Cuilen, if I adopted the more modern appellations without adverting to 
the old ones, which have been current so many years, you might experience some 
difficulty in your reading, in determining what disease was intended, when it was 
merely named. For my own part, I think there is much inconvenience in akering 



480 



CYNANCHE PAROTID^EA. 



the established nomenclature ; and especially in changing such arbitrary terms as, 
though they may not be scientific, are yet definite, and convey no erroneous notions 
respecting the nature of the disorder. I shall give you, however, in most cases, both 
the old and the new denominations. 

Now one of the maladies in Dr. Cullen's genus Cynanche — though not the first 
in the order he follows — is cynanche parotidsea. It is an inflammatory affection of 
the sahvary glands, and of the parotid gland in particular. Accordingly it is called 
parotitis now-a-days. It is not, however, mere inflammation of the parotid, arising 
from any cause whatever; and therefore parotitis, unless some epithet be added, is 
Jess exact than cynanche parotidaea. The vulgar have given it just as good an arbi- 
trary name as the learned ; and they call it, in this country, the mumps. With the 
Scotch it is, I believe, the branks. 

The disorder need not detain us long. The parotid swells ; tumefaction takes 
place beneath the ear; and if the submaxillary and sublingual glands are not impli- 
cated in the outset, they soon participate in the tumefaction, in most instances ; so 
that the swelling extends from beneath the ear along the neck, tov^^ards the chin, and 
the swelled parts are hot and painful, and very tender when touched. The aspect 
of the patient becomes curiously deformed. Sometimes one side only is affected ; 
sometimes both sides at once ; but most commonly of all, first one side and then the 
other. These local symptoms are attended with shght fever. But the only func- 
tion that is materially affected is the motion of the lower jaw, which is impeded by 
the swelling. The inflammatory condition almost always terminates after a few 
days, in resolution, under the use of the antiphlogistic regimen, and the application 
of external warmth. The disease reaches its height in about four days, and then 
begins to decline ; and its whole duration may be stated, on an average, at eight or 
ten days. 

This complaint often prevails epidemically : when it affects one person in a family, 
or school, it usually affects several others, simultaneously or in succession. It chiefly 
attacks children and young persons. There can be no doubt that it spreads by con- 
tagion ; and it seldom happens that the same person is twice aflected by the mumps. 
These are remarkable circumstances, and give the malady a peculiar and specific 
character. I do not dwell upon them now, because they belong also to a very 
interesting group of diseases, which will require to be particularly considered 
hereafter. 

Another curious circumstance connected with the disease, and one which has 
some bearing upon its treatment, is that, in many cases, upon the subsidence of the 
swelling of the neck and throat, and particularly when it subsides quickly, the testi- 
cles, in the male sex, become swollen and tender, and the mammae in the female. 
It is said, but I do not know whether the observation be constantly true, that the 
testicle, or the breast, of the same side with the inflamed parotid, suffers. Some- 
times the testicle wastes away after the swelling recedes ; a circumstance which is 
known occasionally to happen when inflammation of that part arises from other 
causes. This, however, is not usual. In general the inflammation subsides and 
ceases in the one gland as it does in the other; the swelhng is neither very painful 
nor long continued. But sometinies a more serious transference takes place, from 
the testicle to the brain : this I have never witnessed ; but then, to say the truth, I 
have not often been called upon to treat the mumps, and my personal experience of 
it is hmited. I find it stated that the metastasis to the testicle is considered as rather 
a fortunate circumstance, because it serves as a sort of protection against" metastasis 
to the brain ; but I suspect this to be a mistake. Inflammation of the brain, or of 
its membranes, has sometimes occurred on the disappearance of the parotid swell- 
ing : but it hos much oftener supervened, I believe, upon the retrocession of the 
inflammation from the testicle or mamma. It is said also that the inflammation 
sometimes returns from the testicle to the parotid, and back again ; oscillating thus 
two or three times between the' two glands. Fortunate!}^, the metastasis to the brain 
is much more rare than that to the testicle. 

The treatment of the mumps is simple. It consists in the observance of the anti- 
phlogistic regimen ; mild diaphoretics ; laxative medicines, if the head aches, or the 



SPONTANEOUS SALIVATION. 



481 



bowels are confined ; and warm fomentations, or dry warm flannel, to the neck and 
throat. The tendency observed in this complaint to a change of place — to metastasis 
to more important organs — forbids us from using very active measures to check or 
subdue the inflammation. Nor are such measures necessary. We are not to bleed, 
nor violently to purge such patients, nor to apply cold to reduce the swelHng. 
Luckily, hot applications are not only the most safe and proper, but the most grateful 
also to the feelings of the patient. If suppuration should ensue — which is unusual 
and unhkely, but which sometimes does occur from extension of the inflammation to 
the neighbouring areolar tissue — poultices must be substituted for the fomentation. 
Warm applications, and rest in the horizontal posture are to be recommended when 
the inflammation leaves the sahvary glands, and attacks the testicles ; or if the pa- 
tient will not, or cannot, he up, the testicle must be supported by a suspensory 
bandage — a bag-truss. If the inflammation of the testicle or mammae be very vio- 
lent, we must apply leeches, and afterwards poultices ; but this will not often be 
required, or advisable. Finally, if the inflammation should fly to the brain, we must 
lay aside our previous caution, and treat the disease in that active manner which the 
inflammation of so important a part of the body demands. No ivorse metastasis can 
occur on the cessation of the phrenitis. I have fully spoken heretofore of the treat- 
ment to be pursued in that disease, and I have nothing to add respecting it now, 
except that it may be right as an auxihary expedient, to try to reproduce the inflam- 
mation in the parotid, or testicle, or mamma, by irritating applications — mustard 
poultices, for example — in the hope of thus producing what is called revulsion, and 
of diverting the disease from the brain to the part which it previously occupied. 

You know that there is another specific form of parotitis, which is apt to be 
induced by mercury. Of this I have already spoken. When it is severe, it may 
be treated by leeches, without any dread of such metastasis as occurs in the mumps. 
It is usually, though not always, accompanied by a profuse discharge of the secre- 
tion proper to the glands aflfected ; and it is attended also by sponginess and swell- 
ing of the gums. 

I presume that when inflammation of these sahvary glands is not attended with 
ptyalism, the parenchyma of the gland, or the areolar tissue which enters into its 
composition, is principally affected ; and that when there is much salivation, the 
membrane fining the secretory and excretory ducts is implicated. We see the same 
distinctions in other analogous organs. 

Profuse ptyalism sometimes occurs without any obvious cause, and is then said to 
be idiopathic, or spontaneous : and this is a circumstance which it concerns you to 
be aware of, both as practitioners and as medical jurists. The same tenderness and 
stvelling of the salivary glands, the same copious secretion and excretion of saliva, 
nay, even the same fetor, or a smell which can scarcely be distinguished from it — 
the same collection of symptoms which is familiar to you as indicating the specific 
action of mercury upon the human system — will arise sometimes (but very rarely) 
when not a particle of mercury has be^n administered. Several other substances 
are well known to have the occasional effect of producing an increased, and even a 
profuse flow of saliva : preparations, for example, of gold, of copper, of antimony, 
and of arsenic. The castor oil is said to have sometimes the same consequence. 
Digitahs certainly has ; and the iodide of potassium ; and sometimes, I beheve, 
opium. Now and then ptyalism is met with as a symptom among others, of preg- 
nancy. Occasionally it results from some local irritation within the mouth ; from a 
decayed or misplaced tooth. But what I principally wish to call your attention to 
is the fact that salivation may occur as an idiopathic complaint. In the twenty- 
sixth volume of the London Medical and Physical Journcd, there is an instance of 
it described by Mr. Davies, in which two or three pints of saliva were discharged 
daily for some time. This flux at length ceased under the use of laxative medicines. 
In the second volume of the Transactions of the College of Physicians is an extra- 
ordinary example of the same thing, related by Mr. Power. A young lady, of six- 
teen, spat from sixteen to forty ounces of saliva daily for upwards of two years. Mr. 
Power believed that the ptyalism in this case was originally excited by wool, which 
he found, in a fetid state, in her ears. In the Revue Medicaid there is an account 
31 JjQ 



482 



APHTHA. 



given of a patient who was cured of a spontaneous ptyalism after spitting nine pints 
daily for nine years and a half. You may see another instance, as related by Dr. 
Prout, in the old series of the Annals of Philosophy. Dr. Pereira states that he 
has seen a dozen such cases ; and he describes one which was fatal, not from the 
ptyalism, however, but from sloughing of the cheek : and this is no uncommon cir- 
cumstance. In certain cases of idiopathic inflammation and ulceration of the gums 
or cheeks, from some constitutional unsoundness, there may be extensive sloughing 
ptyalism, and a very offensive odour, much resembling that which mercury pro- 
duces. I have met with one example only of well-marked spontaneous ptyalism ; 
and some of its circumstances were so pecuhar, that they may be worth relating. I 
was taken out to Bayswater, by a medical friend, in the beginning of the year 1833, 
to see a little girl, ten years old, who had been in a state of salivation from the 5th 
of November in the preceding year. Up to that time she had been a healthy hvely 
child, with nothing very remarkable about her, except that she was habitually sub- 
ject to profuse perspirations, which had a very acid smell ; so that the washerwoman 
was always aware which were her clothes, when she came to wash them, by this 
smell. She then suddenly became indisposed, had a little headache, and began to 
spit a good deal. This was noticed by her mother, and pointed out to her medical 
attendant, before any medicine was given her ; and mercury, on that account, w^as 
rehgiously withheld. But in spite of all treatment the ptyalism went on increasing. 
When I saw her she was spitting three pints of saliva in twelve hours : transparent, 
rather dark-coloured, and with a small quantity of foam on its surface. There was 
nothing amiss with her teeth, or her gums, and no fetor of the breath. She was 
greatly emaciated, and resembled, in some respects, a person worn down by diabetes. 
From the very commencement of the spitting, the acid perspiration had ceased, and 
even the vapour had failed to make her sweat. A great variety of remedies were 
tried, under Dr. Nevison's superintendence, but without the least good effect. At 
last came the visitation of the influenza, in April of that year. The girl became 
severely affected by that disorder ; and thereupon the sahvation disappeared, and 
has not returned. I heard to-day that she is in excellent health. 

Should you meet with cases of the same kind, you will search for some cause of 
irritation in the neighbourhood of the sahvary glands, and especially in the state of 
the teeth and gums ; and finding none, you will seek further for the cause of the 
salivation in some deviation from the natural condition of one or other of the principal 
functions of the system : and you will regulate your treatment accordingly. I do 
not know of any specific plan of cure to be recommended : but it is certainly of im- 
portance that you should be acquainted with the fact, that ptyalism sometimes exists 
as a separate and independent malady. Astringent washes are found, sometimes, 
of service ; a solution of alum, or the infusion of catechu. 

Before I proceed to the diseases pertaining to the interior of the fauces and throat, 
let me take this opportunity of saying a few words in respect to aphthae. They 
form the characteristic symptom of an especial disease of infancy : and they are apt 
to occur in the course of other diseases in adult age; and are then of some im- 
portance as guides in forming our prognosis, and even in determining our plan of 
treatment. 

Aphthas consist in small, irregular, but usually roundish white specks, or patches, 
scattered over the surface of the tongue, and the fining membrane of the cavity of 
the mouth and fauces; the angles of the hps, the cheeks, the palate, the pendulous 
velum, the tonsils, the pharynx: They look like little drops of tallow, or morsels 
of curd, sprinkled over those parts ; they project a fittle above the surrounding sur- 
face ; and, in fact, they are mostly formed by elevated portions of the mucous epi- 
dermis, covering a small quantity of a serous or gelatinous fluid, which separates the 
epidermis from the subjacent corium. These portions of the epidermis detach 
themselves, and fall off ; leaving behind them a reddish raw-looking surface, or 
sometimes a foul and ash-coloured spot : and successive crops of these aphthae are 
apt to be formed. 

Now children in arms who exhibit these aphthae, are said to have the thrush. 



APHTHiE. 



483 



This occurs at an early age ; seldom, or never, I believe, after the period of lacta- 
tion is over. The spots occasion some inconvenience in themselves — the mouth is 
rendered hot and tender by them. The child may be eager enough to take the 
breast, but is observed to do so with pain and wailing whenever the mouth is applied 
to the nipple, and attempts to suck or to swallow are made. 

But these aphthae, thus occurring in infants, are attended with other symptoms of 
disorder : such as drowsiness, sickness, diarrhoea, and some feverishness. And I 
beheve, a general notion prevails, that the same aphthous condition which is visible 
in the tongue and mouth, pervades, in such cases, the whole of the alimentary canal. 
But this must be a mistake. That some morbid condition exists throughout that 
tract is highly probable, but true aphthae can only form on those mucous surfaces 
which are provided with a continuous epidermis. This erroneous notion has been 
strengthened, perhaps, by the observation of aphthous spots on the pharynx and 
(Esophagus. The complaint sometimes appears to be the result of improper diet, in 
children brought up by hand ; or of milk of a bad quality, from an unhealthy or in- 
temperate nurse. It generally lasts eight or ten days. It is not attended with much 
danger, except in certain cases, when the surface is left brown or bluish after the 
loosening and separation of the crusts. In such cases, the local affection is apt to 
run into a bad kind of gangrenous ulceration, and the discharges from the bowels 
become slimy and shreddy. 

In almost all instances of the thrush in children, there is acidity of stomach present. 
Care, of course, is to be taken to discover and to correct any error of diet ; and any 
unwholesomeness in the quahty of the food. And antacids are to be administered. 
I know of no form of medicine better adapted to remedy the diarrhoea of infants than 
the pulvis sodae cum hydrargyro of our hospital Pharmacopoeia ; composed of two 
parts of the pulvis cretae compositus, two parts of the dried carbonate of soda, and 
one part of hydrargyrum cum creta. From three to five grains of this powder may 
be given thrice daily : and for the local affection of the tongue and mouth, the mel 
boracis is a capital apphcation. It may be painted on the aphthous parts with a 
camel's hair pencil. 

Aphthae occurring in adults, in the course of other diseases, are often the har- 
bingers of dissolution. They denote considerable debility ^ and they point out the 
propriety of sustaining the patient's strength, by bark, wine, and nourishing food. It 
is remarkable how treatment of this kind will sometimes tell. 1 had a patient last 
summer who Hved for some months, and in tolerable comfort, after a second attack 
of apoplexy. Every now and then he would have a crop of aphthee appear, which 
was always an admonition to us that he not only would bear, but that he required 
some tonic. A more generous diet, with bark, would dissipate them in a day or 
two. 

Borax is an excellent application for aphthag, whether they occur in aduks or in 
infants. I have known it afford great comfort to patients who were in the last stage 
of phthisis, and to whom the aphthous state of the mouth was a source of consider- 
able distress. Equal parts of mel boracis, and syrup of poppies, make a good form. 
Or an agreeable as well as useful gargle may be made by mixing two drachms of 
borax, with an ounce of mel rosce, three ounces of decoction of quince seeds, and four 
ounces of water. 

■ Aphthse seem sometimes to depend upon mere derangement of the stomach. A 
nobleman who is well known as a bon vivant, can never eat shell-fish (so I am told 
by his physician) without finding, within two hours, that his mouth is full of aphthae. 
Even lobster-sauce will serve him thus. I look upon this as a sort of internal 
urticaria. 

[The disease of the mouth occurring in infants during the period of suckling, in which the 
tongue, and the inner surface of the lips and cheeks are covered, to a greater or less extent, 
with minute portions of a white matter resembling curd — and which constitutes the muguet 
of the French writers, the thrush or children's sore mouth of nurses^ and the aphthcB lactumina 
and aphtha infantiles of the older physicians, is evidently a very distinct affection from the 
aphtha which occurs in the adult as well as in the infant. The first depends upon an ery- 
tiiematic inflammation of the mucous membrane of the mouth, in which an altered secre- 



484 



APHTHAE. 



tion, in the form of small and curd-like particles or flocculi, or, as in other diphtheritic 
inflammations, of large patches of a soft pseudo-membranous matter, takes place upon the 
surface of the inflamed membrane. Upon the separation of these morbid exudations, the 
membrane beneath is found to be smooth, and without any solution of continuity. According 
to Guersent, the curd-like exudation is deposited beneath the epithelium, and its separation 
is consequent upon the rupture of the latter; Plumbe is of a similar opinion ; Guyot and Bil- 
lard, however, never saw it, excepting upon the surface of the epithelium, and this accords 
with our own experience. 

In mild cases, the inflammation of the mouth quickly disappears, the particles of curdy 
matter becoming detached, fall otT, and leave the membrane beneath of a smooth and healthy 
appearance. In other cases the inflammation continues for a greater length of time with 
little abatement: the spots of card-like matter increase in number, and, occasionally, form 
by their union large patches, often of considerable thickness — these patches, sooner or later, 
become detached and fall off", and their place is quickly supplied by a ne^Y exudation: and. 
this separation and renewal of the patches continue as long as the inflammation lasts. In 
some instances, the patches upon the tongue, lips, and cheeks, coalesce, and the whole of 
these parts become coated with a whitish, granulated crust, which not unfrequently extends 
into the fauces, pharynx, and, occasionally, into the larynx. 

In situations where a number of children are crowded together, in ill- ventilated apart- 
ments, the patches of exudation acquire often a dark colour, the breath of the infant becomes 
fetid: — the submaxillary glands enlarged and painful, the face swollen and of a dvisky-red. 
hue — the lips and gums become tumid, and bleed upon the slightest touch, while a fetid 
sanious saliva flows constantly from the mouth. Diarrhoea often attends, the discharges being 
dark-coloured and highly offensive. The disease, in its milder forms, is rather troublesome 
than dangerous — and it may be removed very speedily by an appropriate treatment; but 
when it is attended by the symptoms last described, it is very apt to terminate fatally, death 
being occasionally preceded by a deep comatose condition. 

There exists some difference of opinion among medical writers as to how far the morbid 
exudation characteristic of this affection extends beyond the mouth and fauces. It is gene- 
rally admitted that, in severe cases, it has been found in the oesophagus, as far down as its 
cardiac orifice : but, while some, including Billard, have asserted that it has been observed 
throughout the whole tract of the alimentary canal, others, with Veron, maintain that, in no 
instance has it been met with beyond the oesophagus — the curd-like crusts, occasionally 
found in the stomach being, as they suppose, conveyed thither from the mouth by degluti- 
tion. Guyot gives a case, in which the disease was detected, after death, throughout nearly 
the whole tract of the intestines. In the few opportunities we have had of examining the 
state of the alimentary canal in infants who have died whilst labouring under this disease, 
we were unable to trace the exudation beyond the oesophagus — a similar statement is made 
by Dewees and Eberle. 

We are to recollect that the disease just described is the result of an erythematic inflam- 
mation of the mucous membrane of the mouth; aphthce, however, are produced by a follicu- 
lar inflammation of the same membrane. This affection is more commonly observed about 
the period of dentition than at an earlier age — it is particularly liable to occur in children 
of a lymphatic temperament, or in whom hsematosis has been rendered imperfect, by impro- 
per or innutritions food, a damp and cold, or impure and stagnant atmosphere, exclusion 
from the light, and neglect of cleanliness. It is, also, of very common occurrence during 
most of the chronic affections, especially of the intestinal canal, in persons of all ages. 

In the commencement of the disease the mucous membrane of the mouth becomes in- 
creased in redness, and upon the inner surface of the lips and cheeks, on the sides and infe- 
rior surface of the tongue, and, occasionally, over the greater part of the soft palate, there 
soon appear a number of distinct white specks, which, upon examination, are found to be 
small transparent vesicles, of a grayish or whitish colour, each being surrounded at its base 
by a raised, hard ring of a red colour more or less decided. These vesicles often occur in 
groups, or they may cover the whole of the lining membrane of the mouth and fliuces ; ex- 
tending, in some cases, into the oesophagus, and throughout the alimentary canal ; while in 
other cases they penetrate into the pharynx, and, according to some writers, into the larynx 
and even the trachea. The follicular inflammation will often continue for some time, as 
just described, without making any further progress, and it may often be arrested beibre 
ulceration ensues. Usually, however, the vesicles enlarge in size, rupture, and give discharge 
to a M'hitish matter ; a superficial ulcer now occurs, with slightly elevated edges, and sur- 
rounded by a circle of inflammation. These ulcers often secrete a white, curdy matter, 
vrhich adheres, at first, to their surface, but becomes subsequently detached, and is either 
swallowed or ejected with the saliva. It is often succeeded by a new exudation of a simi 
lar matter, and thus, in protracted cases, the crusts of curdy matter are repeatedly detached 
and renewed; or only a portion of the crusts are detached, while the general layer of curdy 
matter remains adherent, often for weeks. When the aphthous ulcerations are numerous, 
and in close contact, this ourd-like exudation may spread from one to the other, and form a 



CYNANCHE TONSILLARIS. 



485 



iayer, often of considerable thickness and extent. Occasionally, the exudation from the 
ulcers is mixed with a small portion of blood ; it then forms dark-coloured-crusts, which have, 
not unfrequently, been mistaken for gangrenous sloughs. 

Upon the subsidence of the inflammation the ulcerated follicles readily cicatrize without 
leaving any permanent scar. 

Occasionally, particularly in children of debilitated habits, and who are deprived of pro- 
per hygienic influences, the aphthous ulcerations become gangrenous, their edges shrink, and 
assume a ragged, flabby appearance ; a brownish slough forms in their centre, which, on 
separating, leaves a granulated surface of a vermilion hue; or, in place of a slough, the 
ulcers become covered with a brown, creamy fluid, that exhales a very decided gangrenous 
odour. The parts surrounding the ulcers become tumid, soft, and of a violet hue. From the 
half-open mouth of the child is discharged a ropy, often fetid, saliva. The countenance 
becomes pale and pufly ; the pulse feeble; and the entire surface of the body pallid, and 
deficient in sensibility: — repeated vomiting, profuse diarrhoea, and a tympanitic condition of 
the abdomen, generally occur ; and occasionally, hiccup with frequent eructations, and the 
patient finally dies, according to Billard, without febrile reaction or cerebral excitement. — 
(See Condie on Diseases of Children, page 126 et seq.) 

Recently, M. Gruby has attempted to show that, aphthss and muguet are invariably pro- 
duced by the development of a cryptogamic vegetable. 

According to the researches of this gentleman, the aflection consists, at first, of small, coni- 
cal, whitish elevations, twenty-five millimetres in diameter, dispersed over the mucous mem- 
brane of the mouth. These elevations quickly augment in size, and extend rapidly over the 
adjacent surface, until, finally, the whole of the mouth, fauces, and sometimes the entire ex- 
tent of the alimentary canal, appear to be covered with a pseudo-membranous layer, from 
two to three millimetres thick, and strongly adherent to the subjacent tissue. When a por- 
tion of this substance was examined under a microscope, M. Gruby found it to be composed 
entirely of a collection of cryptogamic plants, the roots of which, of a cylindrical form, trans- 
parent, and about one-four hundred and eightieth part of a millimetre in diameter, are im- 
planted in the cellules of the epithelium. During their development, projections from these 
roots penetrate the entire series of cellules of which the epithelium is composed, to arrive at 
the free surface of the mucous membrane. 

According to M. Gruby, these cryptogamic plants have considerable analogy with the spo- 
rotrichium described by some botanists. Being very fragile, they become detached by the 
movements of the tongue and lips, and mixing with the food, are carried into the alimentary 
canal, a considerable portion of the mucous coat of which they subsequently cover. Those 
children in whom this extension of the disease takes place to any great extent, fall into a 
state of marasmus, and soon die. 

M. Gruby, having never detected in the white substance of aphthse or muguet any thing 
else than the cryptogami just described, and the celkxles of the epithelium, — there being, in 
no instance, any product of inflammation present, — considers himself authorized to conclude 
that aphthse are neither more nor less than a vegetation occurring upon the living mucous 
membrane. Views precisely similar to those of M. Gruby have been advanced by Dr. Berg, 
of Stockholm. 

Dr. Oesterlein has also submitted the matter of aphthas and muguet to microscopic exami- 
nation, and has been able to detect in it a vegetation similar to that described by the ob- 
servers just named. This vegetation he has met with, however, only at the period of the 
fullest development of the aphthas or muguet, which latter he considers to be the product of 
an exudation resulting from an inflammatory condition of the mucous membrane; the pro- 
duction of the confervce being purely accidental. He attempted, repeatedly, to transplant 
them to other animal tissues or fluids, but without success. — C] 

Hard by the salivary glands lie the tonsils : and one of Cullen's species of 
cynanche is the cynanche tonsillaris ; in more modern language, tonsilHtis, or amyg- 
dalatis : or, in the vernacular, quinsy, common inflammatory sore throat : a disease 
which, though internal, is yet within the reach of our sight, and easily recognized. 

The popular term quinsy is in truth, traceable — through the French esquinancie 
— to the scientific term cynanche. 

This common and troublesome disorder occurs with very unequal severity in dif- 
ferent cases. The differences depend upon the extent of the disease, and upon the 
number and variety of the parts which it involves : for it is seldom limited entirely to 
the tonsils, but spreads to the uvula, the velum palati, the sahvary glands, the pha- 
rynx, and even to the. root of the tono^ue, and the neighbouring areolar tissue. When 
the inflammation is superficial it does not produce any great distress, even though it 
may be diflused. When it penetrates through and beyond the mucous membrane, 
it is apt to end in suppuration, and to harass the patient much : the tonsils sweU to 

2q2 



486 



CYNANCHE TONSILLARIS. 



an enormous size, and at length deep abscesses form in them. The disease is worst 
of all when the back part of the tongue, and the muscular and areolar tissue there- 
abouts, become implicated : it may chance to reach even the larynx, and then it 
is always and extremely perilous. 

Under its more ordinary forms, cynanche tonsillaris generally manifests itself, at 
first, by a slight degree of uneasiness and difficulty in swallowing ; with a constant 
dryness and sense of constriction in the fauces, and a feeling as if some foreign sub- 
stance were sticking there. Upon inspecting the throat, more or less of inflamma- 
tory redness and swelhng is seen of one or both of the tonsils. Sometimes both of 
them are affected at once. Very frequently one only is first attacked : and the 
swelling begins in the other as it ceases in the first. This is just what occurs in 
many instances also of cynanche parotidsea. The uvula is commonly enlarged and 
elongated, and of a scarlet colour. Sometimes it drags upon the back part of the 
tongue, or dangles into the pharynx, causing the disagreeable sensation of a foreign 
body continually present, and provoking, by its mere contact, painful and fatiguing 
acts of deglutition. More frequently the uvula may be seen to be adherent to that 
tonsil which is most swollen. The dryness of the fauces soon gives place to a copi- 
ous secretion of transparent mucus, which is frothy and viscid, and sticks to the in- 
flamed surface so as to be detached with difficulty ; and the patient is tormented by 
continual and painful efforts to hawk up, or to swallow, this mucus. In an early 
stage of the disease opaque whitish spots appear upon the red tonsil. They are ex- 
udations from its surface, or the discharged contents of the mucous crypts there 
situate. It is important that you should be aware of this, lest you mistake such 
specks for ulcerating or sloughing points, such as occur in some other affections of 
the throat, but which are not common in the outset at least of this. 

When the inflammation is violent, the submaxillary and parotid glands sometimes 
swell, and become tender on pressure : and, less frequently, the patient is troubled 
by profuse ptyalism. In other words, the inflammation spreads from the tonsils to 
the salivary glands, and secondary parotitis occurs ; sometimes with and sometimes 
without an augmentation of their natural secretion. Unable, or unwilhng, to swal- 
low tTie abundant saliva, the patient allows it to dribble from his mouth. 

Now and then, although the act of swallowing is difficult and painful, you per- 
ceive on looking into the fauces, no appearance which can account for these symp- 
toms. The inflammation is seated lower down in the throat ; out of sight. This 
cannot with propriety be called cynanche tonsillaris ; indeed, it forms a distinct spe- 
cies, the cynanche pharyngea of Cullen. I mention it here because it realJy does 
not require any separate consideration. 

The pain in cynanche tonsillaris is felt almost solely during the act of deglutition ; 
which is difficuh also from the mechanical narrowing of the passage by the enlarged 
glands. When both tonsils are affected at once, and much swollen, they push for- 
wards the anterior pillars of the velum palati, and project in the shape of two great 
balls of flesh, into the arch of the fauces, so as to leave a very small space only be- 
tween them ; and they sometimes even meet and touch each other, and cause ul- 
ceration by their mutual pressure. When attempts are made to swallow hquids, 
they are apt to return through the nose ; the backward passage can no longer be 
shut in consequence of the tumid and fixed condition of the velum palati. The pa- 
tients are unable to swallow even soft sohds ; indeed the pain of swallowing is so 
great, that they are not easily persuaded to try. In severe cases pain shoots from 
the throat to the ear along the course of the eustachian tube ; and this is considered 
important, as being indicative of suppuration. I believe that suppuration does occur 
in the majority of the cases which are attended with this symptom. Sometimes 
there is tinnitus aurium, and partial deafness, from the obstruction produced to the 
passage of air through the eustachian tube : either by closure of its extremity in con- 
sequence of the swollen state of the parts about it, or by some thickening of its fining 
membrane from an extension of the inflammation along its channel. 

When the inflammation is intense, and involves the root of the tongue, the patient 
becomes unable to open his mouth sufficiently to allow the fauces to be seen ; and 
the inflamed parts can be examined only by means of one's finger. In some instances 



CYNANCHE TONSILLARIS. 



487 



the power of separating the jaws is so limited, as not to admit the introduction of 
the finger : and the tongue is incapable of any motion. 

In ordinary cases, however severe the disease may be, there is scarcely any 
affection of the breathing. But the throat is so blocked up, and the free play of the 
velum palati so impeded, that the speech is altered ; becoming thick, guttural, and 
inarticulate. You may often recognize the disease by the peculiar sound of the 
patient's voice, without looking into his throat. When the swelling of the tonsils is 
very great, the breathing does sometimes become impaired ; and it is in such cases 
alone, or nearly in such cases alone, that this disease is at all alarming. 

Cynanche tonsillaris is commonly attended, from the very outset of the inflam- 
mation, by smart inflammatory fever : severe headache often, and a rapid pulse, rising 
to 120 beats in the minute, or more. The constitutional disturbance runs higher 
than we might have expected, considering the Hmited extent of the local inflammation, 
and the comparatively small importance of the part inflamed. At the same time 
there is very httle of that debility and anxiety which are observed, as we shall see 
hereafter, in common continued fever. 

The inflammation often terminates by resolution ; but when it is violent or long- 
continued, it very frequently leads to the formation of pus. When the mucous 
secretion increases in quantity, and becomes less viscid, while the difficulty of 
swallowing diminishes, and the febrile symptoms decline, resolution may be expected. 
Suppuration, on the other hand, may be looked for when the inflammation is un- 
usually intense, when, by the swelling of the tonsils, the breathing is impeded, when 
a pulsating pain is felt, shooting to the ear, when the patient can scarcely open his 
mouth, or protrude or move his tongue, when there is more than usual external 
swelhng, and when the symptoms increase, or even fail to remit, after five or six 
days have elapsed. Rigors sometimes accompany and announce the suppuration : 
and afterwards the pus may be often seen shining through the membrane covering 
the tonsils. In many cases, however, it hes so deep that it cannot be detected by 
the most careful examination. At length the little abscess bursts ; and the refief 
thereupon experienced by the patient is sudden and striking. All at once the pain 
ceases: he can swallow, and he feels himself well; and often indeed he is well, or 
nearly so. The matter discharged has always a nauseous taste and a remarkably 
fetid smell : and sometimes the fetor, or the ill taste, is the only sign, besides the 
improvement in the symptoms, that indicates the rupture of the abscess ; the pus 
being so small in quantity as when mixed up with other matters, easily to escape 
notice, or (what frequently happens), passing backwards into the stomach by an in- 
voluntary movement of deglutition. Suppuration sometimes, but rarely, takes place 
externally, in the areolar tissue of the neck, as well as internally. 

The termination in gangrene is spoken of in books : and it is just possible : but it 
never happens, I imagine, except in unhealthy constitutions ; or when tonsilhtis 
occurs as a complication of more general disease, such as scarlet fever. It is much 
more common to see repeated attacks of cynanche tonsillaris produce what used to 
be absurdly called scirrhus, a permanent enlargement and hardening of the tonsils. 
While they are in this state, a low kind of inflammation is very readily re-excited in 
them. The enlarged tonsils are generally irregular, and notched ; something like 
the surface of a walnut shell; and a white or yellow secretion is often to be seen, 
lying in the hollows. This appearance may be easily mistaken, by an inexperienced 
eye, for ulceration. 

There is not much risk of your confounding cynanche tonsillaris with any other 
complaint. The various species of cynanche enumerated by Cullen are separated 
each from the others by certain broad lines of distinction : all derived, however, from 
different combinations of two symptoms; — dyspncea and dysphagia. Thus, in 
cynanche tonsillaris, deglutition alone is difficult ; and when you look into the throat 
you see at once why it is difficult. There is equal difficulty of swallowing, and 
equal freedom of respiration, in cynanche pharyngea ; but the cause of the dysphagia 
is not visible. In cynanche trachcalis, the respiration is much affected ; the facility 
of swallowing not affected at all. In cynanche laryngea both these functions are 
implicated; there is difficulty of swallowing as well as difficulty of breathing. 



488 



CYNANCPIE TONSILLARIS. 



Cynanche parotidoea is distinguished by the absence of both the symptoms ; its title 
to the name of cynanche is therefore equivocal. Many of these points will soon 
come under our notice again. 

Cynanche tonsillaris is supposed to be most frequent among the young and 
plethoric. But it certainly occurs very often also in persons who are pale, and spare, 
and feeble ; and in those of middle age. Some individuals appear to have, by 
nature, a strong predisposition to the disease ; and in them its attacks are more or 
less periodical ; recurring at particular seasons, and commonly during the variable 
weather of spring and autumn. This peculiarity runs sometimes in families. 
The liability to the complaint is also very much increased by repetitions of the 
attacks. 

The only exciting cause worth mentioning, almost the sole cause indeed, is expo- 
sure to cold. Not unfrequently it assails so many persons at the same time as to be 
epidemic ; and for that reason it has sometimes been thought contagious. But it 
has no contagious property whatever. Although we often see several members of 
the same family affected by it at once, yet we may learn, upon careful inquiry, that 
its commencement in the different cases has been too nearly simultaneous to admit 
the supposition of its having been communicated from one to another. The patients 
have all been exposed to the same unwholesome influences, which operating upon 
similar constitutions, such as those who are sprung from the same parents may be 
expected to possess, have produced similar effects. This prevalence of the disorder 
at certain times and places, is connected, no doubt, with some peculiar conditions of 
the atmosphere. 

The prognosis is almost always favourable. Not but what death may be produced 
by this disease, under peculiar circumstances, and when the inflammation is un- 
usually violent and extensive. The late Dr. Gregory, of Edinburgh, used to men- 
tion in his lectures one instance, the only one he had met with among many hundred 
cases, of death from cynanche tonsillaris. He did not see the patient till he was 
moribund : and he suspected that it was combined with typhus fever. The only 
fatal case that I ever witnessed occurred some years ago at the Middlesex Hospital, 
in one of my own patients. He was a stout young man, 26 years old, a private 
coachman. The complaint was clearly traced to his having got wet through, more 
than once, a day or two before it came on. Besides the ordinary symptoms of 
cynanche tonsillaris, there was great external swelhng on both sides of the throat, 
and the patient was unable either to open his mouth, or to move his tongue. The 
inflammation involved not the tonsils merely, but the base of the tongue, the salivary 
glands, and the surrounding areolar tissue. At length suppuration took place. The 
abscess broke internally, and pointed also externally, just below the symphysis of 
the chin, where it was opened with a lancet. Two days after, there was a sudden 
gush of blood from the mouth. So immovable Avere his jaws that it was impossible 
to determine from which side the hemorrhage proceeded ; it was stopped, however, 
apparently by the treatment adopted. A fortnight later, the bleeding recurred pro- 
fusely. It was now evident that the blood was arterial, and that it came from the 
left side of the throat. Preparations were made for tying the common carotid on 
the left side ; but just as the operation was about to be begun, the patient expired in 
our presence. His death was shocking, but full of pathological interest. He did 
not sink, as you may have supposed, in the way of syncope, from loss of blood ; 
but by suffocation. The blood passed down the trachea and into the lungs ; and he 
had been so weakened by the previous hemorrhage, that he could not expel the 
blood so introduced, which actually choked him. A large clot was afterwards found, 
filling up the wind-pipe. I felt this man's pulse beat firmly and regularly, for a 
minute perhaps, after his last effort to breathe. On examining the body it was dis- 
covered that the abscess had opened internally behind and below the left tonsil. 
The hngual branch of the carotid artery crosst-d the site of the abscess ; and had 
been severed and laid open by ulceration. From this vessel the fatal hemorrhage 
had come. 

It should be borne in mind also, that cynanche tonsillaris does sometimes, by ex- 
tension of the inflammation to the neighbouring parts, superinduce that very formi- 



CYNANCHE TONSILLARIS. 



489 



dable species of cynanche, of which I am soon to speak, the cynanche laryngea. 
All cases in which the breathing is in any degree affected, should excite suspicion, 
and strict scrutiny ; although the dyspnoea may be produced by the mere sweUing of 
the tonsils. 

You will understand, then, that cynanche tonsillaris may, under unusual and 
untoward circumstances, prove a fatal disease ; but that it is so very rarely indeed. 
In almost all cases we may say that the life of the patient is not in danger. 

In the uncomplicated and milder form of the disease, when the inflammation is 
superficial and the fever slight, no great activity of treatment is requisite. The 
patient should be kept within doors, and even in bed : for a troublesome tendency 
to a recurrence of the disorder may be fostered by neglect or imprudence. Cooling 
saHne purgatives will be proper, and the antiphlogistic regimen. A strip of flannel 
may be put round the neck, and some stimulating embrocation applied to the exte- 
rior of the throat, beneath the ramus of the jaw : the compound camphor liniment is 
well adapted to this purpose. Some such plan as this will generally suffice, not 
indeed to stop the inflammation of a sudden, nor to put an end at once to the fever, 
but to cause the complaint to run its course evenly, and to go on to resolution in a 
few days. Commonly it is not completely over until both the tonsils have been 
attacked in succession. 

When you catch the disorder in its very outset, I believe you may sometimes 
succeed in cutting it short by an emetic : a scruple of ipecacuanha, for example, 
with a grain of tartarized antimony. In all cases it is right to administer a brisk 
purgative. 

A great variety of astringent, acid, and other gargles, have been employed in this 
disease ; and their good effects have, I apprehend, been much over- rated. Many 
cases would do quite as well, or better, without them ; for in the early stages strong 
astringents, and the straining and movements of the throat that accompany their use, 
may even be hurtful, and increase the pain and the inflammation. The only gargle 
which I should consider admissible in the commencement of the malady is a gargle 
of warm milk and water. I have known of one instance in which quinsy suddenly 
attacked a gentleman who was extremely anxious to use his throat, in public speak- 
ing, the next day. He occupied himself perpetually, for some hours, in this sort of 
fomentation of the tonsils with hot water ; and with such good effect that on the day 
following he was able to accomplish his object. Still there are cases in which, at 
certain stages of the disease, detergent gargles are serviceable, by assisting the excre- 
tion of the mucus that collects in the fauces, and by correcting fetor. A w^eak solu- 
tion of chlorine in water answers well. In more chronic sore-throats, stimulating 
gargles may often be employed with advantage. When the inflammation is violent 
a slightly stimulant linctus is preferable; it cuts the phlegin as ihey say, i. e., it 
promotes its detachment and removal. Of this kind, currant-jelly is one of the best. 

But far better than any thing else, as a local application to the inflamed fauces, is 
the steam of hot water ; whether we are hoping for resolution of the inflammation 
or whether we desire to promote and hasten the process of suppuration already begun 
The inhaler introduced by myself into the Mid- 
dlesex Hospital, and elsewhere, though somewhat 
clumsy in appearance, is the most convenient and 
effectual that I am acquainted with. I show it to 
you. It was invented in Edinburgh by a friend 
of mine long since dead, Mr. Hercy. It will stand 
upon a table, or lie upon a pillow ; and a large 
volume of steam is carried inwards against the 
fauces by the mere natural breathings of the pa- 
tient. Most of the inhahng machines that I have 
seen require a sucking effort, like that made in 
smoking a pipe : an effort that is apt to be irksome 
and fatiguing, especially in pulmonary diseases ; 
for some of which this method of applying vapour directly to the suffering part is as 
useful as it is for sore-throats. 




490 



CYNANCHE TONSILLARIS. 



Blistering the outside of the throat is a favourite remedy with many. When 
early applied, a blister often does much good, and probably prevents suppuration in 
some cases. But I have found blisters of uncertain efficacy ; they leave a mark 
which lasts for some time, and which patients of the other sex are apt to complain 
of. For these reasons I prefer mere rubefacients ; the liniment I mentioned before, 
or the compound soap liniment, or a mustard poultice folded between two layers of 
/bin Hnen. 

In more severe cases leeches applied to the upper part of the throat, just below 
the angles of the jaw, have been found to give sensible relief: and in the worst 
degrees of the disorder, when there is much outward swelling, and the jaws and 
tongue are fixed, leeches are absolutely requisite. It may be proper to take blood 
from the arm also. The necessity for active depletion must be measured by the 
severity of the local symptoms, the intensity of the fever, and the general strength 
and condition of the patient : and of these things a little experience will teach you 
to judge. 

It is not to be expected that either leeches or bhsters wnll be of much use after the 
process of suppuration has commenced ; nay they may sometimes be injurious by 
retarding it. It is frequently a difficult matter to determine whether pus has yet 
formed or not. 

I have already admonished you to make a careful examination of the throat, and 
to watch your patient narrowly, whenever he experiences any difficulty of breathing. 
Dyspnoea may be produced by the mere swelling of the inflamed part ; and when it 
concurs with much enlargement of the tonsils you had better pierce them with the 
lancet. If they contain matter, it will be evacuated ; and if not, the bleeding pro- 
duced by the puncture will generally reduce the swelling somewhat, and relieve the 
patient. There is an instrument made on purpose for this small operation, consisting 
of a lancet enclosed in a flat silver sheath, from the end of which it is made to pro- 
trude, to a certain extent only, by pressing upon a spring. The instrument should 
be directed towards the centre of the fauces, and not outwards, in order to avoid 
wounding important vessels or nerves. Dr. Cullen indeed says, "this does not 
require much caution :" but notwithstanding this high authority, I must warn you 
that puncturing or scarifying the tonsils is an operation not to be carelessly, or rashly, 
or wantonly performed. Portal mentions a case in which a skilful surgeon, in scari- 
fying the tonsils of his patient, wounded as he supposes some ramification of the 
internal carotid, and the patient was presently dead. That artery lies-, as you know, 
very near the tonsil ; and only a few years ago, in Ireland, it was struck by a sur- 
geon while scarifying a gentleman's tonsil ; and the gentleman died in three minutes. 
This I was told by the late Dr. Barclay. The case I related just now of fatal hemor- 
rhage from the lingual artery points to the same danger : and since that case occurred 
two others involving similar hazard have fallen under my own notice, and impressed 
me with a strong feeling of the necessity of caution. A man was brought into the 
hospital with profuse hemorrhage from the right tonsil or its immediate neighbour- 
hood, the consequence of syphilitic ulceration of those parts. He had lost three or 
four quarts of blood, and was nearly dead. His life was saved by Mr. Mayo, who 
tied the common carotid on that side. 

Last February (1838) a boy from Harrow School was placed under my care, in 
whom cynanche tonsillaris came on during convalescence from scarlet fever. So 
much swelling was there of both tonsils that they met, and pushed the uvula out- 
wards before them, and the breathing was much impeded. A surgeon who was in 
attendance with me punctured the tonsils. The next day a good deal of hemor- 
rhage took place ; and this recurred, several times, to a considerable and even an 
alarming amount. When the clots that formed were wiped away with a sponge, 
the blood could be seen welling out in a httle stream, with a pulsating motion, from 
a small incision in the left tonsil. The hemorrhage was ultimately, after much trouble 
and anxiety, arrested, by applying a pencil of lunar caustic freely, within the bleed- 
ing orifice. Lint, wetted with the muriated tincture of iron, or with a saturated 
solution of alum, is a fit appUcation in similar accidents. 



ACUTE LARYNGITIS. 



491 



Mr. Lawrence, who saw this case, told me that he once knew a patient die of 
hemorrhage from the tonsillar artery. 

I ought, perhaps, here to add, that very recently, Mr. Joseph Bell, of Barrhead, 
has strongly recommended the internal administration of powdered guaiacum, in 
large doses, as being almost specific in the cure of cynanche tonsillaris. He gives 
as much as half a drachm, suspended by means of mucilage, in a draught, every six 
hours. Mr. Bell has no doubt that this remedy, if timely administered, will cut the 
disease short in ninety-nine cases out of a hundred. It has been found successful in 
other hands also. I have never had an opportunity of trying it. 

The chronic enlargement of the tonsils, to which I have already adverted, is some- 
times productive of great inconvenience and distress, and even of danger. Its occa- 
sional consequences are — an habitual trouble in swallowing ; confused and inarticu- 
late speech ; deafness in various degrees, from occlusion of the eustachian tubes ; 
more or less impediment of breathing ; and even spasm of the glottis, and impending 
suffocation. The enlargement may, in such cases, be somewhat reduced, I beheve, 
by repeatedly passing a stick of lunar caustic over the surface of the tonsils ; but a 
much readier and better plan is to amputate them, in part at least. This may be 
done by a ligature ; or still better by scissors, or by a sort of small guillotine invented 
for that purpose. It is not a very painful operation. Mr. Arnott removed one lately 
from one of my hospital patients; and a very few days ago (December, 1838) Mr. 
Mayo brought two, in a piece of paper, to the hospital. He had just before cut 
them off for a patient whose respiration they had much embarrassed. 

[Recently the application to the enlarged tonsils of the iodide of zinc, is said to have the 
effect of causing their rapid absorption. The article is prepared by placing a clean plate 
of zinc over a jar or vial, and sprinkling iodine over it. In a short time the iodine is 
deposited in the vessel, in the form of a semi-fluid deliquescent substance. This is to be 
applied pure, to the surface of the enlarged tonsil, by means of a camel's hair pencil, or a 
piece of sponge, secured to a suitable handle. It is to be held on for a short time, and re- 
peated every two or three days, until the object is accomplished. The application is fol- 
lowed by a pungent smarting, which lasts for twenty or thirty minutes, but by no other 
inconvenience. Dr. Goddard, of this city, we are informed by Dr. Parrish, in his annual 
Report on Surgery, read to the College of Physicians, has used the remedy extensively, and 
speaks very favourably of its effects. He has found it to possess the property of inducing 
a rapid absorption of the enlarged tonsil, by a sort of shrivelling process, without the forma- 
tion of a slough. It does not, like the chloride of zinc, spread to the surrounding healthy 
structure, and hence, may be used without the fear of injury from being swaUowed. (Swwi- 
mary of the Trans, of the College of Phys., of Philadelphia, No. vii, page 191.) — C] 



LECTURE XLV 

^ cute Laryngitis, Symptoms. Treatment ; Blood-letting. Tracheotomy, Mer- 
cury, Antimony. Anatomical Characters of the Disease. Causes. Secondary 
Laryngitis. (Edema of the Glottis. Chronic affections of the Larynx. 

The disease of which I have next to speak is of far more serious character than 
those which were considered in the last lecture. Cynanche laryngea, or acute 
laryngitis, has proved rapidly fatal in a large proportion of the instances in which it 
has been known to occur. Yet, when the patient is seen tolerably early, and the 
nature of the malady is clearly perceived, and the source of peril thoroughly under- 
stood, I believe that our art is sufficient, in most cases, to rescue the sufferer from 
the fate that hangs over him. It is of the greatest importance, therefore, that you 
should be able to recognize laryngitis when you meet with it, and that you should 
comprehend the principles according to which it requires to be treated. 

What is laryngitis? It consists, as that term implies, in inflammation of the parts 
composing the larynx ; and especially of the mucous membrane that covers the 



492 



ACUTE LARYNGITIS. 



laryngeal cartilages, including the epiglottis. The inflammation may be, and some- 
times is, exactly limited to the larynx ; but frequently it extends also to the posterior 
fauces, the velum palati, and the tonsils. 

The symptoms of acute inflammation of the larynx are these. The patient com- 
plains of sore-throat. If you look into his throat you will commonly perceive some 
redness of the velum and uvula, and of the fauces generally. But there is a degree 
of restlessness and anxiety about the patient more than proportionate to the apparent 
inflamm.ation. Among the earliest of the symptoms that bespeak danger, and ought 
to excite alarm, is difficulty of deglutition, for which no adequate cause is visible in 
the fauces ; and to this is presently added difficulty of breathing, for which no ade- 
quate cause can be discovered in the thorax. The mode and character of the respi- 
ration are peculiar ; it is attended with a throtthng noise ; the act of inspiring is 
protracted and wheezing, as though the air was drawn in through a dry narrow reed. 
If you ask the patient what is the seat of his distress, where the disease is situated, 
he points with his finger to the pomum Adami. If he coughs, he coughs with a 
peculiarly harsh, stridulous, busky, abortive sound. He either speaks quite hoarsely, 
or (what is more common) all power of audible voice in the larynx is lost, and he 
speaks by means of his lips and tongue only, in a whisper. There is tenderness of 
the laryngeal cartilages ; they are painful when pressed externally. The face is 
flushed ; the skin hot and dry ; the pulse hard. As the disorder advances, the pa- 
tient's general distress increases; but some of the symptoms alter; his countenance 
becomes pale or livid, anxious and ghastly ; his eyes protrude ; he is miserabl}?- un- 
quiet, impatient for some relief, declares or makes signs that he wants air, and begs 
that the windows may be opened : and if he does not obtain timely relief, he pe- 
rishes — he dies strangled. 

The pathology of this terrible disease is extremely simple. The membrane 
covering the interior surface of the instrument of the voice suffers inflammation. 
One effect of inflammation in mucous membranes is a thickening of those membranes; 
they become turgid and swollen. Another frequent effect is the effusion of serous 
fluid in the subjacent areolar tissue. By such tumid thickening of its lining mem- 
brane, the chink called the rima glotticlis is narrowed : it is still further diminished 
in breadth whenever the membrane is lifted and protruded by infiltration of the tissue 
beneath it: it is so nearly closed up, that air cannot pass inwards in sufficient 
quantity to sustain the vital functions : a small portion only of the blood returned to 
the lungs from the right side of the heart undergoes the requisite change from venous 
to arterial. The miserable patient grows drowsy and dehrious, and dies by a slow 
process of strangulation. If the rima glottidis becomes quite closed up, his suffer- 
ings and his life are quickly at an end. 

This disease affords a good instance of a truth which was announced in a former 
part of this course of lectures; viz., that the danger of a morbid change may de- 
pend entirely upon its situation. It is so, eminently, with laryngitis. The inflam- 
mation is sometimes hmited to a spot of membrane not bigger than a square inch. 
If a square inch and no more of the same membrane, a little lower down, in the 
trachea, were inflamed in the same manner and degree, the complaint would be quite 
unimportant. Cynanche laryngea derives all its peril from the circumstance that the 
inflammation tends to shut up what may well be called the janua vitsc. The part 
affected subserves two purposes : it is the organ of speech ; and it forms a portion 
of the channel through which air is conveyed from without into the lungs. Both of 
these purposes are impeded in laryngitis. Now the animal function of speech may 
be entirely and permanently suspended without any danger to life. The function of 
respiration, which, though under the influence of the will, is an organic function, 
will not bear to be suspended, even for a few minutes ; and life cannot be long sus- 
tained when it is much impeded. 

The difflculty of svv-al lowing is a remarkable symptom, and almost always present. 
Yet it is not absolutely universal ; for Mr. Lawrence describes a case in which it did 
not occur. It appears to depend, in some measure, upon the tumid and tender con- 
dition of the whole membrane which is common to the larynx and pharynx, and 
which is pressed upon as the larynx rises in the act of deglutition : but this symptom 



ACUTE LARYNGITIS. 



493 



depends also, and in a greater measure, upon the state of the epigloitis, which is often 
enlarged, and fixed by the swelhng in an erect position, and unable to execute its 
natural valvular office ; so that when the patient makes efforts to swallow, a portion 
of the food or drink gets into the larynx, and a paroxysm of choking dyspnoea ensues. 
By pressing down the back part of the patient's tongue, and getting him at the same 
moment to make a coughing effort, you may sometimes obtain a sight of the tumid, 
red, and upright valve. 

The dyspncEa is constant : yet there are pauses of comparative ease and quiet ; 
and thert are, commonly, periods of severe aggravation and urgent distress. It is 
probable taat the permanent narrowing of the chink by the inflammation and its con- 
sequences is from time to time increased by spasmodic contraction of the muscles 
that close the glottis. 

This is the first disease that has come before us, in which the respiration has been 
primarily impeded. If you call to mind what was stated in one of the early lectures 
respecting death by apncea, you will be at no loss to understand the manner in which 
life is destroyed in laryngitis. 

This formidable malady has always existed; for you may trace examples of it, 
under various names, even in the writings of the ancients. But it is only in recent 
•times that it has been singled out from the rest of the anginas, and made a separate 
object of study. It has numbered some distinguished medical men among its victims : 
Dr. David Pitcairn, Sir John Macnamara Hayes, Sir George Tuthill. The cele- 
brated General Washington died of it. When it has caused death it has generally 
run a rapid course, and proved fatal before the fifth day. It has carried the patient 
off in less than twelve hours. 

It is of the utmost consequence to make an accurate diagnosis. Laryngitis is 
easily distinguished from cynanche tonsillaris by the extreme and peculiar dyspnoea 
which attends it. There may be difficulty of breathing in the latter disease, from 
enormous swelhng of the tonsils ; but then such swelhng will mostly be visible. In 
laryngitis the marks of inflammation to be seen on inspection of the fauces are gene- 
rally slight and trifling, and quite inadequate to explain the difficulty of swallowing. 
Do not, however, forget that laryngitis ma^ supervene upon cynanche tonsillaris. 
Again, cynanche laryngea is readily discriminated from cynanche pharyngea ; in 
which complaint there is great pain and difficulty in deglutition ; but the breathing 
is quite free. In cynanche trachealis, or croup, which I shall next describe, the 
breathing is affected, and the swallowing is not. 

What is to be done for a patient labouring under acute laryngitis ? How and when 
are we to employ the great remedy for acute inflammation — blood-letting? or are 
we to employ it at all ? These are points concerning which it is quite necessary that 
your minds should be prepared and prompt to decide. If you look merely to the 
results in the recorded cases of this fearful complaint, you will scarcely find an 
answer to the question. In some of them copious bleeding appeared to save the 
patients ; in others, it was of no service, but rather seemed to accelerate their death. 
Sir John Macnamara Hayes suffered two attacks of cynanche laryngea. In the first 
he was freely bled. Dr. Roberts, of Bishop Stortford, informs us that the first bleed 
ing was attended with considerable relief; the second also with manifest advantage; » 
and by the third, his safety appeared to be ensured. Fifteen years afterwards he 
died of the same disorder, for which he was again bled and leeched, under the care 
of the late Dr. Baillie. Washington was largely bled, and died. Again, a Dr. 
Francis, of New York, recovered from acute laryngitis after copious vensesection. 
It is evidently needful to consider and determine the circumstances under which we 
are to use, or to withhold, the lancet. 

Bleeding, to be serviceable, or safe, must be performed early. There is-, perhaps, 
no disease in which the xatpo? o|uj, the fleeting opportunity, is more conspicuous than 
m this. When I say that you must bleed early, if at all, I do not mean that you 
are to reckon so many days or hours from the commencement of the disorder ; but 
you must ascertain what progress it has made ; for it travels sometimes at a railroad- 
pace. You must look to your patient's actual condition ; and I apprehend that your . 
practice, in respect to blood-letting, may be safely guided by the following rules. If 



494 



ACUTE LARYNGITIS. 



there be high inflammatory fever present, and the skin is hot, the pulse firm and 
full, and the cheeks are red, and the hps florid, you may bleed your patient with 
decision and advantage. But if his powers are beginning to sink under the poison- 
ous influence of imperfectly aerated blood, if his skin be cold, or even cool, his face 
pale or leaden, his lips blue, his pulse small and feeble, his mind wavering — you 
xrill do no good by blood-letting : nay, you will increase the debility which already 
'ijxists, and hasten the fatal catastrophe. 

With regard to local blood-letting, and to counter-irritation, there is one remark 
Tiade by Dr. Farre of much practical importance. -It is a common practice, in affec- 
tions of the throat, to apply leeches over or near the laryngeal cartilages, and after- 
,vards to place a bhster there. Now serous infiltration of the neighbouring parts 
often follows leech-bites ; and the effect of a bhster in producing serous effiasion often 
extends beyond the skin : and the cartilages of the throat he very near the surface ; 
and it is possible that (Edema of the glottis might be produced, or augmented, in 
consequence of these topical remedies. It will be better, therefore, when we wish 
to take blood locally, to take it by cupping from the back part of the neck : and when 
we desire to produce counter-irritation, it will be prudent to lay a blister on the upper 
part of the sternum, rather than to the front of the throat. 

In the advanced stage of the disease, medicine, I fear, can effect but little. 

But surgery may be more successful. 

The danger arises from the mechanical obstacle to the entrance and exit of air into 
and from the lungs ; and this state of peril admits of a mechanical remedy. If an 
artificial opening be made between the obstructed part and the lungs, the air is again 
freely inhaled and freely expelled ; the blood undergoes the vital change from pur- 
ple to scarlet; and the patient is placed in a condition of safety. He continues to 
respire through the hole thus drilled in the trachea, until the inflammation of the 
larynx has subsided ; the thickening of the membrane disappeared ; the submucous 
infiltration been re-absorbed ; and the vocal instrument restored to its natural integ- 
rity ; and then the aperture in the wind-pipe may be suffered to heal, and the patient 
will again draw his breath through its natural channels. 

This is one of the triumphs of the •healing art. It requires a knowledge of the 
geneml pathology of the disease, i. e., an acquaintance with the facts that acute in- 
flammation may affect the larynx almost exclusively, and that its tendency is to nar- 
row the fissure of the glottis, and destroy life by suffocation. It requires a knowledge 
of the symptoms of such inflammation : and it requires an accurate knowledge of 
all the essential circumstances of the particular case. For it is not every case in 
which the transit of air through the slit in the larynx is hindered, that is a fit case 
for the operation of tracheotomy. Some years ago there was brought to me by a 
surgeon a man breathing with considerable labour and constraint, the air passing 
through the larynx with an audible hissing noise. The surgeon wished to know my 
opinion of the propriety of opening the patient's wind-pipe. He had come to the 
conclusion that there was ulceration of the membrane lining the larynx, with thicken- 
ing ; that the cause of the sibilous respiration was partly mechanical, partly spasmo- 
dic ; the little muscles that close the glottis acting with injurious energy in conse- 
quence of the neighbouring irritation : and he thought that this mischief in the 
larynx would have a better chance of being repaired, if the functions of the organ 
could be for a time suspended. He was aware, however, of the necessity of ascer- 
taining what was the condition of the lungs ; and he had not studied auscultation 
long enough to trust his own ear in that matter. The patient was pale and thin, and 
emaciated ; and three minutes sufficed to convince me that his lungs were exten- 
sively disorganized. His respiration was not so difficult as to threaten suffocation ; he 
was not dying of the laryngeal obstruction ; and I recommended that he should not 
be subjected to an operation which might curtail his existence, but could not effect a 
cure. The man died soon after ; and we examined his body together. There was, 
as my friend had supposed, ulceration of the membrane near the chords vocales, 
and the lungs were full of suppurating or softening tubercles. I mention this case 
to show you that it is necessary to ascertain the condition of the thorax generally, 
before we perform or sanction such an operation as tracheotomy. Not that there is 



ACUTE LARYNGITIS. 



495 



anything very formidable, or painful, or dangerous, in the operation itself. But if 
we cut a hole in a patient's throat, who is sure to die soon after of some other 
incurable complaint, we shall incur the risk of being charged with having killed 
him. Do not misunderstand me, however. If a patient's life be threatened by acute 
laryngitis, or by laryngeal oedema, and we are sure of that, and if at the same time 
we are sure that he carries another mortal disease about him, we are not for that 
reason to let him die, if we can help it, of the laryngitis ; any more than it would 
be lawful for us to administer a drachm of prussic acid to a man condemned to be 
hanged the next morning. Biit we must state the whole of the case plainly to the 
patient's friends, and propose the operation as a mode, not of effecting an absolute 
cure, but of staving off the immediate danger. 

And here let me repair an omission of which I was guilty when speaking just 
now of the diagnosis. My object was to guard you against mistaking laryngitis for 
some other malady : but I must also warn you against the converse error, that of 
mistaking some other malady for acute laryngitis. I can assure you that such a 
mistake has been made ; and tracheotomy has been performed, too, when there was 
no disease in the larynx ; and the practitioners by whose authority it was performed 
have been ungenerously reproached for their error, although no harm beyond the 
slight pain and inconvenience of the operation resulted from it. The cases in which 
this blunder has been committed have nearly all, I believe, been cases of aneurism 
of the thoracic aorta, which by its pressure on the first divisions of the air-passages, 
or on the nerves thereabouts distributed, had caused that kind of laboured andstridu- 
lous breathing v/hich is characteristic of laryngitis. I may venture to say that no 
person who has had opportunities of educating his ear for the purposes of ausculta- 
tion, and has made a proper use of those opportunities, could ever overlook such a 
comphcation as this. I have myself seen a woman (I mentioned her case before) 
whose trachea was laid open by a surgeon while she was suffering under mere hys- 
teria ; so closely did that disease mimic laryngitis. 

When you have good evidence that a mechanical obstruction to the passage of the 
air exists in the larynx, and that the tubes beyond the larynx are pervious and free ; 
there are two things w^hich I would urge upon you. First, I would most earnestly 
advise you not to wait too long before you propose or perform tracheotomy ; and 
secondly, never to omit performing it merely because it may appear to be then too 
late. If, in the acute and limited disease, an artificial opening be made while the 
patient's strength is yet entire, and before his whole system is poisoned with venous 
blood, or his lungs are overwhelmed with sanguine congestion and serous effusion, it 
will almost infallibly save his life. But if the sinking of the vital power has got 
beyond a certain point, tracheotomy will not, in that case, rescue him. It is bad and 
foolish practice to wait, and try_ other methods, and postpone the operation as a last 
resource, when the circulation is evidently loaded with unarterialized blood. In my 
own case I should choose to be operated on early; the moment that I found early 
blood-letting was not telling upon the local distress, and that any shade of duskiness 
became perceptible in the skin ; just as I should choose to be operated on at once 
for strangulated hernia, after one fair attempt had been made by a skilful hand to 
return the bowel ; without waiting till inflammation set in, or had been caused by 
the taxis. On the other hand, if you do not see your patient until his powers are 
nearly exhausted, do not abstain from the operation even though you may feel con- 
vinced that it will be unsuccessful ; for if it does not save life, it will disarm death 
of its agony. A patient will lie sometimes for hours, painfully labouring for breath 
in deep and strong catches, at considerable intervals from each other : in fact, he is 
just in the condition of a man with a cord round his neck, not pulled quite tight 
enough to suffocate him at once. Besides, it is not always easy to say whether the 
period of possible recovery is yet gone by. I had a female patient in the hospital 
who had suffered one or two attacks of frightful dyspnoea, in which the main diffi- 
culty was referred to the larynx; but she had rallied from them before any steps 
could be taken for performing tracheotomy. On the next occasion, however, the 
seizure was so sudden and rapid, that although Mr. Arnott was luckily in the hospital 
at the time, the woman was, to all appearance, dead, before he could be found and 



496 



ACUTE LARYNGITIS 



brought to her bedside. Respiration had entirely ceased. This quietude of the 
larynx rendered the operation more easy. Mr. Arnolt speedily made an opening 
into the trachea ; some air was blown in through the aperture, and then pressed out 
again ; and presently the natural respiration was renewed. The woman recovered : 
the orifice healed up, and she left the hospital. Three or four months afterwards 
word was brought that she had died at her own home after a short attack, and when 
there was no one at hand to open her windpipe. We got permission to examine 
the body, and found a large ulcer in the trachea, near the larynx ; which ulcer by 
its irritation had occasioned, as we presumed, the spasmodic closure of the glottis. 
A preparation exhibiting the diseased parts is on the table before you. You see that 
there was an enlargement of the thyreoid gland. This had probably nothing to do 
with the symptoms. There was also a large ulcer in the left bronchus. 

Mr. Goodeve, surgeon to the Chfton Dispensary, operated on a patient in whom 
"no pulse could be found at the wrist; his face was suffused with blood, and his 
lips hvid ; and it was hard to say whether he breathed or not :" yet he recovered. 

It so happens that there is at present (December 1838) under Dr. Wilson's care, 
in the hospital, a woman named Slack, who was rescued when almost in articulo 
mortis, by the same expedient. She had chronic disease of the larynx ; but a sud- 
den aggravation of the symptoms occurred ; she became stupid and comatose, her 
countenance was cadaverous, her skin covered with a cold clammy sweat, and her 
breathing, which had been stridu'lous and laryngeal, had almost, if not quite stopped. 
She was making short, gasping efforts to respire, not oftener than twice in a minute. 
Her pulse was intermittent, and extremely feeble. In this state the house-surgeon 
(Dr. William Merriman) made a small incision in the skin over the cricoid cartilage, 
and then thrust a large trocar into the windpipe. Air rushed through the opening, 
the respiration returned, the pulse revived, and the stupor passed away. This hap- 
pened on the 10th of October. She is still in the ward ; the aperture has closed up ; 
and though she is not well, she is living. 

What is the reason, you may ask, of these different and inconsistent results 1 How 
is it that tracheotomy shall reanimate one patient, Avhose last breath, but for its help, 
was already drawn, who was already motionless in apparent death; and yet shall 
fail to save another patient, who is still ahve, and sensible of his danger, and strug- 
ghng with his disease ? The difference depends, I make no doubt, upon the time 
that elapses between the commencement of extreme dyspnosa, and the performance 
of the operation ; upon the slow or the speedy completion of the stranghng process. 
And this, again, obviously depends upon the manner and degreis in which the pas- 
sage is narrowed. When the obstruction, though considerable, is incomplete, and 
does not rapidly augment, the respiration continues to be performed, however, im- 
perfectly. Meanwhile the brain gets oppressed, the circulation tends to stagnate, 
and, above all, the lungs become gorged with black blood, and clogged up by effu- 
sion into their cells and substance. Secondary causes of apnosa are thus established, 
which do not cease when the primary cause is at length removed, by the unbarring 
of the main channel for the admission of air. Whereas when the access of the 
atmosphere is suddenly or soon shut out, the lungs are not thus mortally injured, 
but remain capable of resuming their functions when they are again supplied 
with air. 

Tracheotomy, then, will be the most likely to succeed, while the patient is still 
hvely and strong ; and after that the chance of success will be worse in those cases 
in which the apncea has been slow in its prog'ress, than in those in which it has 
been rapid. I repeat that, in threatening circumstances, the operation should be done 
early ; but that it should not be withheld, through despair, at any period of the 
disease. 

The effect produced upon the condition of the patient by the timely formation of 
an artificial glottis is very striking. The moment that the scalpel penetrates the 
rings of the trachea, air begins to hiss through the incision ; and when a fair opening 
is established, and a full inspiration is drawn in through the wound, several forcible 
expirations generally succeed, whereby a considerable quantity of mucus is expelled, 
which could not pass the contracted aperture of the natural glottis. Then the 



ACUTE LARYNGITIS. 



497 



breathing soon becomes easy, the anxiety and distress are followed by a perfect calm, 
and usually the exhausted sufferer sinks into a tranquil slumber. This sleep is apt 
to be from time to time interrupted by the clogging up of the orifice with frothy 
mucus. It is requisite that some intelligent person should remain by the patient, 
to assist him in these emergencies, or he may still be throttled, notwithstanding the 
apparent prosperity of the operation. 

When a sufficient hole has been made in the instrument of the voice, below the 
glottis, the voice of course becomes extinct, or nearly so ; and the patient is as unable 
to utter a cough as he is to use vocal language. Now this it is of some importance 
to notice, for he often wants to cough, in order to clear the air-passages of mucus, or 
of blood, by which they may be embarrassed ; and he may be helped to do so, or 
taught to help himself. First he should draw in a full breath, and then stop the ori- 
fice for a moment with his finger, while he makes the expiratory effort. And as the 
parts within the larynx recover, the patient, by a similar mana3uvre, may enable 
himself to speak aloud. 

As actual examples are more interesting and often more instructive than an ab- 
stract of results, I will tell you in a summary manner the history of a case of laryn- 
gitis, which occurred in one of my hospital patients, in the latter part of the year 
1832. He was an old man, about sixty. His name was Kent. He was brought 
to the hospital bloated with anasarca, which was most conspicuous in his legs and 
thighs. His breathing was laborious and difficult, and attended with a wheezing 
noise, audible at some distance. He could not lie down : he had a hard, but not full 
pulse. The dropsical swelling had come on suddenly five or six days before ; and 
in the outset his face (he said) was so puffed up that he could scarcely see. He 
had been bled to the amount of a pint and a half, according to his own account, on the 
previous evening. I had a vein opened immediately, and twenty-four ounces of 
blood were drawn ; and eight ounces more were taken from the chest by cupping. 
He was thoroughly purged with calomel and senna. The bleeding gave him very 
little relief, so far as the respiration was concerned ; but the next morning the ana- 
sarca had totally disappeared. I found him sitting up in bed, breathing with much 
effort, and with a loud stridulous noise which accompanied both inspiration and ex- 
piration. He referred all this uneasiness to two points ; one of these was the 
larynx, the other the ensiform cartilage. He swallowed with great pain and diffi- 
culty ; and every attempt to do so excited a fit of choking cough. There was no 
morbid appearance visible in the fauces : every part of his chest sounded well on 
percussion, and the murmur of healthy respiration could everywhere be heard in the 
lungs, almost drowned, ho^vever, in the louder laryngeal noise. As his strength was 
entire, I had him again cupped, to twelve ounces, at the back of the neck ; and pre- 
scribed three grains of calomel every three hours. He also inhaled the steam of hot 
water. 

Upon visiting him again the same evening, I found the dyspnosa increased. Each 
act of respiration was attended with a loud croupy noise. His countenance was be- 
ginning to be anxious and ghastly. He was restless ; and his pulse was less firm. 
Being now firmly convinced that the operation of tracheotomy was the only thing 
that could save him, and that it could not be safely delayed, I sent to request that Sir 
Charles Bell would come and perform it. By the time he arrived the restlessness 
had increased. The patient was shifting perpetually from one side of the bed to the 
other, as if seeking some new point of support : his face had become pale ; and his 
lips were turning Hvid. He spoke with sudden, and as it were with convulsive 
efforts; stating earnestly how thankful he should be to have the obstacle to his 
breathing removed ; and pointing to the larynx as the seat of his distress. 

The ordinary operation, under such circumstances, is by no means an easy one to 
perform. Its difficulties were well exemplified in this patient. In the first place he 
was sitting up ; he could not bear to be placed in the recumbent position. Then the 
dyspncEa caused him instinctively to elevate his shoulders, and sternum, and clavi- 
cles, to the utmost, so that the trachea was sunk deeply into the thorax ; and the 
larynx was in constant and rapid movement up and down with a plunging motion, 
like that of the piston of a steam engine. Sir Charles, after some trouble, succeeded 
33 2r2 



498 



ACUTE LARYNGITIS. 



in cutting out a piece of the cartilage ; for a mere slit did not suffice : it closed tightly 
during every inspiration, although it was open enough during expiration. At length, 
when the air was freely admitted, the breathing became gradually easy. I shall 
never forget the whole spectacle : there sat the poor man gasping and fighting for 
breath ; his face covered with sweat, and wearing the most anxious expression. By 
and by what I have called an artificial glottis is opened for him ; and presently after- 
wards, though half a dozen candles (as Sir Charles has himself painted the scene) 
are held close to his face, to throw light upon the wound, and though the surgeons, 
their hands smeared with blood, are still busy about his throat, making arrangements 
to ensure the patency of the orifice, the patient falls fast asleep. It was necessary 
to place an assistant behind him to prevent his head from nodding forwards, and 
deranging the apparatus in the wound. Nothing can express more strongly than 
this fact the great distress and fatigue which had previously existed, and the perfect 
rehef afforded by the operation. 

This man ultimately got quite well ; and he has since shown himself occasionally 
at the hospital, in excellent health. There were two or three points about the case 
which I am unwilling to pass over without notice. It was evident that after the 
opening was made in his windpipe, he still breathed in part through the rima glot- 
tidis also; for the stridulous sound did not wholly cease. The aperture was formed 
as low as the circumstances of the case appeared to permit : the tube was perforated 
in the membranous space between the thyreoid and cricoid cartilages. Strictly 
speaking, laryngotomy was the operation performed. I do not enter into the con- 
sideration of the best place for making the opening ; that point you will be taught 
by the professor of surgery : but it was observed in the case in question, that the 
slightest touch of the irritable mucous membrane, with a hook or a probe — especially 
if the touching instrument w^as turned upwards towards the gloitis — produced a fit 
of coughing, and a paroxysm of still more laborious breathing. For some days after 
the operation, it was noticed that a part of whatever liquid he swallowed appeared 
immediately at the wound. Now this proved as plainly as if we could have seen 
the parts, that the epiglottis was thickened, and erected, and incapable of performing 
its protective function to the larynx : and it accounted for the paroxysm of choking 
cough produced by each act of deglutition. At first the lining membrane of the 
larynx and trachea was so irritable, that the patient could not bear to have a metal- 
lic tube inserted ; and an ingenious contrivance was adopted for keeping the orifice 
from being covered over by the hps of the w^ound. They were held apart by two 
bent wires, which were tied together at the back of his neck. After twenty-four 
hours had elapsed, the irritability of the mucous membrane had so far abated that he 
was able to breathe through a canula. 

There cannot be a doubt that this man was snatched from the very jaws of death 
by the intervention of the surgeon. A function indispensable to life was nearly sus- 
pended ; and a substitute for the faulty organ was provided by art, until the inter- 
rupting cause was removed. Scarcely a year passes over our heads without the 
occurrence of one or two such events in the hospital. When lecturing upon this 
subject last season, I w^as able to show you a female patient whose hfe had been 
saved in a similar way. And there is now also (December 11, 1839), in Pepys' 
ward, a rescued man, with the tube still in his windpipe. The operation was done 
on the spur of necessity by Mr. Tomes, the present house-surgeon, with a trocar. 
The patient, who was previously in a state of extreme distress, said, in a faint whis- 
per, as soon as the opening was effected, "It's all right now." 

He had been exposed to rain and cold about a week before ; and had suffered 
pain and tenderness of the larynx. Prjor to his admission he had been bled, and 
salivated, and had a blister on the throat which embarrassed the operation. 

Within the last eight years the operation of tracheotomy has been performed in 
the Middlesex Hospital fourteen times. Seven of the patients recovered : seven 
died. In two of the seven fatal cases, the condition of the patients was hopeless at 
the time of the operation. In four at least of the five others much relief from suffer- 
ing; was afforded by it, and life apparently prolonged. One of the patients was a 
young child : the opening was made by a trocar ; much blood got into the air-pas- 



ACUTE LARYNGITIS. 



499 



sag-es, and the child, which seemed to he sinking previously, died within the hour. 
Life might, I think, have been preserved in this case, by a timely operation, pro- 
perly done. For a trachea so small, the scalpel is preferable to the trocar. But in 
the adult subject I have seen the larynx penetrated so neatly, easily, and speedily, 
both by Mr. Arnott and by Mr. Shaw, with a small curved trocar, that I am per- 
suaded of the general superiority of that method over the common operation with 
the knife or scissors. If this be granted, the fit place for the opening must be the 
membranous space between the thyreoid and the cricoid cartilages. The superja- 
cent skin is first nicked with a scalpel : the larynx is then fixed for a moment by 
I the operator's left hand, while with his right he thrusts the instrument steadily 
inwards and downwards. 

I have said nothing hitherto about the use of mercury in this acute disorder, be- 
cause I hold it to be of very secondary importance, and because I have been anxious 
not to divert your attention from the two great practical points, bleefling and trache- 
otomy. Mercury may very fitly be given in those cases and circumstances in which 
I blood-letting appears proper ; but we cannot depend upon it ; we cannot reckon upon 
I its influencing the system in time ^ nor upon any marked improvement of the symp- 
! toms when it does produce its specific effects. After the operation it is, for the most 
I part, unnecessary. 

Nor do I recommend the employment of tartar-emetic, powerful as that drug is 
1 known to be in subduing inflammation of the mucous tissues. In the swollen and 
i unpHant state of the epiglottis it would not be prudent to excite, or to hazard, vomit- 
j ing. The contents of the stomach passing upwards would be apt to enter the un- 
, protected larynx, and to cause hurtful, distressing, and even perilous attacks of suffo- 
cative cough. 

In the examination of fatal cases, sometimes the thickened membrane forming the 
I edges of the rima glottidis is found covered with viscid mucus, which had formed 
I an additional impediment to the passage of air towards and from ihe lungs : some- 
I times pus is discovered, lying in the sacculi laryngis, or scattered among the carti- 
I lages and surrounding muscles : and sometimes the chief morbid condition is the 
! infiltration of the submucous areolar tissue. The effect in all cases is the same, that 
of closing up, wholly or partially, the narrow fissure between the arytenoid carti- 
lages. The state of the epiglottis I have several times described. 

This very serious disease is a disease of adult age ; it is not often known to occur 
in children. They again are almost as exclusively liable to croup: and cynanche 
laryngea has been called the croup of aduljii. But as the part occupied by croup, 
and the event of the inflammation, are both different from those of laryngitis, this 
name, croup of adults, is objectionable. I may remark, however, that sometimes in 
true croup, the inflammation, beside-s specially affecting the membrane of the trachea, 
extends to that of the larynx also. 

[Children are very liable to a mild form of laryngitis accompanied with a spasmodic 
affection of the glottis. The disease is marked by many of the symptoms of genuine croup, 
and is probably the most common form of croupal disease met with in this country. — C] 

The main exciting cause of laryngitis is exposure to cold, or to cold and wet. My 
hospital patient, Kent, was a seller of small wares in the streets, and must, therefore, 
I have been habitually in the way of such causes. The first attack of the disease in 
I Sir J. M. Hayes was brought on by exposure at an open window to the night air 
j for some time, while he was undressed, and in a profuse state of perspiration, with 
j a strong breeze blowing upon him. Dr. Craigie states that young persons from tro- 
' pical climates, from the West Indies for example, are apt to be attacked by laryn- 
I gitis soon after their arrival in Europe. 

The disease is liable to be produced also by mechanical violence, or chemical 
I injury done to the larynx. It has been caused, on several occasions, in children, by 
j their attempting to swallow boihng water from the spout of a tea-kettle ; and life has 
I been saved in such cases by the performance of tracheotomy. The mineral acids, 
I taken as poisons, have excited the disease. Fatal laryngitis has followed the incau- 
j tious application of ammonia to the nostrils, in cases of hysteria, and of suspended 
; animation : and I once knew a man nearly killed by the inhalation of the fumes 



500 



ACUTE LARYNGITIS. 



evolved from cinnabar thrown upon a hot iron, in what is called fumigation of the 
throat for venereal ulceration of that part. I am afraid that I must confess also to 
have once seen acute laryngitis produced by a bunghng attempt to introduce the 
stomach-pump, in a case of poisoning. 

In all these cases the laryngitis is primitive. But laryngeal inflammation, and 
especially laryngeal oedema, not unfrequently take place, and prove suddenly fatal, 
in the course of other diseases. I have apprised you that in cynanche tonsillaris, the 
inflammation sometimes steals onward to the larynx. I have seen two or three cases 
of erysipelas of the head, attended, as it almost always is, with sore throat, wherein 
death took place suddenly and unexpectedly, and vi'here the epiglottis, and the 
edges of the fissure of the glottis, Avere found to be oedematous : the inflammation of 
the throat had extended to the areolar tissue beneath the mucous membrane of those 
parts, and had led to the effusion of serous fluid there. The very same thing is apt 
, to happen in other forms of exanthematous disease attended with sore throat, and 
especially in small-pox, measles and scarlet fever. I have known a similar condi- 
tion of inflammatory oedema arise from a jnercurial sore throat in a broken-down 
constitution. In these cases the laryngeal affection is consecutive, and secondary ; 
and in all of them the great remedy is the formation of a sufficient aperture beneath 
the obstructed glottis. In all of them, also, the essential symptoms, warranting and 
demanding the operation of tracheotomy, are the same. 

A distinction has been made between laryngitis and oedema of the glottis ; and 
it is a just and real distinction. CEdema of the loose areolar tissue subjacent to the 
mucous membrane of the glottis, is, indeed, one common consequence of inflammation 
of that membrane : but it may occur independently of inflammation. The lips of 
the glottis become tumid and dropsical ; sometimes, (as I have just pointed out,) 
in consequence of a low inflammatory action in the throat, but sometimes also 
from obstruction of the veins leading from that part. When laryngeal dyspnoea 
accompanies aneurism of the thoracic aorta, it may, in some instances, result from 
local dropsy thus produced ; and then tracheotomy is fully justifiable, and indeed 
demanded. 

The main practical difference between mere oedema glottidis and acute laryngitis, 
is this : that in the former, there being no fever or inflammation, blood-letting is not 
requisite ; and the operation of tracheotomy becomes the sole resource to which, in 
the extremity of danger, we can look for help. Mere oedema glottidis is seldomer 
attended with dysphagia, too, than is laryngitis : yet if the epiglottis be involved in 
the oedematous swelling, and unable to ^hut over the glottis, the act of swallowing 
will be followed by stranghng cough, and increased dyspncea. 

Besides the affections which I have now described or referred to, the larynx is 
liable to chronic disease : to chronic irifiammatioyi ; chronic thickening of the mem- 
brane ; slow ulceration: necrosis of its cartilages. Chronic inflammation and ulce- 
ration of that part are very common in consumptive patients. It is attended first 
with hoarseness, then with aphonia, a barking or stridulous cough, and all the melan- 
choly accompaniments of tubercular phthisis. There has accordingly been a species 
of phthisis spoken of as phthisis laryngea. But in most, if not in all cases, this 
laryngeal affection is only a part of the complaint under which the patient labours ; 
and what I have further to observe respecting it, I shall postpone until we come to 
the consideration of tubercular consumption. 

Acrain, the membrane lining the laryngeal cartilages is not unfrequently thickened 
and ulcerated in secondary syphilis ; giving rise to a hoarse croaking voice, and a 
noisy and painful breathing. In such cases, or in chronic thickening of the same 
parts from common inflammation, you may do great good by gently introducing mer- 
cury into the system, until the gums rise. I have again and again seen the uneasi- 
ness about the throat, the noisy respiration, the rough or whispering voice, all cease, 
as if by enchantment, so soon as the specific influence of the mercury became 
manifest. There was a woman who used to apply at the Middlesex Hospital for an 
affection of this kind : whether it was syphilitic or not I could not well determine, 
but she lost it under the employment of mercury, two or thr^ee times : the complaint 



CHRONIC AFFECTIONS* 



501 



returning again after the interval of a few months, upon the re-application of some 
irritating cause. In another female patient, who was long under my care in the 
hospital with similar symptoms, every thing failed to give permanent relief, till I 
began to leech the neighbourhood of the larynx repeatedly. She had four leeches 
applied, I think, every night, and then every other night, for a fortnight or three 
weeks ; the hoarseness and difficulty of respiration gradually diminishing all the 
time, until at length the perfect use of the instrument of the voice was restored. In 
these cases, while using local depletion, or mercury, it is often necessary to uphold 
the strength of the patient by nourishing but unstirnulating diet : and it is always 
expedient that the organ should be kept, as much as possible, in a state of repose. 

It is said that a httle practice will enable a person to pass his finger into a patient's 
throat, and to familiarize his sense of touch with the ordinary condition of the upper 
part of the respiratory apparatus, so as to be able to detect swelling, or irregularity, 
or thickening about the chink of the glottis. And great advantage is said to have 
been obtained from applying remedies directly to the diseased or irritable part. This 
practice was much followed by the late Mr. Vance, who had been for many years a 
naval surgeon ; and he called it, in naval phrase, swabbing the affected organ. A 
small piece of sponge, secured with a string, or fastened to the end of the finger of 
a glove, is dipped in a strong solution of nitrate of silver, and then carried down into 
the throat, as far as that spasmodic state of the muscles which the' attempt induces 
will permit, and pressed downwards against the superior surface of the larynx. I 
believe other stimulating applications are sometimes employed in the place of the 
nitrate of silver. Now of this method of cure I do not know much, except by report. 
I have heard that many cases of chronic hoarseness and cough have speedily been 
cured by it. But I have more than once had what seemed satisfactory evidence of 
the beneficial effect of this expedient. The man Kent, whose case I have related, 
gradually regained the power of easy breathing through the natural passage ; and 
the opening, which Sir Charles Bell had made, closed up perfectly. About a week 
after this took place, he began again to respire with a wheeze almost as audible as 
that which existed at the time of his admission : and to speak in a hoarse voice ; and 
a night or two after the return of the wheezing, he had a paroxysm of extreme 
dyspncEa. I began to be afraid that the whole process of laryngotomy and the 
metallic tube would be again requisite. However I got Sir Charles Bell to examine 
the interior of the throat, and we agreed that it would be advisable to swab the 
epiglottis and upper part of the air-passages with a strong solution of lunar caustic. 
For he had no fever, and we thought it probable that the membrane might have 
been left lax, and in a state to be benefited by astringents. Sir Charles applied the 
sponge with very fittle difficulty ; and the next day the breathing was greatly im- 
proved, and the hoarseness almost gone : and he never had, from that time, any 
recurrence of troublesome dyspnoea. 

Mr. Arnott has twice or thrice, at my request, swabbed the upper part of the 
larynx for intractable hoarseness and aphonia : but with no good, nor any bad con- 
sequence. 

The lining membrane of the larynx is liable also to warty growths, which impede 
the entrance and exit of air, and ukimately destroy life. There are several examples 
of that kind on record. I extract the following from my note book : — 

George Tenon la Font, aged 11, admitted March 4, 1828. He speaks in a 
whisper; complains of difficult breathing, and of cough. Inspires with a loud 
wheeze. Coughs with a sort of whistling sound, as through a narrow tube. — The 
cough is most troublesome at night. Expectoration mucous, and inconsiderable in 
quantity. 

Has been ill, in this way, all the winter — having had hooping-cough in the pre- 
ceding autumn. There are marks of cupping on his throat. Little can be heard 
in the chest, the loud wheeze of his respiration obscuring all other sounds. In about 
a fortnight his gums were brought under the influence of mercury. No perceptible 
improvement ensued. A careful examination was again made of the thorax, and 
the conclusion arrived at was, that the obstacle to his respiration lay in the larynx, 
or upper part of the trachea, and that the lungs themselves were not concerned. 



. 502 



CYNANCHE TRACHEALIS. 



After this, a blister to the throat, a seton near the thyreoid cartilage, small doses of 
ipecacuanha, emetics, and iodine were successively tried — but in vain. Towards 
the end of the month he began to suffer occasional, very violent, and apparently 
spasmodic attacks of extreme dyspnoea. He died during the night, two months after 
his admission. For some days before he had been manifestly worse than usual, 
was more feeble, wandered somewhat, and complained that his vision was imperfect. 
No noticeable increase had taken place in the difficulty of breathing, except during 
the paroxysms of aggravation already mentioned. His death was sudden, and pro- 
bably took place in one of these paroxysms. 

When the body was examined, the lungs were found sound as to structure, but 
copiously infiltered, especially on the left side of the thorax, with serous fluid. At 
the very top of the larynx, involving the base of the epiglottis and the vocal cords, 
was a considerable warty growth, closing the rima glottidis almost entirely. The 
excrescences sprang ckiefiy from one continuous base, and branched out precisely 
after the manner of what is vulgarly called a seedy wart. There were, however, 
several distinct smaller growths or warts. The main excrescence, having several 
heads, passed upwards from and through the rima, and so came to act partly as a 
valve during inspiration, which was always sensibly more difficult than expiration. 

Ought tracheotomy to have been performed in this case ? I now think so. But 
supposing it to have been done, and to have been successful, the boy would have 
been under the necessity of breathing through an artificial tube for the remainder of 
his life. 

There are two excellent specimens of warty growths in the larynx upon the table 
before you. 

I might have referred, when speaking of chronic enlargement of the tonsils, in the 
last lecture, to the case of a little boy at present under the care of one of my col- 
leagues. He was brought to the hospital on account of great dyspnoea, and a hissing 
respiration, produced apparently by two enormous tonsils. With some difficuky 
(arising from his unmanageable age) a large part of one of the tonsils was cut off 
with scissors : but after the operation (either from some fresh swelHng of the parts, 
or from pressure made by the remaining tonsil, which grew downwards, I under- 
stand, into the throat), his difficulty of breathing became extreme ; and it was thought 
necessary to perform tracheotomy, which afibrded him signal relief. He breathed 
for some time through the artificial opening in his windpipe. At length the other 
tonsil was partly removed : and the child is now well, and about to be discharged. 



LECTURE XLVI. 

Cynanche Trachealis ; Symptoms ; Pathology; Prognosis; Treatment. Child- 
crowing, or Spurious Croup. 

I PROCEED this afternoon to another of Dr. Cullen's species of cynanche ; the last 
that I propose to consider in this part of the course : viz., cynanche trachealis — 
tracheitis — croup. 

The essence of this complaint is violent inflammation, affecting the mucous mem- 
brane of that portion of the air-passages which hes between the laryngeal cartilages 
and the primary bronchi; in one word, of trachea, or wind-pipe. That is the 
genuine seat of the disease ; but the inflammation sometimes ascends into the larynx; 
and not unfrequently it dives into the bronchi and into their ramifications. 

[In perhaps the majority of cases, the inflammation in croup commences in the mucous 
membrane of the larynx, and from thence extends into the trachea — the disease is there- 
fore, strictly speaking, a laryngeo-tracheitis. In many instances, however, we have reason to 
believe that the inflammation commences in the bronchi, and from thence extends to the 
trachea 5 but there are, we suspect, very few cases indeed, if any, in which the disease is 



CYNANCHE TRACHEALIS. 



503 



confined to the trachea. In cases of croup that have terminated rapidly m death, the in- 
flammation and pseudo-membranous exudation which form so striking a feature in this dis- 
ease are found only in the larynx and upper portion of the trachea — when death occurs at 
a later period the exudation is often present in the trachea alone, or in the trachea and 
bronchi ; it is never found to exist in the latter tubes alone. It has been attempted to be 
shown by Jurin and others, that, in the ordinary form of croup, the disease is, in its first 
stages at least, simjUy a tracheitis, and that in the more violent and rapid form, (suffocating 
croup,) the inflammation is confined to the larynx. Although this is not true, as is shown 
by the result of numerous dissections, yet our observations have shown us, that in cases 
marked by symptoms of great violence, which are sudden in their onset and rapid in their 
progress, the indications of inflammation are to a much greater extent, and the pseudo-mem- 
branous exudation more copious about the larynx, glottis, and upper portion of the trachea, 
than in cases in which the disease succeeds to bronchitis, runs a more protracted course, and 
is attended by sj'-mptoms of less violence. For a more detailed account of the pathology 
of croup, the reader is referred to the Editor's Treatise on Diseases of Children, page 301 
et seq. — C] 

CuUen makes no distinction between cynanche trachealis and cynanche laryngea. 
Yet they are separated from each other by very definite boundaries. They differ in 
anatomical position : they differ in gravity. Both indeed are serious diseases ; but 
croup is the more serious, because it seldom admits of that mechanical relief which, 
when rendered in time, deprives cynanche laryngea of its dangerous character. 
The two disoj-ders differ also in respect to the period of life at which they occur. 
Idiopathic laryngitis is seldom met with except in adults; croup seldom after the 
age of puberty. Cynanche trachealis is indeed a very remarkable disease, for it 
exhibits an event of inflammation which does not usually belong to that process when 
it affects the mucous tissues. In this, too, it differs from laryngitis. 

I say that croup is peculiarly a disease of early life. The interval that hes be- 
tween the two periods of weaning and puberty, is the time during which its visitation 
is chiefly to be apprehended. Comparatively few cases of it occur during the first 
year of infantile life. There are more in the second year than in any other. This, 
in all probability, is connected with the change that ensues in regard to diet, upon 
the child's being weaned. Dr. Cheyne, whose experience of croup was very ex- 
tensive, says, that the younger children are when weaned, the more liable are they, 
cxteris paribus, to this malady. From the second year onwards the number of 
children affected with croup gradually decreases. Of ninety-one instances referred 
to by Jurin, one only was after the tenth year. But it does occasionally happen 
subsequently to the period of puberty, and up to the twenty-first year ; and even 
later. A girl of nineteen, one of my hospital patients, died of it. Some of the cases 
recorded of croup in the adult, were probably, in reality, cases of laryngitis. 

[We have met with the disease most frequently in children between ten months and five 
years old. By numerous writers the occurrence of croup previous to the seventh months 
has been denied ; others, however, declare that they have seen it to occur, as a primary 
disease, repeatedly, at an earlier period. — C] 

It is curious that inflammation should thus, at different epochs of life, fix itself upon 
limited portions of the same continuous surface, and lead to consequences so diverse. 
We are unable to give any account of this. 

Cynanche trachealis is frequently preceded by a slighter and more diffused affec- 
tion of the membrane hning the air-passages. The child has what is popularly 
called a cold ; sneezes, coughs, and is hoarse. Now with respect to this last symp- 
tom, Dr. Cheyne makes the following practical remark. Hoarseness (he says) in 
very young children, does not usually attend common catarrh. When noticed in a 
district where croup is not unfrequent, it ought to put the parents or the medical 
attendant of the child upon their guard ; especially as much depends upon the early 
treatment of the disorder. With these symptoms the child is feverish and fretful, 
and does not sleep well. In the course of a day or two the signs peculiar to croup 
begin to show themselves: they are well stated by Cullen, in his definition of the 
complaint. *' Cynanche, respiratione difficili, inspiratione strepente, voce rauca, 
tussi clangosa, tumore fere nuUo in faucibus apparente, deglutitione parum difficili, 
cum febre synocha." These are the phenomena that characterize croup. Diffi- 



504 



CYNANCHE TRACHEALIS. 



culty of breathing, and sonorous inspiration. The last is often ahnost enough, of 
itself, to identify the disease. Hoarseness ; a.grufif voice ; sometimes a total loss of 
the power of vocal speech. A very peculiar and distinctive cough, to which the 
epithet "brassy" has been justly applied ; the noise resembling that which vv'ould be 
occasioned by coughing through a brazen trumpet. This remarkable sound is 
always easily recognized when it has once been heard. It is a vinging cough ; and 
the expiration has a ringing character ; and either of these, the cough or the expira- 
tion, is followed by a loud croiving inspiration. Then there is the negative symp- 
tom ; the absence of any difficulty of swallowing ; and with all this, inflammatory 
fever ; a flushed face, hot skin, a frequent hard pulse, thirst. 

However, it is by taking the symptoms collectively, that we judge of the existence 
of croup, and by the rapid progress of the disease, rather than by any particular or 
pathognomic sign. Some of the symptoms may occur, separately, when there is no 
croup. The brassy or metalhc cough, for instance, has been known to accompany 
some chronic affections of the larynx. Dr. Gregory — the late Edinburgh Professor 
of Physic — knew a man with a venereal disease of the throat who coughed so 
exactly the cough of croup, that he was admitted into the clinical wards of the 
infirmary every session for some years, that the students might have an opportunity 
of hearing this peculiar sound. So also the remarkable crowing inspiration may 
take place, as we shall soon see, without croup. 

In the outset the fever generally runs high ; and it is of importance, as respects 
the diagnosis, to mark the presence or the absence of pyrexia. As the obstruction 
to the passage of air increases, the blood ceases to be duly arterialized : and then, 
of course, the skin grows dusky, the pulse feeble and irregular, the extremities cold. 
The cough, also, as the malady thus goes on from bad to worse, ceases to be loud 
and clanging, becomes husky, and inaudible at a short distance, and the voice sinks 
into a whisper ; the head is thrown back ; the nostrils, in perpetual motion, dilate 
widely ; the face is pale and hvid, and sometimes bloated ; the pupils often expand. 
When these indications of sinking have come on, the case usually terminates ill : 
the bottoms of the feet turn black and hard ; drowsiness supervenes ; some tossing 
of the arms perhaps ; the breathing becomes gasping and interrupted, and the child 
dies aftej an i?ispiration. 

In other cases the croupy symptoms make their attack very suddenly. A child 
shali go to bed apparently well, and in the course of the night have all the worst 
signs of the disease. And it is observable, that whether the attack be altogether 
unexpected or whether it has been preceded by hoarseness, sore-throat, and catarrh, 
it usually comes on in the night. 

[These will be generally found, however, to be cases of spasmodic laryngitis or false croup, 
and to be unattended with the formation of false membrane in the larynx or trachea. — C] 

Croup resembles laryngitis in this respect, that it runs its course rapidly, proving 
fatal sometimes within twenty-four, and often within forty-eight hours. It may, 
however, continue for five or six days before it terminates, whether death or recovery 
be the resuk. Dr. Craigie affirms that it is never protracted beyond the eleventh day ; 
the fatal or the favourable issue having always taken place by that time. Life is de- 
stroyed, in pure circumscribed tracheitis, by the accumulation in the windpipe of a 
concrete membrane-like substance, Avhich so frequently attends this disease, and is 
so peculiar to it, that it is called the membrane of croup. In cases of recovery this 
substance has been expectorated in the form of a nearly perfect tube, representing a 
cast of the trachea ; at other times it is coughed up in flat or tubular fragments. In 
fatal cases it is found sometimes lying in close contact with the mucous membrane, 
and sometimes quite detached from it ; so that it might have been expelled without 
much forcing or difficulty, if the child could have sufficiently inflated its lungs, and 
the requisite muscular power had remained, and spasmodic irritabihty of the glottis 
had not opposed. 

But, in many instances, this albuminous exudation is not confined to the trachea. 
It often stretches down to, and enters the ramifications of the bronchi, and reaches 
even to their termination in the pulmonary vesicles. Sometimes also it is found 



CYNANCHE TRACHEALIS. 



505 



clothing the mucous membrane belonging to the laryngeal cartilages. This Dr. 
Craigie denies. But I show you two specimens in which the false membrane, besides 
filling the trachea, evidently extends into the larynx. One of these comes from the 
museum^ up stairs ; the other I have borrowed from the Middlesex Hospital Museum : 
it is the larynx and trachea of the young woman whom 1 mentioned just now as 
having died there of croup, at the age of nineteen. The false membrane reached 
from the tip of the epiglottis to the bifurcation of the trachea. You see the same 
thing represented in this excellent plate of Dr. Carswell's, pictured from nature. 
Usually the adventitious membrane commences just below the larynx, where it is 
thin and soft : about the middle of the windpipe it is more dense and firm ; lower 
down in the trachea, and in the bronchi, it is generally looser again, pulpy, and 
broken : it sometimes, I repeat, penetrates to the very air-cells. What are called 
(absurdly enough) bronchial polypi, branch-like casts of the smaller ramifications of 
the air-tubes, are then apt to be coughed up. And even when this concrete substance 
is not formed, we have other evidence, often, of the extension of the inflammation 
throughout the whole downward course of the membrane. 

On the other hand, there are a few cases in which this adventitious membrane is 
not formed at all ; the inner surface of the windpipe is seen to be merely reddened 
and tumid, and covered with viscid mucus ; or perhaps with a shred or two of con- 
crete albumen here and there. 

The difficulty of breathing, and the characteristic sounds that accompany it, 
depend, in part, I believe, upon spasmodic contractions of the small muscles of the 
larynx ; for remarkable aggravations of the dyspnoea are apt to occur, and to subside 
again ; and these aggravations are sometimes brought on by sudden causes — by the 
movements of deglutition, for example. 

I shall have to recur to this spasmodic constriction of the glottis : but I may here 
remark, that because it has not been (and cannot be) seen, doubts have been expressed 
by some about its having any thing to do with the dyspncea. Such doubts seem 
scarcely reasonable. It is easy, at any time, by an efibrt of the will, to close the 
glottis, and to prevent the passage of air to and from the lungs. This is mainly 
effected by the action of the little muscles that bring together the arytenoid cartilages. 
But those muscles, like the other muscles concerned in respiration, act also inde- 
pendently of the will, spasmodically therefore, through the reflex function of the 
spinal cord. And it is by a providential and conservative appointment that they do 
so act, as janitors, admitting, in the healthy state, the vivifying air, but barring the 
door against certain hurtful gases, and against solids and liquids which would be 
injurious to the respiratory apparatus. We know that if a drop of water, or a crumb 
of bread, or a whiff of carbonic acid gas, gets past the outer defence, the epiglottis, 
and into the larynx, spasmodic action of the little muscles in question is instantly 
excited. We cannot see these intruders, and voluntarily resist their entrance, but 
the unsleeping sentinel is there to guard the passage. We may well conceive, there- 
fore (and I know not how the supposition can be disproved), that the noisy and diffi- 
cult respiration of croup may be caused, in part, by spasm. 

[As further evidence of the correctness of this remark may be adduced those cases in 
which all the diaj^nostic symptoms of croup are suddenly induced by an irritation seated in 
the stomach, as from indigestible food, &c., and are as suddenly removed the moment the 
cause of irritation is expelled. A medical friend has informed us, that in one of his own 
children, symptoms resembling croup are produced by eating fish, and are immediately re- 
moved upon the operation of an emetic. — C] 

The presence of the adventitious tubular membrane in the trachea affords a 
plausible explanation of one of the symptoms observed in these little patients ; the 
tendency they show to throw the head back. The cylinder of the membrane is kept 
open in that position ; whereas, if the head were inchned at all towards the chest, 
the membrane would be bent upon itself, and the passage through it obstructed. 

This concrete exudation is often adduced to prove that the mucous membranes 
may exhibit, under certain circumstances, the phenomena of adhesive inflammation. 
Similar films sometimes form upon, or are thrown off by, the mucous surfaces of 
the intestines, and of the uterus. Whether they are to be regarded as essentially 

2s 



506 



CYNANCHE TRACHEALIS. 



identical with the layers of coagulable lymph poured forth in inflammation of the 
serous and areolar tissues, may be made a question. There are certainly some strong 
points of distinction between them. The concrete membrane of croup is more 
brittle, less fibrous, more decidedly albuminous, than the false membranes that cover 
the inflamed pleura, pericardium, or peritoneum. A still more remarkable difference 
is this, that it is not plastic, in the sense in which that term was formerly explained ; 
it never becomes organized, never connects itself by blood-vessels with the surface 
from which it proceeds. On the contrary, it is partially detached ; and by degrees, 
if the patient live long enough, it is completely separated from the subjacent parts. 

Hypotheses have been framed to account for the limitation of this product o.f 
tracheal inflammation to the early periods of life ; and for its variation from the usual 
products of inflammation of the same part. Dr. Stokes thinks that the predominance 
of the white tissues in young subjects may explain the greater frequency of croup, 
with its peculiar membrane, in infants. Dr. C. B. "Williams starts the very reason- 
able supposition that the inflammation involves the submucous areolar tissue, which 
is abundant during youth ; and that the natural product of this phlegmonous inflam- 
mation transudes readily through the thin, simple, and dehcate mucous membrane 
proper to that age. 

The formation of this adventitious membrane, and even its renewal, appears to be 
sometimes very rapid. 1 have here a preparation made by the late Dr. Sweatman, 
illustrative of this. It now belongs to the Middlesex Hospital Museum. Upon a 
child, on the very brink of suffocation from croup, the operation of tracheotomy was 
performed, at one o'clock in the morning, by Mr. Chevaher. A tubular portion of 
membrane, of the shape and size of the trachea, was presently forced through the 
artificial opening. Immediately the child's respiration became easy, and it fell asleep. 
In the course of the same morning. Dr. Sweatman was hastily summoned, and arriv- 
ing at eight o'clock, found the child dead. It had slept six hours, and upwards ; and 
then the distress of the breathing had returned, and was soon fatal. The trachea 
was found to contain a new tube of lymph, or of concrete albumen. The prepara- 
tion shows that such a membrane may re-form in that short space of time ; namely, 
in from six to seven hours. 

The croup is not contagious ; although, like cynanche tonsillaris, and for the same 
reasons, it is found sometimes existing at the same time, or in quick succession, in 
more than one child of the same family. Thus two twin children of Dr. Gregory's 
were seized with croup on the same night. They had both been walking in the 
evening on the sea-shore during a cold wind. This is in accordance with what Dr. 
Cheyne has stated, that the attack is almost always noctural, and often when the 
child has during the preceeding day been exposed to the weather. It frequently 
occurs sporadically ; but there are places in which the disease appears to be endemic. 
Dr. Cheyne found it so on the coast of the Frith of Forth. Indeed, the first distinct 
account of it that we possess was drawn up by Dr. Home, of Edinburgh, in 1765, 
from much personal observation of its ravages in Leith and Musselburgh. Cold situ- 
ations — and damp places, more than such as are merely cold — are subject to the 
prevalence of this disease. It is accordingly frequent in the seasons of winter and 
spring. It is said to be most common near the sea-shore, and in the neighbourhood 
of large bodies of water generally. It occurs in low, moist, what are called in. Scot- 
land carse districts, more than in upland situations that are more exposed to cold 
winds. It is more common at Leith than it is in Edinburgh ; and in Edinburgh, it 
is most frequent in the lowest parts of the town. This I learned from Dr. Ahson, 
who, having long been physician to a dispensary there, had had ample means of 
observing the disease. Canal Street and the Cowgate, both low spots, as some of 
you may know, have long been famous, or rather infamous, for cases of croup. 
Towns situated on the banks of rivers are more than commonly visited by it ; and it 
has been observed to be particularly frequent among the children of washer-women 
in such places ; and thus evidently connected with exposure to moisture. It has 
been known to prevail epidemically in towns so situated after an inundation. And 
Dr. Alison has made a very curious remark respecting it. He says that it seems 
to b(? often produced by the child's sitting, or sleeping, in a room newly washed : 



CYNANCHE TRACHEALIS. 



507 



and that he has noticed its frequent occurrence on a Saturday night — the only day 
in the week on which it is customary for the lower orders in Edinburgh to wash 
their houses. 

Like cynanche tonsillaris, and unhke cynanche parotidasa, the croup is exceeding 
apt to recur. Relapses may happen within a few days after apparent recovery ; and 
these are very perilous. But besides this tendency to a renewal of the severer symp- 
toms, the little patients are often affected with cough, and hoarseness, and even with 
aphonia, for a long time. And while these relics of the acute attack continue, it is 
easily brought back again. The first seizure is generally, I beheve, the worst : but 
to this rule there are numerous exceptions. 

[The remarks contained in the foregoing paragraph are applicable rather to Spasmodic La- 
ryngitis than genuine croup. — C] 

Croup is a disorder which justly excites extreme alarm in the friends and parents 
of the patient : for the prognosis can never be better than doubtful. It is said that 
four children out of five attacked by it used to die : but that now, the treatment being 
better understood than formerly, the number of deaths and the number of recoveries 
are nearly equal. We judge of the probable issue, in a given case, by the apparent 
circumstances and progress of the malady. If we could see the interior of the air- 
tubes, we should know that the chance of escape was small, in proportion as the 
inflammation, and its albuminous product, descended along the ramifications of the 
bronchi. But in these httle patients, and amid the tracheal noises, it is difficult to 
ascertain the physical state of the lungs. The prognosis is chiefly to be collected 
from the general condition of the child. If the distress of breathing seems to remit, 
and free expectoration to come on, while the strength is yet entire, we venture to 
hope. On the other hand, we begin to despair when the hps are becoming blue, the 
skin is losing its heat, the pulse is already feeble and intermitting, and the little pa- 
tient is drowsy or comatose : in other words, when we perceive the final symptoms 
of death in the way of apnosa. Some few patients die suddenly and unexpectedly 
without any previous coma. 

The mortality will differ according as the disease is detected early, and treated 
vigorously, — or otherwise. And with respect to treatment, there is no specific re- 
medy for this, any more than for any other inflammation. We must put in force 
the general principles upon which the treatment of inflammation is founded ; adapt- 
ing them, however, to the malady in question by those particular rules which the 
experience of the best observers has collected for our guidance. 

I need scarcely say that where cough and catarrh, and especially hoarseness or loss 
of voice, are noticed in a young child, he should be narrowly watched, and protected 
against all circumstances likely to excite or to aggravate inflammation: he should 
be kept in the house, and put upon farinaceous diet ; and the functions of the bowels 
and of the skin should be attended to. 

The three remedies that most require consideration are blood-letting, tartarized 
antimony, and calomel. 

• Bleeding is to be unhesitatingly employed when the patient is strong, and ple- 
thoric, and seen in the outset of the disease. In judging of its mode, and of its 
amount, we must recollect that what is no more than a topical bleeding in an adult, 
becomes equivalent, in its effects upon the system, to general bleeding, when it is 
used for a very young child. Abstraction of blood, by venesection or cupping in the 
case of older children, and by leeches in the case of infants, should be practised 
whenever the symptoms are violent, and there is much fever, and the patient is seen 
within a few hours after the commencement of the symptoms. The relief that is 
given by this measure, under such circumstances, is often so decided, that no doubt 
can remain of its usefulness and propriety. 

It is impossible to lay down any fixed rules for the quantity of blood that should 
be taken in this complaint. Under two years of age, it should not, says Dr. Cheyne, 
exceed five ounces. I should esteem that a large bleeding, at that age. Upon an 
average, a moderate bleeding will be produced by the application of a couple of 
leeches to an infant in its first year : and an additional leech may be employed for 



508 



CYNANCHE TRACHEALIS. 



every additional year : so that six may be put to a child five years old ; or eight if 
he be stout. Dr. Copland estimates the amount of blood which these patients may, 
with safety, bear, to be somewhat more than an ounce, or as much as an ounce and 
a half, for every year of their age. Much, however, must depend upon the special 
circumstances of the case: the quantity of blood extracted by a given number of 
leeches is less in one instance than in another; and then, of course, the number 
must be increased. They should be applied at the upper part of the sternum, and 
not upon the throat itself; for this reason : — that the pressure which may be neces- 
sary to stop the bleeding, or to regulate its quantity, cannot well be borne upon the 
throat in these cases. 

After one sufficient evacuation of blood, whether by means of the lancet, or of 
leeches, or of cupping-glasses applied between the shoulders, it will always be right, 
before repeating it, to ascertain the effects of other measures ; such as emetics and 
purgatives, the beneficial operation of which, in this disorder, is often very re- 
markable. 

Full vomiting sometimes affords relief so sudden and complete, as to lead to the 
persuasion that the symptoms had been principally owing to spasm. And even 
when the disease is unequivocally inflammation — sometimes even late, but particu- 
larly in the early part of its course — the effect of a vomit is often very striking. It 
promotes expectoration ; and is not unfrequently followed by the expulsion of shreds 
of the adventitious membrane. When blood-letting is employed, it should precede 
the emetic ; or, at any rate, it should precede the act of vomiting. Dr. Cheyne 
recommends that the bleeding should be practised ten minutes after the emetic has 
been swallowed. The loss of blood assists the operation of the emetic, and lessens 
the risk (which is not a fanciful one) of injurious congestion of the vessels of the 
head during the straining efforts of vomiting. 

It is desirable, not simply to excite the act of vomiting, but to produce and to pro- 
long a state of nausea and faintness : and so to depress and to keep down the in- 
creased action of the heart, and to keep empty the capillary vessels of the inflamed 
part. Now the substance best adapted to this purpose is tartarized antimony. This 
medicine, as I have often mentioned before, has great power over inflammation of 
the mucous tissues : and there is one very great advantage belonging to it in cases 
of croup; namely, that children maybe induced to take it without their knowing 
that they are taking medicine ; for the solution of it has little or no taste : whereas 
the struggling which is often occasioned by the administration of other emetics may 
be the cause of much inconvenience, and even of much injury to the patient. It 
should be dissolved in boihng water, in the proportion of a grain to an ounce ; and 
the cold solution given. A tea or a dessert-spoonful may be repeated every quarter 
of an hour, till some effect is produced. When vomiting is thus excited on the very 
first appearance of the symptoms, and before the disease seems thoroughly formed, 
it sometimes puts it off : so that no other treatment remains necessary beyond the 
exhibition of some purgative medicine. But if this perfect rehef does not ensue 
upon the operation of the emetic, Dr. Cheyne advises (and this is in conformity with 
the practice of many other persons), that a powder, consisting of two, three, or four 
grains of calomel, with two or three grains of James's powder, should be given at 
short intervals ; every two or three hours, for example. A dose of castor-oil is to 
be administered occasionally, to clear the bowels. And another expedient, of great 
efficacy sometimes, and therefore never to be omitted, is the warm bath. This is 
often properly resorted to just after the act of vomiting, particularly if any tendency 
to perspiration is apparent. The temperature of the water should not be lower than 
98° Fahrenheit; and the child should remain in the bath for ten minutes at least. 
When taken out, he should be wiped dry, and put immediately into bed again. 
The change for the better produced by the bath is sometimes so marked and so 
speedy as to strengthen the conclusion that the most distressing of the symptoms had 
resuked from spasm. 

The usual efiect of calomel thus frequently repeated is not, as in adults, that of 
causing salivation, but the discharge of a quantity of green fecal matter, resembling 
chopped spinach ; and when stools of this kind begin to make their appearance, 



CYNANCHE TRACHEALIS. 



509 



there is often a sensible mitigation of the symptoms. The green colour is a common 
consequence of mercury given to young children ; and will occur, I believe, what- 
ever be the disease, when the full effect of calomel as a purgative is obtained. The 
green matter has been found, after death, in all the intestines, small as well as large, 
up to the duodenum. I presume that the colour is owing to some chemical action 
that takes place between the calomel and the bile. We know that calomel does 
tinge bile green when mixed with it out of the body. It may be, however, that the 
calomel provokes a flow of altered bile. 

Calomel, thus administered, is the purgative that has received the strongest recom- 
mendations. Its usefulness appears to have been fully borne out by the test of ex- 
perience : and the well-knov/n virtue belonging to mercury, of preventing or arrest- 
ing the effusion of coagulable lymph in other textures, has formed (I conceive) one 
cogent reason for its adoption in this disorder, of which the chief peril results from 
the pouring forth of the albuminous part of the blood. But whether mercury really 
has the same power of controlling adhesive inflammation, when that process is set 
up in mucous tissues, which are so commonly exempt from it, may be questioned. 
On the other hand, the effect of full doses of tartar emetic in restraining active inflam- 
mation of those tissues is well ascertained : and I should certainly make use of it in 
the early stages of this dangerous malady. The system can be brought to feel its 
decided influence with much more certainty, and in a much shorter space of time, 
than that of calomel : and if it fails to make a beneficial impression, it need not long 
interfere with the mercurial treatment. Let me quote to you the statement of Dr. 
Cheyne (whose experience of this disease was far ampler than mine has been,) re- 
specting the efficacy of tartarized antimony in what he calls the second stage of 
croup. He recommends that half a grain, dissolved in a tablespoonful of water, 
should be given to a child two or three years old, every half hour, till sickness and 
vomiting ensue. lo two hours after the last effort of vomiting, the same process is 
to be recommenced ; and so repeated while the symptoms require it, and the strength 
will permit. This mode of treatment v/as suggested to him by the accidental ob- 
servation of a particular case, in which it was remarkably successful. From that 
time he placed his whole reliance on that remedy in the second stage of croup ; 
especially as he had found that blood-letting in that stage only accelerated the death 
of the patient. He noticed that the cases were feiv in which he had known children 
survive the second stage, but in all of these few, they recovered while using a solu- 
tion of tartarized antimony. He held that no other medicine was, at that stage of 
the disorder, entitled to confidence. In short, he declared that tartar emetic, so given 
as to produce continued nausea, had been his sheet-anchor, in the treatment of croup, 
since the year 1799. This was written in 1801, in a separate work on the patho- 
logy of the larynx and bronchi ; and Dr. Cheyne recently has affirmed, in the Cy- 
clopedia of Practical Medicine, that he still found reason to adhere to the same 
opinions, and the same practice. 

Now what is good for the second stage, would, a fortiori, I think, be likely to save 
life, if employed during the earlier stage of the disease. I therefore should say, take 
blood in the very outset, as largely as may seem prudent: then give the tartar 
emetic solution in the way already described. As soon as it causes vomiting, and 
pallor, and a sinking of the pulse, stop ; and suffer the heart to recover itself. And 
if, with the rallying circulation, the difficulty of breathing returns, have recourse 
again to the same remedy. The faintness and collapse are sometimes so great as to 
threaten the extinction of Hfe : the child, with a flying pulse, and a clay-cold sur- 
face, seems gasping its last. When this happens, a few drops of sal volatile, or of 
brandy, mixed with water, will presently bring the little patient round again. If no 
ground is gained after two or three repetitions of the nauseating treatment, then it 
will be well to make trial of the calomel plan. 

Sometimes the tartar emetic acts severely on the bowels : it may occasionally, 
therefore, be necessary to combine with it a small quantity of syrup of poppies, or 
of laudanum. 

Blisters are often apphed in this disease ; but with very questionable propriety. 
In the outset they are hkely to do harm ; in the advanced periods they are not likely 

2s2 



510 



CYNANCHE TRACHEALIS. 



to do good. If used at all, they should be placed, not on the throat, but across the 
upper part of the sternum. 

[We do not approve of the use of blisters in this disease ; but if applied, they should only 
be kept on for a few hours, so as to tender the skin. — C] 

When signs of approaching death have come on — lividity of the hps, coldness of 
the skin, and a tendency to stupor, the question will obtrude itself, whether there 
may not still be a chance of saving the patient by performing tracheotomy. In the 
first place you will consider ihat the operation is much more difficult to execute upon 
children than upon adults ; and is attended with more perplexing hemorrhage. But 
there is a greater objection than this to tracheotomy in such cases ; an objection 
which you will have anticipated, namely, the existence of the preternatural membrane ; 
which often extends so far down, that air would not be admitted into the lungs, even 
if an aperture in the windpipe were made at the lowest possible point. Another 
consideration, forbidding much hope of success from this expedient at any period of 
the disease, is that the ramifications of the bronchi and the ultimate air-cells get filled 
up with serous, or mucous, or puriform matter, or even sometimes Avith a mem- 
branous exudation, whereby suffocation is effected in the lungs themselves. The 
membrane in the trachea, being tubular, does not entirely exclude the air from those 
organs ; but it does not admit it in sufficient quantity. Tracheotomy has again and 
again been practised in this complaint to no purpose : and I should be inclined to 
look upon it as absolutely hopeless, but for two instances of its successful perform- 
ance, recorded in the Medico- Chirurgical Transactions : the one achieved by Mr. 
Andre, and related by Dr. Farre, in the third volume ; and the other by Mr. Che- 
valier, in the sixth volume. These were both apparently desperate cases. Immediate 
relief followed the operation in both, and the patients recovered perfectly. 

There seem to be just two predicaments in which there is a chance that tracheo- 
tomy may be useful. They are perhaps rare : yet they have been noticed by several 
observers. The one is where the preternatural membrane extends but a very little 
way down the trachea, and is chiefly confined to the larynx ; and the other is where 
there is no preternatural membrane at all, or only a very slight coating in some part 
of the trachea, the impediment to the breathing having arisen mainly from the 
thickening of the mucous membrane. And you will observe that an impediment 
from this cause will always be the greatest at the narrowest part of the canal : and 
therefore incision of the windpipe in such a case may be expected to bring relief. 
The effect produced by the tracheotomy in Mr. Chevalier's case was very instruc- 
tive. Air was fully inspired through the opening, then a strong cough took place, 
by which a large quantity of viscid reddish mucus was forced out by the natural 
channel, through the glottis. It was evident that the child could not expectorate before, 
simply because it could not sufficiently fill its lungs with air to drive the collected 
mucus out. Dr. Farre gives a circumstantial account of a case in which the adven- 
titious membrane did not reach more than a finger's breadth below the cricoid car- 
tilage ; and the rest of the tube was so free that he was convinced the child's hfe 
might have been saved by a timely opening into the trachea. Unfortunately, we 
cannot tell, before death, to what degree or extent the preternatural membrane exists. 
All that can be said, I think, is, that when dyspnoea and much croup come on sud- 
denly or quickly, the disease is probably limited to the larynx and upper part of 
the windpipe : but that when the progress of the disorder is slower, and the croupy 
symptoms are not so well marked, it is more likely that a greater extent of the tra- 
chea, below the larynx, participates in the mischief. Our expectations of success 
from tracheotomy will vary accordingly. It affords a bad chance at the best ; but it 
affords also, in many cases, the only chance. 

[The subject of tracheotomy in croup is one of considerable interest.— That it may, in 
many cases, when timely performed, save the life of the patient, we have the most unques- 
tionable evidence. In a statement by M. Trousseau of the result of the operation, as per- 
formed by himself, and by others, according to his method, in one hundred and fifty cases, 
the patients were saved in thirty-nine. In the case of his own child, three weeks old. re- 
cently published by Dr. Scoutetten, the operation was performed on the third day of the 
disease, under circumstances apparently the most desperate, with complete success — the 



CYNANCHE TRACHEALIS. 



511 



infant recovering in a short time from the effects of the operation as well as from every 
symptom of the croup. The class of cases, the period and particular circumstances of the 
disease in which the operation is most likely to afford relief, are questions of no little im- 
portance, and we believe that much of the want of success, which many practitioners have 
experienced in performing the operation, is to be attributed to its having been resorted to 
under improper circumstances. M. Trousseau, whose experience on this subject has been 
somewhat extensive, has presented the following as a summary of the prognosis of tracheo- 
tomy in croup — 

" 1st. If the commencement of the attack dates several days back, if, consequently, the 
disease has advanced slowly, whatever may be the extent of the false ipiembranes in the 
trachea and bronchi, the children either recover, or live at least several days after the ope- 
ration. 

" 2d. But if the disease has been very rapid, even although at the time of the operation, 
we ascertain that the false membranes do not extend beyond the larynx, the children die 
very quickly. 

" 3d. If previous to the operation, the false membranes have extended to the nares, or if 
they cover the blistered surfaces ; if the child is pale and somewhat bloated, without hav- 
ing taken mercury or been bled, or if he has lost much blood, there is little chance of the 
operation succeeding. 

" 4th. If previous to the operation, the pulse is moderately frequent, and if, after it, the 
pulse remains calm, hopes may be entertained. 

" 5th. It is a bad sign, if, immediately after the operation, the respiration becomes very 
frequent, without any cough or with very little. 

" 6th. More boys than girls are cured. 
7th. Children under two, and over six years of age, rarely recover. 

".8th. The more deeply the false membranes have extended, the greater, cceteris paribus, 
the danger. 

" 9th. If the child has been subject to chronic catarrhs, and if he had been suffering from 
a cold for some time when he was attacked with the croup, tracheotomy is more successful. 

" 10th. Even when all is going on favourably, very great frequency of respiration is a bad 
sign. 

' 11th. The more rapid and energetic the inflammation which attacks the wound in the 
trachea, the better are the chances of success — a sudden sinking of the wound is a mortal 
sign. 

" 12th. So long as the respiration is silent or the noise is only occasioned by the displace- 
ment of mucosity, there is nothing to fear; but when the respiration becomes saw-like (ser- 
ratique), in other words, when it is attended with a sound like that produced by a saw cut- 
ting stone, death is certain. 

" ] 3th. There is no reason to despair of the patient, even if a pneumonic or pleuritic 
attack should supervene. 

" 14th. Agitation and sleeplessness are bad signs. 

" 15th. Should the wound become covered with false membranes ; if, after withdrawing 
the canula, it remains gaping for a long time, or, if after having become entirely cicatrized 
it reopens largely, the child is in danger. 

" 16th. The sooner after the operation the larynx is disembarrassed, the sooner may we 
remove the canula, and the more rapid and certain is the cure. 

" 17th. If the croup supervened upon rubeola, scarlatina, variola or pertussis, although 
there is not ordinarily any connection between the malignant angina and these pyrexia, 
tracheotomy does not succeed. 

" 18th. If the expectoration becomes mucous and catarrhal by the third day after the ope- 
ration, the children will recover. If there is no expectoration, or it is serous, or like half- 
dried portions of gum Arabic, they will die. 

" 19th. If the patients react vigorously under tire injections into the trachea of water or 
nitrate of silver, and under the sponging out of the trachea, we should not despair, how- 
ever unfavourable may be the other signs. 

" 20th. Children attacked with convulsions after the operation die, and the younger the 
patients and the more blood they have lost before or during the operation, the more often 
convulsions supervene. 

" 21st. When, after the tenth day, the drinks pass almost entirely from the pharynx into 
the larynx and trachea, even if they are readily rejected, the children most generally die. 

" 22d, The increase of the fever after the fourth day, agitation, sinking of the wound, and 
dryness of the trachea, frequency of the respiratory movements, and attempts to cough, 
announce the invasion of pneumonia, which, at first lobular, becomes sometimes pseudo- 
lobar, and is to be treated by the same means as are usually employed in the pneumonia 
of children ; we should, however, exclude blisters, because they too often become covered 
with false membranes." (See Rilliet and Barthez, Traite des Mai. des Enfans, t. i. 365-7 



512 



CHILD-CROWING, OR 



There is a sort of bastard croup, with which it is quite necessary that you should 
be acquainted, for it is not at all uncommon ; nay, it is far more common in this 
place at least, than the real disease. It has received a variety of names, which 
shows that it has been recognized, as a distinct malady, by various observers. Yet 
no doubt can be entertained that it has very often indeed been confounded, — and is 
still continually confounded, — with the true croup, with cynanche tracheahs. In 
their most obvious symptoms the two affections are much aHke. The broad and 
essential distinction between them, is the absence, in the spurious disorder, of inflam- 
mation and of fever — and consequently of any concrete or other effusion from the 
mucous membrane of the air-passages. The child is seized all of a sudden, roused 
perhaps from its sleep by a catch, or interruption of its breathing, more or less com- 
plete. It strives and struggles to inspire, but is apparently unable to do so ; at 
length the effort is successful, and the breath is drawn in -with a shrill whisthng or 
crowing sound, like that which characterizes the inspirations of croup, or of hooping- 
cough, and depending, no doubt, upon the same cause — a narrowing (in this com- 
plaint temporary) of the fissure of the glottis. Spasmodic croup is the most com- 
mon of its names. It is the thymic asthma of the Germans. My late colleague, 
Dr. Ley, in a volume upon this curious disorder, pubhshed a short time before his 
death, adopts from Dr. Mason Good the appellation of laryngismus stridulus. Dr. 
Gooch called it child-crowing, a homespun term, which I must prefer to the some- 
what pedantic and cacophonous title bestowed upon it by Dr. Good. The crowing 
noise, and its concomitant phenomena, take place in paroxysms, which vary in re- 
spect to frequency and severity, and which are separated by intervals of easy and 
natural breathing. 

"When the closure of the chink of the glottis is not perfect, the child struggles 
for its breath : the respiration is hurried ; the countenance generally bluish or livid ; 
the eyes staring ; and each inspiration is attended with a crowing noise. When 
the closure is more complete (and this state was found by Dr. Ley, whose words I 
am now quoting, to be much the most frequent at the commencement of the pa- 
roxysm), the function of respiration is entirely suspended for a w^hile ; there is an 
effectual obstacle to the admission of air. The child makes vehement struggles, by 
some termed convulsive, to recover its breath. At varied intervals, from a few 
seconds up to a minute, or upon some occasions nearly two minutes, air is at length 
admitted through the glottis, now partially open ; and this rush of air, passing 
through a very narrow chink, produces the pecuhar sound. To these symptoms not 
unfrequently succeed a fit of coughing or crying, which terminates the scene : or, if 
the glottis be not thus partially open, the child, at the end of from two to three 
minutes at the utmost, will die suffocated. Pallid and exhausted, it falls lifeless 
upon its nurse's arms ; and it is then that the child is generally said to have died in 
a fit." 

Sometimes, but not always, with the symptoms now described there is a con- 
tracted state of the flexor muscles of the thumb, fingers, wrist, ankle, and toes ; 
giving to the foot an appearance approaching to that of club-foot. 

Now till very lately most of those persons who had learned not to confound this 
child-crowing with true croup, were of opinion that it depended upon cerebral disease 
or disorder. This was the doctrine of Dr. John Clarke, who has left a very good 
description of the complaint, which he called " a peculiar species of convulsions." 
Dr. Ley doubted the correctness of that notion, and beheved that the bending of the 
limbs results rather from feebleness or paralysis of the extensor muscles, than from 
spasmodic contraction of the flexors. It was obviously a great point to make out, 
whether the disorder depends upon pressure within the head or not. Our treatment 
will be regulated by what w^e know, or believe, in that respect. But what is chiefly 
original, and very interesting, in Dr. Ley's views concerning this bastard sort of 
croup is this, that he attributes the temporary closure of the glottis to pressure made 
by enlarged glands in the neck or chest upon the recurrent nerve, or upon some part 
of the eighth pair ; " subverting the exact antagonism by which the glottis is automa- 
tically and involuntarily kept open, and allowing its margins to come together, and 
to occasion the peculiar kind of inspiration so much like that of croup." Dr. Ley 



SPURIOUS CROUP. 



513 



looks upon the affection altogether as more aUied to paralysis than to convulsive 
movements. This certainly is a very original, but, I think, a mistaken view of the 
matter ; 1 must refer you, however, to his book for the facts and reasonings upon 
which it is founded. The important practical fact is, the connection of the child- 
crowing with tumefaction of the glands in the neck and chest, and with the entangle- 
ment of the pneumogastric nerve or its branches among these glands. " Scarcely 
an instance (says he) has occurred to me since my attention has been very much 
directed to the subject, in which there has not been the strongest foundation for the 
belief that either the glandulEe concatenatse of the neck, or the thoracic absorbent 
glands, had become morbidly enlarged." 

Even in the short period that has elapsed since Dr. Ley wrote, this curious and 
intricate knot has been somewhat further (though perhaps it is- not yet completely) 
untwisted. Dr. J. Reid has ascertained, by a well-contrived set of experiments, that 
the inferior laryngeal (or recurrent) nerve, is an efferent or motor nerve, by which 
nearly all the mo-t^ements of the larynx are regulated; and. that the superior laryn- 
geal is 'an afferent or incident nerve. We may easily conceive, therefoie, how 
pressure upon, or irritation of either of these nerves, may affect the aperture of the 
glottis. If the superior laryngeal nerve be implicated, the impression is communi- 
cated to the spinal cord, and thence reflected, through the recurrent, upon the laryn- 
geal muscles. Irritation of the gastric ramifications of the par vagum may have 
the same result. It is an observation of Dr. John Clarke's, that the attacks " very 
commonly take plade after a full meal." Nay, it seems probable that not only any 
of the afferent fibrils of the eighth pair of nerves, but those of the fifth pair also may 
have a similar exciting power; for a transient crowing is readily produced in some 
children, by exposure of the surface of the face and chest to a breeze of wind, or 
by their being suddenly tossed in the arms of a nurse. We must even suppose that 
the effect produced upon the central cord may, by reflexion, influence other muscles, 
and cause the contractions that are sometimes observed in the flexors of the feet and 
hands. Again, if the recurrent nerve itself be pressed upon, or interfered with, 
undue contraction or paralysis, according to the kind and degree of interference, will 
be likely to ensue of the muscles belonging to the glottis. Spasm of those muscles 
would close the chink, and stop the breath. And Dr. Reid has shown that their 
palsy, except while the breathing is perfectly quiet and tranquil, sensibly impedes 
inspiration, and alters its character. 

It appears, therefore, that the ingenious view taken by Dr. Ley of the special 
pathology of this child-crowing disorder, or croup-hke convulsion, merges in the 
more general principles of reflex function advanced by Dr. MarshaU Hall. 

At the same time it is interesting to observe how Dr. Ley's theory harmonizes 
Vith what has been noticed of the predisposing causes of this crowing inspiration. 
In the first place, it is often manifestly connected with dentition. Now one effect 
of dentition is the production of glandular swellings of the neck, which happen even 
in the absence of all strumous taint, but with still more certainty if any such taint 
exists. And thus he explains the fact, that the disorder has appeared in the most 
robust as well as in the most delicate infants. Thus, also, he explains another well- 
known fact, viz., that, when child-crowing accompanies painful dentition, the symp- 
toms do not vanish instantaneously, as if by magic, the moment that the tooth starts 
through the gum, but pass off by degrees. Dr. Ley remarks that, " after the gum 
and enveloping membrane of the tooth have been reheved from swelHng and inflam- 
mation, by the free use of the gum-lance, some time is still required for the irritation 
and tumid state of the cervical glands to subside." It is not improbable that the 
gingival irritation alone may sometimes suffice, through the channel of the trifacial 
nerve, to determine the reflex spasm. 

Again, this child-crowing is found to occur in connection with excoriations behind 
the ears, and with inflamed and irritable scalp ; and these complaints very frequently 
lead to enlargement of the absorbent glands of the neck, which enlargement may 
thus form an intermediate link in the chain of events. And upon some occasions 
Dr. Ley has had strong reason to suspect that bronchitis, or other disease of the 



5U 



CHILD-CROWING, OR 



lungs, has occasioned enlargement of the bronchial glands, and so given rise to the 
crowing inspiration. 

I think that Dr. Ley has made out fair grounds for his view of the patholog}^ of 
what is called spasmodic croup. But it is too partial and Hmited a view. Again, 
the aJieged connection between child-growing and cerebral disturbance is not a mere 
fancy, although its bearing may have been sometimes misapprehended. The cere- 
bral disturbance is mostly the consequence, and not the cause, of the impediment to 
the function of respiration. 

[We doubt the correctness of Dr. Ley's views, as well as the views of those who refer 
the disease to enlargement of the thymus gland. — For an examination of the facts connected 
with the pathology of laryngisinus stridulus, the reader is referred to the Editor's Treatise on 
the Diseases of Children, page 31 i, et seq. — C] 

The practical fact which you have to remember is, that croupy breathing may 
occur, and return in paroxysms, when there is no croup. And the practical lesson 
which you have to learn is, how to discriminate between these two similar, yet dif- 
ferent disorders. I have already specified the distinctive characters of cynanche 
trachealis. The complaint that copies it may be known by its sudden accession and 
its sudden departure ; by the freedom of breathing in the intervals between the pa- 
roxysms ; by the absence of fever, of preceding or present catarrh, of hoarseness, 
and of any abiding cough. The diagnosis, easily enough reached when these points 
are sufficiently attended to, will be still more sure, if you discover enlarged glands in 
the neck ; or hot, tense, and tender gums. 

According to Dr. Clarke, " convulsions of this description seldom, if ever, occur 
after the expiration of the third year of a child's life." 

It must be necessary for me to urge the importance of the diagnosis. Those 
active measures which befit the outset of the inflammatory disease, would be mis- 
placed and mischievous in the other. It was the resuk of Dr. Ley's experience that 
" those children have, upon the whole, a much better chance of being preserved, 
who are not subjected to very severe discipline, than those who, in comphance with 
the prevailing doctrine, have been treated by very copious bleeding, large doses of 
calomel, and such other remedies as the supposition of the invariable dependence 
of the disease upon cerebral turgescence, or excitement, has suggested." 

Do not, however, imagine, from what I have just been saying, that this disorder, 
child-crowing, is a trifling disorder, and unattended with danger. It is really a 
perilous, as well as a terrifying condition. The respiration is sometimes so long 
suspended that death takes place in the paroxysm. And each paroxysm is accom- 
panied by a tendency to stagnation and congestion of blood in the brain, lungs, and 
heart : a tendency w^hich, by its frequent repetition, may lay the foundation of seriouj 
and fatal disease in one or other of those vital organs. 

The treatment of this affection must depend a good deal upon the nature of the 
predisposing and exciting causes. To go into it fully would require that I should 
speak of the mode of cure in painful dentition, in eruptive complaints about the head, 
in certain pulmonary and cardiac diseases, and in all those conditions which are apt 
to cause enlargement of the catenated or bronchial glands ; or to fret in some other 
way the pneumogastric nerves. 

In addition to the special methods of treatment which these disorders may severally 
need, great care must be taken, in all cases, to regulate the state of the bowels, and 
of the skin. Fresh air also is a powerful adjuvant ; and sometimes of itself a suffi- 
cient remedy. Change of place, therefore, and especially a removal from the air 
of a city or town to the pure atmosphere of the country, should be urged whenever 
it is practicable. 

In the paroxysm itself the warm bath might be useful, if it could be got ready in 
time. The application to the throat of a large sponge from which hot water has just 
been squeezed, is a more accessible, and often a very effectual expedient. Sprinkling 
the face and chest freely with cold water will sometimes unlock the spasm, and set 
the little sufferer free. 

I should have stated, that Dr. Ley's views were amply supported by the researches 



SPURIOUS CROUP. 



515 



that he had made into the morbid anatomy of this affection. Had he lived, I should 
have had it in my power to show you some very beautiful and interesting prepara- 
tions, illustrative of the connection of the disorder with enlarged glands, which had 
come to press upon, or stretch, the par vagum, or its branches. As it is, I can only 
show you the published engraving from some of them, appended to his book. 

[Spasmodic Lartistgitis or False Croup is a disease bearing many of the characteristics 
of genuine croup, and has no doubt been frequently confounded v/ith it. It diflers from it, 
however, in the absence of any tendency to the formation of false membranes in the larynx 
or trachea, and in being a far more manageable and less fatal disease. 

The attack of spasmodic laryngitis is usually preceded by slight catarrhal symptoms; 
coryza, watering of the eyes, a sense of chilliness followed by flushes of heat; slight hoarse- 
ness and some cough. These symptoms may continue for twenty-four or forty-eight hours before 
a paroxysm of the disease is observed. In general this occurs at night; the child being sud- 
denly awoke from its sleep by a sense of impending suffocation. He starts up in a sitting 
posture, or throws himself forwards on his knees. He cries out that he is choking, seems 
anxious for air, tears off every covering from his throat, and pushes away all who sur- 
round or offer to assist him. The face becomes swollen and of a dark red or violet hue; 
the eyes projecting and humid, and the expression of the countenance extremely anxious. 
The inspiration is long and hissing ; and so loud as occasionally to be heard in an adjoining 
apartment. There is also, at intervals, a frequent hoarse cough. The voice is constrained, 
but seldom whispering or abolished. The pulse is quick, and the skin hot. In a short time 
the paroxysm ceases, and the patient falls asleep. The disease may be confined to a single 
paroxysm. More commonly, however, the child continues during the ensuing day tolerably 
well, excepting perhaps that he is somewhat hoarse and has an occasional short barking 
cough, with or without expectoration ; and on the succeeding night is again attacked with a 
paroxysm as on the night previous. The disease may continue thus, with one or two 
paroxysms each night, for several days, when the paroxysms will cease to recur, and the 
cough and other symptoms speedily disappear. In some cases, however, the paroxysms con- 
tinue to recur at shorter intervals, and gradually augmenting in intensity, the patient dies 
from asphyxia, or, in other cases, after one or more paroxysms, he becomes affected with 
the utmost inquietude, with almost constant nausea and repeated vomiting, with symp- 
toms of great exhaustion, cold extremities, and a small frequent pulse, and soon dies. 
Usually, however, the disease is one very readily controlled, and has seldom a fatal ter- 
mination. 

Spasmodic laryngitis is very liable to recur after three, six, nine months or a year, or 
whenever the child is exposed to cold and damp, or during seasons marked by sudden 
vicissitudes of temperature. 

Barthez and Rilliet, by whom the term spasmodic laryngitis has been given to the disease, 
believe it to be dependent upon an actual but slight inflammation of the larynx. This opinion 
is based upon the fact that its attacks generally follow sudden exposure to cold, and by its 
being preceded by catarrhal symptoms, and being attended by some degree of febrile excite- 
ment. In connection with this mild bronchitis there occurs also a spasmodic affection of the 
glottis, to which they attribute the paroxysms of suffocation. That the disease is attended 
with some degree of laryngeal inflammation is evident from the result of post-mortem exa- 
minations. In the few instances in which an opportunity has been afforded for an examina- 
tion after death, traces more or less decided of inflammation of the mucous membrane of 
the larynx have generally been detected — even when no traces of increased redness are pre- 
sent, the secretion of the membrane is usually found to be augmented, and of an opaque, 
yellowish or reddish colour. When, as sometimes happens, death takes place suddenly 
during a paroxysm, it is probably the result of asphyxia, caused by a complete spasmodic 
closure of the glottis. 

The disease usually occurs in children from ten months to eight years of age, but more 
frequently between two and five years. It occurs more often in boys than in girls. 

There is in some families a peculiar predisposition to the attacks of spasmodic laryngitis 
— nearly all the children becoming affected with it as they attain the age of between two 
and three years. Though generally sporadic, it occasionally prevails as an epidemic. 

Its occasional cause is almost exclusively exposure to cold and damp, or sudden alterna- 
tions of temperature. After an attack has occurred, the paroxysms may be excited by any 
sudden or violent mental emotion. 

The prognosis in this disease is generally favourable — but when the occurrence of the 
paroxysms is prolonged beyond the third da)^, and constantly augments in intensity — espe- 
cially when they are succeeded by great restlessness, nausea and vomiting, when the pulse 
becomes soft and feeble, when a frequent suffocative cough remains, and the patient's strength 
gradually diminishes, an mifavourable termination is to be apprehended. 

The disease with which spasmodic laryngitis is most liable to be confounded, is pseudo 
membranous or genuine croup. 



516 



CHILD-CROWma, OR 



The following comparative diagnostic peculiarities, borrowed partly from M. ValleiXj 
and partly from MM. Rilliet and Barthez, will enable us very readily to distinguish the two 
diseases — 

In Croup. In Spasmodic Laryngitis, 

There is fever of variable intensity — The symptoms of invasion are slight — 
pseudo-membranous angina, and slight hoarse- there are a slight catarrh, and a cough some- 
ness. what hoarse — the throat is unaffected — some- 

There is a gradual increase of the hoarse- times there are no prodroma. 
ness, and sooner or later a hoarse cough. The attack is sudden — usually at night. 

The fever does not remit; the cough be- Between the paroxysms the patient ap- 
comes hollow and. feeble, and the voice faint pears well — the fever disappears or declines 
or extinct. — the voice is rarely extinct. 

The disease is sometimes attended with an There is an expectoration of mucus, 
expectoration of false membrane. The paroxysms of the disease decrease in 

The dyspnoea constantly increases, the violence, 
cronpal sound continues during the parox- 
ysms — finally the voice and cough become 
extinct. 

The proper treatment of a case of spasmodic laryngitis will depend in a great measure 
upon the violence of the attack and the age of the patient. 

When there are decided indications of laryngeal inflammation, and the spasmodic parox- 
ysms are intense and prolonged, the application of leeches to the throat, in numbers pro- 
portioned to the violence of the symptoms, and the age and strength of the child, will be 
proper. In robust children of five years and upwards, bleeding from the arm will often be 
productive of the best efiects. In no case, however, will it be proper to draw much blood 
either from the arm or by leeches ; nor sliould the operation be repeated at short intervals, 
or too late in the disease — and in the milder cases the abstraction of blood will not be 
demanded. 

On the first accession of the disease it has been advised by Lehmann to apply a sponge, 
dipped in very hot water, and then carefully squeezed out, upon the anterior part of the 
neck, and leave it a moment in contact with the skin — the application being repeated at 
short intervals. This will produce a redness of the surface, and a general perspiration, 
which is to be promoted by giving some mild tepid diluent. By this simple procedure the 
paroxysm, we are told, together with all the leading symptoms of the disease may be cut 
short. 

An emetic given at the commencement of the attack, when followed by the warm bath 
and sinapisms to the extremities, will generally abate the violence of the paroxysm, and 
shorten its duration. The exhibition of an emetic, or of small nauseating doses of ipeca- 
cuanha, in the intervals of the paroxysms, when considerable hoarseness of the voice, and a 
frequent short barking cough continue, will generally be' found to remove very promptly 
these symptoms, and prevent their recurrence. 

The bowels should always be attended to, and if not freely and regularly open, a dose of 
calomel, followed by castor oil or magnesia, will be proper. 

Blisters to the neck or chest, or between the shoulders, are recommended by some writers. 
We have seldom seen much benefit to result from their application. When employed they 
should be allowed to remain on only for an hour or two ; and when removed the part occu- 
pied by them should be covered with a soft emollient poultice. 

In violent cases, subsequent to depletion and the use of the warm bath, much benefit has 
been derived from the administration of assafoetida, either by the mouth or by enema, a 
few hours after the paroxysm has terminated. Covering the breast -with an assafcEtida plas- 
ter we have, also, found to be decidedly beneficial. 

Several of the German physicians recomm_end in the highest terms the use of musk ia 
this disease. Wendt gave it in the dose of a grain every hour. 

When the paroxysm, from its length and violence, threatens the destruction of the child 
by asphyxia, the operation of tracheotomy should be performed without delay. 

During the entire continuance of the disease the child should be warmly clad, and kept 
1 t a warm, well ventilated room. His diet should be light, and of easy digestion, and his 
drinks should consist of weak, lukewarm lemonade, barley or toast water. The utmost care 
should be taken to preserve the patient in a state of perfect tranquillity. During the parox- 
ysms he should be supported in an erect position ; all covering or ligatures being removed 
from about the neck. 

There is another affection of not unfrequent occurrence, to which attention has been re- 
cently directed by Dr. Behrend of Berlin (Journ. der Kinderkrankheiten) , that has no doubt 
been frequently mistaken for spasmodic laryngitis. It is a spasmodic cough of a peculiar 
character, to which children are liable, and which occurs only during the night. 



SPURIOUS CROUP. 



517 



This affection is most generally observed in spring and winter; it, however, also frequently 
occurs during the autumn, and but rarely in summer. It is seldom, if ever, observed in 
infants at the breast, but occurs at every subsequent period of childhood, and more fre- 
quently in boys than girls. There is no cough whatever during the day, not the slightest 
catarrhal symptom, and, when put to bed, the child falls into a sound quiet sleep at the 
usual hour. In the course of a few minutes, however, it becomes restless, and before awak- 
ing, coughs violently. It now commences to cry, and the cough becomes more and more 
severe, until, in some cases, it produces vomiting ; after one or two hours of suffering, the 
child again falls asleep, and passes the remainder of the night quietly. . The cough returns 
at the same hour the following night, and continues sometimes for weeks and even months ; 
finally, it begins to diminish in violence, the fits become of shorter duration, and occur at a 
more advanced period of the night, so that the length of the sleep enjoyed previously to its 
coming on, is gradually prolonged : — at length the cough disappears entirely and sponta- 
neously. The subjects of this affection are pale, readily fatigued, and troubled with a cold- 
ness of the feet towards evening ; they eat and play, however, as usual, and appear other- 
wise to enjoy good health. The nocturnal cough has frequently a catarrhal character, and 
is generally accompanied with a mucous rattle ; sometimes, the cough is dry, croupy, and 
whistling : the kinks are short, isolated, and uniform, and may recur every five minutes, or 
extend only to one or two. 

This nocturnal periodic cough cannot be mistaken for genuine croup — which has well 
marked symptoms ; and it may be distinguished from spasmodic laryngitis by the complete 
intermission which follows the paroxysms, by its not being preceded by any catarrhal symp^ 
toms, and by the entire freedom from fever throughout the attack. It may be distinguished 
from hooping-cough from the latter being almost always epidemic, and occurring as well during 
the day as during the night, and always accompanied with a peculiar dyspnoea. In the noc- 
turnal periodic cough there is no true appearance of suffocation : the children do not awake 
suddenly, as in a fit of asthma or spasm of the glottis, but they awake slowly, after having 
coughed several times during sleep. It most nearly resembles the cough of catarrh or bron- 
chitis, but it is distinguished from those by the entire absence of the physical signs, and by 
the nocturnal periodicity of the fits, which arc followed by complete remission. 

Dr. Behrend considers this cough to depend on an affection of the nerves, and bases this 
opinion chiefly on the symptoms, and on the circumstance of its having frequently appeared 
after an epidemic of hooping-cough, and whilst intermittent fevers were very prevalent among 
adults. This latter remark has been made by several physicians whose attention was drawn 
to this cough by Dr. Behrend. 

The prognosis, we are told, is always favourable. In one case the periodic cough was 
followed by bronchitis, but this was probably merely accidental. In another case there was 
repeated epistaxis. 

The disease, upon the whole, is generally more troublesome than serious, and demands 
no active treatment. Gentle purgatives, as manna with the tincture of rhubarb, given in 
the evening, with attention to diet and regimen, are recommended. A drachm or two of the 
liq. acetatis ammonias, in a little sugar, may also be given, before putting the child to bed. 
One physician found small doses of quinia, given at bed-time, of great service ; another 
found slight irritation of the skin, chiefly by means of pediluvia, and friction of the soles of 
the feet with roasted onions, and even enveloping the limbs, after the manner of Preissnitz, 
beneficial. — C] 



LECTURE XLVII. 

Diseases of the TTiorax. General observations. Dyspnoea. Cough. Methods 
of exploring the physical conditions of the chest, by the senses of sight, touch 
and hearing. 

From the throat — and especially from that part of it with which we were last 
occupied — the transition is natural and immediate to the thorax. Now the interior 
of the chest is the theatre of numerous and most important morbid changes. Within 
that cavity are lodged two of the three organs most essential to hfe. The heart, 
lungs, and brain, have been said, by a bold figure of speech, to constitute the tripod 
of life : and the two former are planted in the thorax. In the same division of the 
body lie also the greater blood-vessels, and many other parts of scarcely less conse- 
quence. With respect to the heart, its alternate swinging movement cannot long 

3t 



518 



DISEASES OF THE THORAX. 



Stop, and the patient continue to live : while three minutes' total interruption to the 
play of the lungs would in most cases be irremediably fatal. And lesser impedi- 
ments to the free working of either of these two vital organs are productive of much 
danger and distress ; and lead often to consecutive changes of a very serious kind, 
in various other portions of the body. 

These parts, of which the function is so indispensable, and of which the disorders 
are so grave and perilous, are encased in such a manner by the ribs and other 
boundaries of the chest, that they can neither be seen nor handled. And until a 
very late period in the history of medicine — until our own times, in fact — the diag- 
nosis of the formidable maladies that befal the viscera of the thorax was exceedingly 
uncertain and imperfect. Physicians were able, indeed, by the observation of indi- 
rect symptoms, manifested through the general system — by remarking the presence 
of inflammatory fever, I mean — to infer that inflammation had been somewhere 
lighted up : and symptoms that denoted disturbed functions of the respiratory appa- 
ratus — cough, difficult breathing, or local pain — might suffice to apprize them that 
the inflammation was situated in the chest. But what tissue it aflected, where 
was its exact place, what was its extent, or what were its physical consequences — 
these were points concerning which they had no means of obtaining any precise 
Knowledge. "Under the title of pneumonia, or pneumonic inflammation," says 
Cullen, "I mean to comprehend the whole of the inflammations affecting either the 
viscera of the thorax, or the membrane lining the interior surface of that cavity : for 
neither do our diagnostics serve to ascertain exactly the seat of the disease, nor does 
the difference in the seat of the disease exhibit any considerable variation in the slate 
of the symptoms, nor lead to any difference in the method of cure." You will see, 
as we proceed, how very inaccurate this last statement would be, if it were made 
under our present mode of investigating these diseases. " Pneumonic inflammation 
(he continues), however various in its seat, seems to me to be always known and 
distinguished by the following symptoms : — Pyrexia, difficult breathing, cough, and 
pain in some part of the thorax." 

I state these things to you — who do not recollect the time, as 1 do, when no medi- 
cal man in this country could, with truth and candour, say more of his knowledge 
of diseases of the chest than Cullen said — that you may the better estimate the ex- 
ceeding value of the discovery of what is called the method of auscultation, in the 
detection and discrimination of disease ; and most particularly of thoracic disease. 
In the present day, we are able to obtain more exact information respecting the dis- 
orders of the parts contained within the chest, than of any other internal, and there- 
fore invisible parts of the body. Indeed, in a vast number of instances, we can tell, 
as accurately as if we saw them, the actual condition of the thoracic viscera : can 
follow, step by step, the successive processes of disease, or of repair, in which they 
are involved. We can penetrate beyond the symptoms which denote deranged 
function, and detect and understand those much less fallible symptoms w^hich arise 
from alterations of structure. And this vast addition to our pathological knowledge 
has been given us by the simple application of one of our five senses to the investi- 
gation of disease, the sense of hearing, which for so many centuries had been 
(strangely as it now seems) neglected, or but httle used. By the assistance of the 
ear it has come to pass that those diseases which, besides being the most common and 
the most destructive, were also the most obscure, are now better understood than the 
diseases of any other internal part whatever. 

The direct symptoms which arise out of the changed conditions of the parts affected 
in thoracic complaints, are so mixed up with all that we know or can learn of such 
complaints, that what in other cases is called the morbid anatomy of disease, becomes 
here a part of its descriptive history. I shall not say, therefore, — as in regard to 
many other maladies I am obliged or I find it convenient to say, — so and so are the 
symptoms ; and afterwards, So and so are the morbid appearances : but I shall de- 
scribe the morbid conditions in the outset, as the only way of rendering the symptoms 
which result from them intelhgible. 

But before I enter upon the subject of auscultation, it may be useful to make a 



PHYSICAL SIGNS. 



519 



few remarks upon those symptoms of thoracic disease which were previously known, 
and which depend upon, or rather which express, derangement of the pulmonary 
functions. 

One of the most constant, and obvious, and distressing, and instructive of these 
symptoms, is embarrassed or laborious breathing : what is technically called dysp- 
noea. You know that by a healthy aduit, under ordinary circumstances, the act of 
respiration is performed, unconsciously almost, about eighteen times in a minute. 
There is about one act of respiration for every four beats of the heart. In various 
diseases this proportion is materially altered. The reciprocal movements, by means 
of which, in measured succession, air is drawn into and again let out of the lungs, 
are performed v/ith hurry, or effort, or unusual slowness. Dyspnoea imphes some 
deviation from the natural manner or rate of alternately expanding the thorax, and 
suffering it to collapse again : of inspiring and expiring : in one word, of breathing. 
The patient himself may, or may not, be conscious of this deviation. In most of the 
cases in which dyspncea claims to be regarded as a symptom, he is conscious of it. 
Now, upon what does this symptom depend? It may ultimately be referred to an 
altered proportion between the quantity of atmospheric air that reaches the lungs, 
and the quantity of blood that is sent into them, from the right side of the heart, to 
be converted from venous to arterial. That, doubtless, is at the bottom of almost 
every case of dyspnoea. Let me remind you that respiration is an automatic move- 
ment ; subject, nevertheless, to the occasional control of the will. The pulmonary 
branches of the par vagum constitute the principal and constant excitor, as the nerves 
that supply the muscles of respiration are the motor links of the nervous chain by 
which the automatic movements are governed. It is beheved that the presence of 
venous blood in the capillary vessels of the lungs forms the natural stimulus to the 
pulmonary part of the par vagum. In the ordinary bregithing of a healthy person, 
this stimulus or impression is not felt ; perhaps because, being shght and habitual, 
and exactly apportioned to the need of the individual, it is not attended to ; or, it is 
at once appeased by the admission of air, and the corresponding change in the blood. 
But when that change is not immediately or perfectly accomplished, then arises the 
distressful sensation which everybody has felt, but which our own language has no 
one word to express. The French call it the hesoin de respirer. The English 
phrase, ward of breath, denotes the peculiar sensation equally well. It calls into 
exercise, frequently, the voluntary power of performing the mechanical act of breath- 
ing — a power which is superadded to the automatic process. 

Various are the ways in which the natural manner and frequency of the respira- 
tory movement may be deranged. They v/ere fully considered when I was on the 
subject of death by apnosa. They all operate, ultimately, by destroying the just 
equilibrium between the blood and air which meet to undersfo chemical changes in 
the lungs. We haA^e lately been considering certain diseases in which the difficulty 
and distress of breathing is often extreme. In croup and laryngitis, the only inlet 
for the air is narrowed at its very entrance : there is more blood passing through the 
lungs than can be arteriahzed under the ordinary motions of respiration : instinctive 
efforts take place to increase the quantity of air: to make up by more numerous 
acts of inspiration for the diminished amount of air introduced by each single act. 
For a time these compensatory efforts may suffice. But if the access of air be still 
impeded, blood begins to circulate through the arteries but half decarbonized, and to 
linoer and stagnate in the lungs : the lips become livid, and the skin grows dusky. 
Make, however, a free opening in the pipe that should conduct air to the lungs, and 
the balance being restored between the blood in those organs and the air that reaches 
them, the dyspncea is soon at an end. The quantity of blood being the same then, 
but the air inspired too Utile, there will be dysj)noea. The very same thing occurs 
whenever a portion of lung, from being spongy, is rapidly rendered solid. No air 
can then penetrate it, nor perhaps any blood ; but the same quantity of blood as 
before arrives at the right side of the heart, and is transmitted thence through the 
pulmonary artery ; and consequendy those portions of the lungs which are pervious 
to blood and air, are supphed with blood in excess, and require air in excess : i. e., 
dyspnosa is necessitated. And you will perceive that similar consequences may 



520 



DISEASES OF THE THORAX. 



arise from any pressure made upon the lung-, obliterating in a certain degree its cel- 
lular structure ; as by fluid collected in the pleura ; by enlargement of the heart ; by 
aneurism of the great vessels ; by tumours, of whatever kind, within the chest ; or 
by pressure upwards against the diaphragm by reason of a distended abdomen, whe- 
ther the distension be occasioned by disease, such as ascites, or by obesity, or by a 
full stomach, or by a gravid uterus. A like disproportion will ensue, if the free 
expansion of the thoracic cavity be prevented by pain, by disease or rigidity of its 
boundaries, or by palsy of its muscles through interruption of the nervous circle 
whereon their contractions depend. 

But on the other hand the balance may be destroyed from the opposite quarter : 
the air admitted during a single ordinary inspiration being the same, the quantity 
of blood requiring to be converted from purple to scarlet may be augmented ; and 
in that case also, in order to maintain the due equilibrium, more numerous acts of 
respiration must be performed : in other words, dyspnoea will arise. This is the 
case under brisk exercise : the pressure of the muscles upon the veins propels their 
contents with greater velocity towards the right side of the heart ; the heart contracts 
more frequently in proportion as it is more rapidly filled with blood ; a greater quan- 
tity than usual is sent through the pulmonarj^ artery to the lungs ; and the individual 
breathes more quickly, to supply this augmented quantity of blood with air : he is 
out of breath, in a state of dyspnoea. But this is not disease. Disease, however, 
will often have the same effect. The quickened circulation in fevers, any obstacle 
to the free passage of the blood from the heart into the arteries, will tend to gorge 
the lungs with blood, to destroy the requisite equilibrium between the air and the 
blood in those organs, and so give rise to dyspnoea. 

Other conditions still may be mentioned, as predisposing to hurry of the breathing 
— a pecuhar state of the nervous system ; certain qualities of the blood ; — but I need 
not dwell on these at present. 

There are two important corollaries derivable from what I have now been stating. 
In the first place, you must perceive how intimately the functions of the heart and 
lungs are dependent upon each other ; and that disease originating in either of these 
vital organs may readily be the cause of consecutive disease in the other. We shall 
have many examples of this before us as we proceed. It would aflord materials for 
an interesting essay, this mutual relation between cardiac and pulmonary disease. 
At present I merely glance at it in passing. 

In the second place, what I have said of dyspncea must have sufficed to show you 
that, taken by itself, it has not much value as a diagnostic symptom. All that it 
tells us is, that the healthy and natural relation between the quantities of blood and 
of air in the lungs is disturbed : but to determine the cause of that disturbance — to 
decide whether the heart be in fauk, or the lungs, or both, or neither — we must have 
recourse to other sources of information. 

Cough is another of the symptoms, mentioned by Cullen, as denoting disordered 
function of the breathing apparatus. I need scarcelj^ tell you that it is produced by 
closing the glottis, and then making a sudden and strong expiration. Its purpose is 
the dislodgement of mucus Avhich may have collected in ex'cess in the air-passages, 
or of any other source of irritation to the membrane fining those parts. To be effectual 
it requires the admission of a certain quantity of air, and the possession of a certain 
degree of muscular strength. I pointed out to you, in the last lecture, a remarkable 
exemplification of this : the boy whose case is described by Mr. Chevalier in the 
Medico-CIiirurgical Transactions, was dying of croup ; was on the brink of being 
suffocated by the collection of mucus in his wind-pipe and bronchi, which mucus he 
was unable to expel : and he was unable, not from defect of muscular strength, but 
because he could not sufficiently inflate his lungs beyond the collected mucus. When 
a.n ample opening was made in his trachea, he drcAvina strong breath, and coughed 
the mucus up throygh the rima gloitidis. In old and feeble persons labouring under 
chronic bronchitis with profuse secretion from the mucous surface, strength is often 
■wanting to cough the phlegm up ; and they die suffocated. 

But the sensation which prompts to the acts of coughing may arise from various 
other causes besides the accumulation of mucus in the air-passages. Any slight 



PHYSICAL SIGNS. 



521 



irritation about the glottis ; a long, trailing and tickling uvula ; the inspiration of 
irritating vapours ; pressure of any kind upon the respiratory organs ; may any of 
them produce cough. Nay, it sometimes is provoked by sympathy with other parts; 
an instance of which we have in what is called a stomach-cough. Some morbid 
condition, some irritation of the stomach exists, which being appeased, the cough 
ceases. You will recollect the name and the functions of the pneumo gastric nerves. 
We have, in the fact just mentioned, another example, in addition to those which I 
glanced at in a former lecture, of irritation of the sentient extremities of one branch 
of a nerve, declaring itself by uneasy sensations referred to other branches of the 
same nerve. For these reasons, therefore, cough is not more diagnostic of particular 
diseases situated in the thorax, than is dyspncea. There are, indeed, certain varieties 
of cough, as there are certain modifications of the breathing, from which we may 
obtain very useful information even in respect to the nature and seat of some diseases: 
and these varieties and modifications I will point out as I go along. 

Let me admonish you, also, before we come to auscultation, not to fall into an. 
error which has been too common ; that of trusting entirely to the ear in the investi- 
gation of thoracic disease, to the exclusion or neglect of those phenomena which are 
perceptible by the eye, or by the hand ; or of those indirect revelations which are 
furnished by the condition of other parts and functions, or by the previous history 
of the patient. Even before the discoveries of Avenbrugger and Laennec, physicians 
were too remiss (if we may judge from their writings) in what may be called the 
mechanical exploration and notice of the actions of respiration. A good deal may 
be learned, sometimes, by merely placing one's hand upon the chest, or belly, as I 
shall explain more particularly by and by : and a great deal, also, may be made out, 
in some cases, by the simple inspection of those parts, when they are uncovered. 
You may see, for example, that the ribs, in respiration, scarcely move at all, while 
the belly rises and falls alternately with the descent and ascent of the diaphragm. 
This is called abdominal respiration. It may arise from a painful condition of the 
intercostal muscles, or of the plurse, rendering the patient unwilling to elevate his 
ribs; or it may arise from disease of the spinal cord, between the origins of the 
phrenic nerve and of the intercostal nerves, rendering the patient unable to raise 
them; or the same inability may result from disease of the lungs themselves. The 
symptom may guide us at once to the seat of the malady. Again, the breathing 
may be entirely thoracic, no motion of the abdomen taking place ; and this may de- 
pend upon an affection of the diaphragm, or of the pleura which is reflected over it ; 
or upon disease, accompanied with tenderness, within the abdomen — upon perito- 
nitis, for example ; or upon mere distension of the abdomen. Or by looking at the 
naked chest, you may see that one side of it moves, and that the other moves less, 
or does not move at all : and the motionless side may be of the natural size as com- 
pared with the other, or it may be flattened and contracted, or it may be round and 
bulging ; and most important conclusions, and most important indications of treat- 
ment, will flow from a knowledge of these circumstances. The general form of the 
chest is also instructive. Never neglect, then, to examine the thorax, in cases where 
it is supposable that the disease may be seated in that part of the body, by your eyej 
as well as by your ear. The eye needs but httle training to enable it to perceive 
and comprehend those signs which are within its sphere : the ear, unfortunately, 
requires to be carefully educated. I will just remark, further, that in the case of 
females, no indelicate exposure of the person need be made. In most instances the 
morbid conditions I have been adverting to may be recognized through a thin linen 
covering. 

Auscultation signifies the investigation of internal diseases through the sense of 
hearing : and it is especially applicable, for reasons which I either have stated or 
will state, to the study of thoracic diseases. In its full meaning it includes all that 
we learn by listening to a cough, and all that we gather by striking the chest, and 
attending to the resulting sound. But in general, the term percussion is used to 
express this last mode of ehciting information, although the information is conveyed 
through the medium of the ear : and the word auscultation is applied to the art of 
distinguishing diseases by listening to internal sounds, by means of the ear placed 



522 



DISEASES OF THE THORAX. 



in apposition with the surface of the body ; or by means of some conductor of sound 
interposed between the ear of the hstener and the person of the patient. In the first 
of these two modes the auscultation is said to be immediate; in the second, mediate. 
By percussion we ascertain the degree of resonance, or want of resonance, of the 
part struck : by auscultation we learn the qualities and modifications of the voice, as 
reflected through the chest ; and of the breathing ; and of the sounds of the heart. 
The invention of the method of percussion we owe to a German, Avenbrugger, who 
wrote an excellent treatise upon it, which was brought into notice by Corvisart, who 
translated it. For the more brilliant discovery of auscultation we are indebted, as 
every body knows, to Laennec. 

Now it will save us much trouble, and conduce, I hope, to your future progress as 
practical auscultators, if, before I speak of any of the diseases of the chest, I pre- 
mise some general observations respecting these modern methods of examining the 
human body, with the view of detecting and discriminating its diseases. Indeed, I 
could not make myself intelhgible unless I did so. 

And first, with respect to percussion, which you will please to recollect is nothing 
else than auscultation of, or listening to, sounds which we ourselves artificially and 
purposely produce. 

You know, every child knows, by daily experience, that different substances, 
when struck, give out very different modifications of sound. If you strike a drum, 
you get one kind of sound ; if you strike a brick wall, you get another. The one 
is loud, trembling as it were, and prolonged ; the other dull, short, and flat. But 
why should I attempt to describe in words things which are familiar to you already? 
Bodies that are solid, or inelastic, give the dull flat sound in proportion to their solid 
thickness, or their want of elasticity. On the other hand, hollow vessels, i. e„ ves- 
sels containing air, with thin, firm, elastic boundaries, give out a sound more or less 
approaching in its qualities to that of a drum : the sound is called a hollow sound 
from that circumstance. If you have a wooden cask containing air only, it is resonant 
when struck : fill it half full of water, and the lower part will render a flat sound, 
the upper empty portion a hollow sound ; less hollow, however, than when the 
vessel contained no water ; fill it up with water, and the whole is dull on percussion; 
pour out the water, and fill it loosely with wool — it will still be resonant, though in 
a different and less clear note than when it held air alone. 

Now this experiment may be transferred to the human chest, which is a cavity, 
bounded by firm, thin, tense, and elastic walls, and containing, in its natural state, 
the spongy lungs, "which are full of air ; and other parts that are solid, whereof the 
heart is the chief. If you strike the surface of the chest (it requires a Httle knack 
to do it properly), and if the blow falls over a portion of healthy lung, you will 
produce a resonant or hollow sound. If the lung be not there, if it be pushed aside, 
and its place supplied by some more solid or inelastic substance, by fluid for example, 
you will hear a dead sound. So you wili if the lung be there, but has lo.st its spongy 
character, is void of air, and somehow or other solidified. But you may have a 
resonant sound, though the lung is in a state of disease ; nay though the lung is not 
there : so that percussion alone cannot always be depended upon. I shall tell you, 
hereafter, how to guard against being misled by it in such cases. Again, if you 
strike over the region of the heart, you will get a positively dull sound, or at any 
rate a much duller sound than in most other parts of the chest. 

It is really a singular thing, that this method of searching for indications of disease, 
and of heakh, should have been so long neglected or overlooked in our profession. 
I am sure that I had a practical acquaintance with the principle of percussion long 
before I knew any thing of physic ; and so, I make no doubt, have most of you. 
Many a time, when wishing to know whereabouts I might drive a nail firmly into a 
wall, I have tried with the hammer to find which was brickwork, and w^hich was 
wooden joist ; and percussion is an art in daily use for similar purposes, with car- 
penters and bricklayers. Yet it does not appear to have been thought of by physi- 
cians till the middle of the last century, when Avenbrugger, after studying its results 
for seven years, as he tells us inter tsedia et labores, published at Vienna his " In- 
ventum novum, ex percussione thoracis humani, ut signo, abstrusos interni pectoris 



PHYSICAL SIGNS. 



523 



morbos detegendi." This was almost totally neglected however, until, as I stated 
before, Corvisart's work on diseases of the heart brought it into general notice. 

Avenbrugger and Corvisart, and indeed every body who used percussion at all, 
until a very few years ago, employed direct percussion : that is, they struck the chest 
with the extremities of the fingers. More recently, mediate percussion has been 
introduced into practice, by M. Piorry. In mediate percussion some sohd substance 
is placed upon the spot, the resonance of which is about to be explored, and the 
blow is made upon that substance, which is called a pleximeter — a stroke-measurer. 
A round thin plate of ivory, laid flat upon the surface, is the most common sort of 
pleximeter ; or metal, or wood, or leather, or India rubber, may be employed. Many 
persons, and I am one of them, use no other pleximeter than the fingers of the left 
hand. 

I shall explain, as briefly as T can, the method of employing percussion, and the 
cautions requisite to render it an eflfectual and a true interpreter of the state of the 
parts beneath the stricken surface. 

The position of the patient is of some consequence. It should be one that is con- 
venient to the examiner, and not inconvenient to himself; and it should be one 
calculated to render the part struck as firm and lense as possible. The best position 
of all is a sitting position, on a firm chair. But you may percuss a patient very 
eflectually as he sits up in bed, or while he stands, or some parts even when he is 
lying down. A good deal is said, — more, in my opinion, than is necessary, — about 
the effect of curtains, and so forth, in deadening the sound. I do not beheve they 
will ever interfere with your conclusions, especially as we learn more from com- 
paring the sounds given out upon percussing the corresponding parts of the opposite 
sides of the chest, than from the absolute resonance or want of resonance of any 
single part. But there are some exceptions to this ; and if your patient can be made 
to sit on a chair in the middle of the room, so much the better. 

Then, if you are about to percuss the front of his chest, make him hook his arms 
over the corners of the back of the chair, and throw his head back. If you desire 
to explore in this way the lateral portion of the thorax, he must place the hand of 
that side upon his head, and lean a httle to the opposite side. If you would know 
how the posterior part of the chest sounds, he must lean forwards, fold his arms 
across his breast, and bend down his head. 

Next as to the mode of percussing. For direct percussion, the ends of the fingers 
of the right hand should bf brought together, and into a line with each other, so that 
no one of them may project beyond the rest ; and care should be taken, first, to 
compare the sound produced by striking any part of the chest on one side, with that 
produced by striking the corresponding part on the other side. It follows from this 
rule that we should not examine all the points on one side before passing to the other, 
because we should thus lose the remembrance of, and the power of accurately com- 
paring, the sounds obtained from corresponding points, it is best to strike first on 
one side of the body, and then on the corresponding spot of the other. It follows 
also that we are not to compare the result of percussion on one of the ribs, with the 
result of percussion on one of the intercostal spaces. The blow should fall upon 
the rib, and parallel to it. 

A second point requiring attention, is the state of the chest in respect to the act 
of breathing. If one side be percussed after the movement of inspiration, and the 
other after that of expiration, some little difference in the resulting sounds will be 
manifest, even in the healthy condition of the thorax. And this might mislead. 
Let corresponding spots on the two sides be therefore both struck, either while the 
chest is expanded, or while it is collapsed, or while the patient holds his breath. 

Thirdly, you must take care to strike the corresponding pans at the same angle, 
and not with the fingers perpendicular to the surface on one side, and inclined 
obliquely to it on the other : also to strike corresponding parts with the same degree 
of force. And the blow should not be hard enough to give the patient pain ; indeed 
such a blow would not produce a good sound. It should be smart and quick ; the 
ends of the fingers should not remain on the chest. Under some circumstances, 
however, the patient cannot bear to be percussed at all 



524 



DISEASES OF THE THORAX. 



The latter cautions are most necessary when direct percussion is employed ; over 
which mediate percussion has, however, many advantages. Some of these are ob- 
vious. In the first place, the space examined by mediate percussion is very exactly 
defined and limited. Secondly, you may strike the pleximeter much more forcibly 
than you could strike the unprotected body, and so produce a more decided sound. 
Even when the surface is morbidly sensible, or the patient unusually irritable, so 
that percussion in the ordinary way cannot be performed at all, it may generally be 
done through the pleximeter. A third and very great advantage is, that mediate 
percussion is available when made over certain parts where, even although there 
may be no pain occasioned by it, ordinary zmmediate percussion is attended with 
no useful result. Parts, I mean, where there is much fat, and parts which are fleshy, 
or cedematous. If the pleximeter be pressed firmly upon these parts, even upon the 
mamma in females, the hollow sound is attainable ; whereas, if they were struck by 
the fingers, the sound would be perfectly dull. Mediate percussion may be applied 
also, with effect, through the clothes. 

I say that a convenient way, and one which I find quite sufficient, of employing 
mediate percussion, is by making a pleximeter of the finger or fingers, of the left 
hand ; taking care that they are closely in contact with the subjacent parts, and simi- 
larly applied to corresponding spots ; and that the backs of the fingers be outwards. 
Piorry declares, indeed, that the resonance produced by this mode is scarcely one- 
tenth part so great as that elicited by using a thin, solid and elastic plate. For all 
practical purposes, however, I am certain that the finger, as it is the readiest, so also 
it is a very satisfactory and sufficient pleximeter. It has, moreover, this positive 
advantage, that the sound made by striking it is not loud, and does not obscure or 
interfere with that which depends upon the condition of the chest. 

ft is right that you should be aware of differences of sound which belong to the 
individual. Cseteris paribus, the sound given out on percussion is more resonant 
during mspiration than during expiration ; in childhood and youth than in middle 
age : in middle age than in old age ; in females than in males ; in thin persons than 
in fat : and, they say, in nervous, irritable people, than in those of a contrary tem- 
perament. 

And it is still more necessary that you should be aware of differences of sound 
given out in health, by different parts of the surface of the thorax, in the same indi- 
vidual. And in order to explain this more distinctly, and for the sake of refer^mce 
hereafter, let me here exhibit to you the regions of the thorax, as they have been 
artificially mapped out for the purposes of auscultation. 

It is unnecessary for me to describe particularly the method followed in this arbi- 
trary division of the thorax into regions. I will state the names that have been com- 
monly applied to them, and the sounds which in health they respectively yield, ac- 
cording to their number in the diagram before you. 

The first region is that of the clavicles ^ one, of course, on each side. Upon these 
bones it is immaterial whether direct or mediate percussion be made. The sound 
given out should be very clear at their sternal extremities, dull at their humeral ex- 
tremities, and clear at their middles. The resonance diminishes from the sternal 
towards the acromial end of the clavicle. These parts correspond to the summits 
of the lungs. 

The second region is the subclavian. It lies between the clavicle and the fourth 
rib on each side. Beneath this superficial region lies the upper lobe of the lung; 
and towards the sternum large bronchi are situated. You will understand, there- 
fore, that the sound educed by striking this part ought to be very clear. 

A little lower down, number three, is the mammary region, extending from the 
fourth to the seventh rib on each side, and answering to the middle lobe of the lungs. I 
Here also the resonance afforded by percussion is clear ; but in the lower part of ! 
this region, on the left side, we find the heart, which is more or less covered by | 
lung : and on the right side the liver begins to mount. The sound is somewhat i 
modified and deadened by these deeper-seated viscera. In women we can deter- 
mine the degree of resonance of this region through the mammae, by mediate per- 
cussion only. 



PHYSICAL SIGNS. 525 

♦ 

The fourth is the mfra-mammary region. It comprehends that part of the bony 
compages of the thorax on each side, which hes between the seventh rib and the 




edge of the cartilages of the false ribs. Into this region, on either side, may descend 
the thin anterior margins of the lower lobes of the lungs ; but in the same region, on 
the right side, lies the hver, over which the sound of percussion is dull ; and on the 
left side is placed the stomach. Hence, when the stomach is tympanitic, a preter- 
naturally resonant sound will proceed from this part; and when the stomach con- 
tains no gas, the sound will be irregularly dull. 

All the regions hitherto described are double. There is still the mesial part of 
the front of the chest to be subdivided, and we may call the three regions there situ- 
ated, and numbered 5, 6, 7, the ujijitr sternal region, the middle sternal, and the 
lower sternal. In all these the sound on percussion ought to be clear, except, per- 
haps, in the inferior portion of the last, which may be rather dull, or Vv^hich, from its 
vicinity to the stomach, may be t3''mpanitic. 

The eighth region is the axillary ; the axilla above the fourth rib on each side. 
The ninth is the lateral region, between the fourth and seventh ribs. In both these 
regions the resonance should be distinct and clear. The tenth, which may be called 
the lower lateral region, below the seventh rib at the sides, gives ih^ same sounds 
as the infra-mammary, namely, on the right side a dull sound, on the left a sound 
which at times is preternaturally hollow : on account of the presence of the liver in 
the former case, and of the stomach in the latter. 

But we have yet to look at the hind part of the thorax. Here we have the space 
(region eleven) which- forms the top of the shoulder, and Hes between the clavicle in 
front, and the superior spine of the scapula behind ; the acromial region. Very 
little can be made out by percussion in this spot ; the sound is dull. But the depres- 
sion immediately above the scapula, the supra-spinal fossa, as it is called, is a space 
which affords valuable information to the ear aj)plied over it. 

The twelfth region is the scapular. It comprises the part covered by the scapula 
on either side. It corresponds to the posterior part of the middle lobe of the lungs, 
but yields a dead sound, unless a pleximeter be used. 

The thirteenth region is the intra-scapular. It lies between the inner edge of 
the scapula and the spine on each side. It corresponds to the roots of the lungs, 
and to the middle parts of their lower lobes. You may get a good clear sound here, 
if the patient's arms be crossed, and his head bent forwards, and his back arched, 
so as to stretch and tighten, and make as thin as possible, the superincumbent 
muscles ; you will find also that the ridge of the spinal column in this part gives a 
hollow sound. 



526 DISEASES OF THE THORAX. 

The last region to be mentioned, number fourteen, the dorsal, is the lowermost 
part of the ribs behind. It answers to the base of the lungs, and gives a clear sound: 
but the liver on the right side is apt to render its inferior portion dull ; and the 
stomach on the left to make it unduly resonant. 

Now, knowing these circumstances, if you find that a dull sound is' yielded on 
percussing a part that should render a hollow sound, you conclude that beneath the 
pan struck there is not the natural quantity of air. But whether this arises from 
consolidation of the lung itself, and the obhteration of its cells, or from fluid effused 
into the cavity of the pleura, you cannot, by mere percussion, determine. So, again, 
f the sound be unnaturally tympanitic, you cannot say whether that results from 
what is called pneumothorax, or from emphysema of the lung. Percussion testifies 
that air is there ; but further this deponent sayeth not. 

The information which the exercise of percussion may leave thus imperfect, aus- 
cultation of the sounds produced by the acts of breathing, speaking, or coughing, 
will in most cases supply. 

If the ear be laid close to the surface of a healthy thorax (or if the instrument 
called the stethoscope be interposed between that surface and the ear), the ear will 
hear the air enter and fill the lungs, and then withdraw and leave them again, in 
perpetual succession. The sound produced by this ingress and egress of air has 
been called the respiratory murmur. I might tell you that this sound, to my mind, 
is rather a rustle than a murmur : that it is like the sighing of the wind in the 
branches of a tree. I might say, with Laennec, that it resembles the sound made in 
the deep inspiration of a sleeping person ; or, with Dr. Davies, that it reminds one 
of the soft murmur of a pair of bellows, of which the valve does not click. But 
one minute's appliance of your ear to the subclavian region in a child, or even in 
an adult, will give you a clearer notion of the nature and character of this sound 
than any verbal description could convey. Yet, respecting this natural respiratory 
murmur, there are some things of which it is desirable that you should be previously 
informed. 

In the first place, the entrance of the air is much more noisy than the exit: which, 
sometimes can scarcely be heard. You will see, by and by, the importance of 
noticing this fact. 

In the next place, the murmur of respiration is not equally audible in all persons. 
It may differ much in intensity, though not in kind, in two persons, each of whom is 
in perfect health. Thus it is much more loud and distinct in children than in grown 
persons. So remarkably is this the case, that when we meet with an unusually noisy j 
respiratory murmur in an adult, we say that his breathing is puerile ^ it has the cha- i 
racter of the respiration of a child. Now, I tell you before hand, that puerile respi- 
ration in the lung of an adult is generally a sign of disease ; and it is mostly partial ; 
heard in certain parts only of the chest. 

Again, casteris paribus, the natural murmur of respiration is more clearly audible 
in lean and spare persons than in such as are muscular and fat. Fat and muscle 
are bad conductors of sound, and act as dampers. Listening to the breathing through 
a thick layer of adipous tissue, is like listening (as Dr. Latham says) to the respira- 
tion of a person through his clothes. | 

But if you take two heakhy men who are ahke in respect to leaness and fatness, i 
you may often find that the respiratory murmur is very loud in the one, and very j 
feeble, or almost inaudible, in the other : but in this last it becomes audible when he | 
takes a deep and forced inspiration. | 

The reason of this difference is not very well understood. The breathing may j 
be very indistinct, though the thorax be capacious, and well formed, and healthy. 
Some persons seem to require less effort than others to maintain the due equilibrium | 
between the air in the lungs, and the blood in the lungs : as if they had not only, i 
pulmonary space enough, but to spare. So that the difference in the manner of 
breathing, and in the sound occasioned by the passage of the air in and out, depends, 
in all probability, upon individual peculiarities of the circulation. At any rate, it is [ 
very important that you should be aware of the existence of these differences. ^ f 

But the sounds which reach the ear applied to the chest of a breathing person will j, 



PHYSICAL SIGNS. 



527 



differ in different parts, and under different circumstances. The sound given out by 
the air as it passes through the trachea and larger bronchi, differs from that which 
results from its passage into and out of the smaller bronchi and air-passages. I am 
anxious not to refine too much in these matters : and, therefore, I pass by minuter 
points of difference. Place the stethoscope over the trachea, and you will hear just 
such a sound as you might expect to hear : the sound of air rushing through a tube 
of considerable size, a blowing noise. We will call that sound, which you will re- 
cognize again when you have once heard it, bronchial breathing. It accompanies 
the outward as well as the invvard passage of the breath. Again, place your ear 
or your stethoscope upon the right mammary region ; there you shall hear that rust- 
ling sound, which I propose to call vesicular breathing, and which is chiefly audible 
during inspiration. We shall find these distinctions of much use in the discrimina- 
tion of disease. We shall find, for example, that the breathing sometimes is bron- 
chial, where it ovght to be vesicular. 

Now if any part of the chest where we should hear breathing, we can hear none, 
this may result from solidification of the subjacent portion of lung; or from some 
obstacle in a large bronchus, preventing the air from entering that part ; or from air 
being in any way shut up and stagnant in that part ; or from an effusion of liquid 
into the pleura at that part. And here again percussion comes into play, and de- 
termines for us which of these possible circumstances is the one really present. If 
the part when struck emits a hollow sound, there is stagnant air beneath it, either in 
the healthy lung, or in the lung altered by disease, or in the cavity of the pleura. 
If a flat sohd sound be given out, there is solid lung beneath, or liquid in the pleura, 
between the ear and the lung. All these points, and the conclusions to be deduced 
from them, will become clear to you, I trust, as we proceed. iVIinuter analysis of 
the diagnostic signs would be premature. 

A word or two preliminary I must say about the voice. 

The voice passes outwardly through the mouth and nostrils into the surrounding 
air; it passes also inwardly through the trachea and bronchi into the lungs, and it 
may be heard through the lungs, by the ear laid flat against the chest. Bu^ it gives 
quite a different sensation to the ear in different places. If you place the stethoscope 
on the trachea, the voice will articulate itself into your ear as if it came from and 
through the instrument. This sound, which is natural here, would be unnatural, and 
a mark of disease, if heard beneath the clavicles. When heard beyond its natural 
situation, it is called pectoriloquy. A less degree of this, a sound like that of a 
person talking into a tube, and whose words, for that reason, are muffled and indis- 
tinct, is called bronchial voice, or bronchophony. When to this modification of the 
voice there is added a twanging vibration, a cracked discordant tremor, resembHng 
the squeak of Punchinello, or (as some think) the bleating of a goat, oegophony 
is said to exist. All these unnatural modifications of the voice are indicative of 
most important changes within the thorax. I merely introduce them to you now: 
you will become better acquainted with them in due time. 

What is true of the natural voice, is true, mutatis mutandis, of that unnatural 
vocal sound, cough. The cough may be so modified by the condition of the internal 
parts, as to reveal that condition. 

There are yet other ways in which some information can be gathered respecting 
the interior of the chest. If you give certain patients a sudden smart jog while your 
' ear is applied to their thorax, you may hear a splashing sound, like that produced 
by shaking a barrel or a bottle partly full of water. From this expedient you in fact 
determine that the cavity of the pleura, or perhaps a large excavation in the lung, 
does contain both air and a liquid. This is called the method of succussioyi. It was 
employed long before the other forms of auscultation v/ere thought of. Hippocrates 
mentions it. 

Again (but that is not auscultation), you may sometimes collect useful information 
respecting the state of the chest by simply laying your open hand upon it. In most 
persons there is a distinct vibration or thrill produced by their speaking, which thrill 



528 CATARRH. — BRONCHITIS. j 

is very sensibly felt by the hand. Now, this thrill may be felt on one side of the | 
chest, and not on the other. And such a difference is an unequivocal sign of ; 
disease. 

The positions which I described before as being the most convenient for the per- | 
^ormance of percussion, are the most convenient also for the purposes of auscultation, i 
You may hsten with the unassisted ear, or you may hsten through the stethoscope^ i 
This, as you know, is a sohd or perforated piece of wood, of which one end is adapted ' 
to the ear ; and the other, which is to be applied to the chest, is hollowed out, or , 
expanded, into the shape of a bell, or funnel. The object of the instrument is to | 
collect and convey to the ear of the observer the vibrating impulse of the air, or of 
the solid walls of the thorax, occasioned by the motions within. The stethoscope is i 
sometimes useful for examining a circumscribed spot in the thoracic cavity. With | 
it we gauge, more nicely than we could do with the naked ear, the signs furnished I 
by the patient's voice. We must use it also when we would investigate the breath- ; 
ing in parts to which the ear itself cannot easily be applied ; and in cases where, i 
from the filth of the patient, or because he has some infectious disorder, we desire to \ 
avoid any immediate contact with his clothes or person ; and in cases of young or j 
old ladies, to whose breasts it might not be seemly or dehcate to be putting our faces, i 
But, with these exceptions, the stethoscope, in my experience, is rather a hindrance i 
than a help. Much, however, depends upon custom. I can best distinguish most j 
of the sounds to be heard within the thorax by my unassisted — perhaps I should say ' 
my unimpeded — ear ; and I therefore employ the stethoscope or cyhnder in such 
cases only as I have just adverted to. I cannot do without the instrument ; but I do 
without it as much as 1 can. Care should be taken that the end of the stethoscope 
next to the ear be closely and comfortably fitted to that organ ; and that its other 
extremity be blunt, so as not to hurt the patient ; and further, that it be uniformly 
and evenly applied to the surface of his chest. If these precautions be attended to, 
the shape and fashion of the instrument are very unimportant. , 



LECTURE XLVIII. 

t 

Catarrh ; its Varieties. Acute Bronchitis. Dry Sounds attending the Respira- \ 
tion ; Hhonchus, and Sibilus ; Moist Sounds ; Large and Small Crepitation; \ 
how these are produced^ and what they denote. Treatment of Acute Bronchitis, i 
Peripneumonia Notha. Sudden Infraction of a large Bronchus. i 

In the last lecture I described to you, in a general manner, the method of ausculta- ! 
tion, or the employment of the sense of hearing in the investigation of disease ; an(^ [i 
particularly of thoracic disease. I explained, as well as I could, the different sounds I 
which result from percussing various parts of the chest ; and from the entrance and 
exit of air during the several acts of breathing, speaking, and coughing. I men- ' 
tioned certain conditions in which those natural sounds are abolished ; but I did not 
speak, except incidentally and very cursorily, of the altered and new sounds to j- t 
which the presence of disease within the thorax has been found to give rise. Nor i i 
do I propose to enter now upon any /orma/ account of these morbid sounds. I shall : 
endeavour to make you acquainted with their characters, and causes, and significa- 
tion, as they arise in the progress of the separate thoracic diseases which I am about i 
to consider. ji j 

Before you can possibly appreciate the morbid sounds, you must make yourselves \ I 
familiar with the natural and healthy. You must have a standard, by which you | 
may measure the numerous deviations from the natural sound that will meCT yoar '! 
ear in disease. Listen to the voice and the breathing of healthy children, or of some '} 
of your friends and fellow-students; and you will soon recognise those respiratory i 
sounds which accompany the perfect state and working of the breath-machine. | j 



PHYSICAL SIGNS. 



529 



I intend to commence with those diseases of the lungs in which the mucous mem- 
brane lining the air-passages is primarily or principally involved. This membrane 
is often affected alone. It is much exposed to known causes of disease : to alterna- 
tions of temperature in the air which is constantly passing over it ; to the irritation 
produced by acrid or noxious matters, solid or gaseous, which are mixed and inhaled 
with the air. And when disease commences in other parts of the lungs, it seldom 
fails to reach, sooner or later, the mucous membrane. In diseases also of the heart, 
the same mucous membrane is very liable to be consecutively affected, by reason of 
those alterations in the condition of its capillary vessels which the disorder of the 
circulation produces. 

Now I shall first point out the changes to which this mucous membrane is liable ; 
and then describe the modifications of the natural sounds that result from such 
changes ; and, lastly, consider the different forms of disease which these changes 
constitute, and these altered sounds denote. 

In a former part of the course, I gave you some account of the peculiarities which 
differences of texture impress upon the phenomena and prpcess of inflammation ; 
and, among the rest, I spoke of the behaviour of the mucous tissue when inflamed. 

The mucous membranes, in the state of health, are perpetually moist. The 
exhalation of this moisture, to a certain amount, and not beyond a certain amount, 
constitutes an essential part of their healthy functions. Now, their inflammation 
(for I am about to consider first the inflammatory affections of the membrane of the 
air-passages ; some of them indeed I have already discussed), I say the inflammation 
of these mucous surfaces alters their ordinary secretion. An inflamed mucous mem- 
brane is in the first instance dry ; its secretion is suspended. But this is not the 
only change that takes place in it; it becomes tumid also, swollen, thicker than 
before ; it is redder than natural, and its sensibility undergoes a perceptible modifi- 
cation. Pain, in mucous membranes, is not a common phenomenon ; for their text- 
ure enables them to expand or dilate freely, so that they escape much tension, and 
the pain which is produced by tension ; but their natural sensations are blunted, and 
new and uneasy sensations arise in them : sensations of heat, fullness, itching. It 
happens that we can see a portion of the mucous membrane that belongs to the air- 
passages ; and by noticing the changes produced in it by inflammation, we infer 
those which are apt to take place in the parts we cannot see. We have all often 
experienced in our own persons an inflammatory state of the membrane lining the 
nasal cavities ; the Schneiderian membrane. At first the nostril is preternaturally 
dry ; yet, though it is dry, you cannot breathe through it : it is stuffed up, not with 
accumulated mucus, but by the mere swelling of the membrane : the sense of smell 
is perverted or lost ; the part is evidently red ; it is tender, also, and irritable ; the 
contact of atmospheric air a little colder or a little less pure than common, provokes 
sneezing. The affection extends often into the frontal sinuses, and headach and 
oppression ensue ; or it passes into and through the lachrymal sac, the conjunctiva 
participates in the inflammation, the puncta lachrymalia become impervious, and the 
tears flow over the cheek. And with all this there is sometimes shivering or chilli- 
ness ; and the pulse, especially in the evening, becomes a little more frequent than 
common. There is slight fever. After the unusual dryness, the membrane begins 
to secrete a thin serous fluid, having acrid properties ; for it reddens and frets the 
alse nasi and upper lip, over which it flows. By degrees this thin serous fluid be- 
comes thicker, and as it becomes thicker it becomes less irritating also, more viscid, 
opaque and yellow : the swelhng of the membrane diminishes ; it is less raw and 
sensitive : at length the secretion resumes its natural quality, and is reduced to its 
natural quantity again ; and the tumefaction of the membrane entirely disappears. 
This is the course of what is properly called a cold in the head. When the defluxion 
from the nasal membrane is considerable, systematic writers call the complaint cory- 
za ; when it is attended with much pain and weight about the frontal sinuses, it is 
named gravedo. It is a variety of catarrh. In catarrh, sometimes one part, and 
sometimes the whole, of the mucous membrane of the air-passages suffers inflamma- 
tion. If the disorder goes down into the lungs, it is said to be a cold in the chest ; 
or, from one of the most prominent of its symptoms, a cough ; in medical language, 
34 2u 



530 



CATARRH. — BRONCHITIS. 



bronchitis. It sometimes travels from one part of the membrane to another. Be- 
ginning, for example, in the nose, it gradually creeps down into the windpipe and 
lungs. Sometimes the inflammatory condition passes from the throat into the Eusta- 
chian tubes, and produces deafness ; or down the gullet and to the stomach, causing 
qualmish or other uneasy sensations, and loss of appetite. And occasionally this 
order appears to be reversed. There are some persons who will tell you that when- 
ever anything disagrees with their stomachs, whenever dyspepsia is produced by 
some error in diet, they are sure to have catarrh. 

Now I have adverted to this cold in the head, or coryza, because the phenomena 
which are open to our inspection in the Schneiderian membrane take place also, no 
doubt, in the bronchial. The membrane is first dry, and tumid, and irritable ; the 
uneasy sensations of which it is the seat prompt to the action of coughing. The 
chest feels tight, stuffed, constricted. There is some hoarseness, and a sense of 
roughness and soreness in the windpipe ; and a dry cough, which seems to arise 
from some irritation about the glottis. Sometimes, with these symptoms, pains in 
the hmbs, like the pains of rheumatism, occur; the appetite is impaired ; the patient 
is thirsty ; and a general lassitude is feh all over the body. 

But what effect has the altered state of the membrane upon the sounds elicited by 
percussion ; or heard within the chest, by the ear, during respiration ? Why it 
brings us acquainted at once with two remarkable modifications of the natural sound 
of breathing; and these I must describe and explain. 

I will take this opportunity of again recommending you to read and study the 
httle book of lectures recently published by Dr. Latham. It contains a very plain 
and clear account of the auscultatory signs of disease w^thint he chest ; and he speaks 
of these signs in more, easy and popular language, with less of over-refinement, and 
a less subservient adoption of the French mode of thinking and writing on these 
subjects, than any other Enghsh author that I know of. I recommend his httle 
volume the rather also, because he uses the nomenclature which is the most famihar 
to myself : in fact, as we some years ago saw and talked of these matters together in 
the wards of St. Bartholomew's, we were likely to employ the same terms. 

When you listen, I repeat, to the breathing of a healthy person, you hear, as the 
breath goes in and out, but especially as it goes in, a smooth and gentle rustle — the 
respiratory murmur, or the vesicular breathing. But when the inner surface of 
the bronchial tubes, and of their ramifications, is pre ternatu rally dry, and turhid, this 
sound is altered : you hear a hissing, or wheezing, or whistling, as the breath goes 
in and out ; and this is technically called sibilus : or j^ou hear a deeper note, a snoring 
noise, as the patient inspires or expires — a sound hke the cooing of a pigeon, or the 
bass note of a viohn, or the droning hum of an insect in its flight ; and this is called 
rhonchus. These two, in their various modifications, constitute the dry sounds of 
respiration ; and it will be worth while, once for all, to reflect upon their cause and 
nature, and the manner in which they are combined, and what they denote. You 
are aware that when air is propelled through a cylindrical tube of a certain size, and 
when that tube is narrowed in a particular way at one or more points, a musical 
note is produced. Now this is what often happens in the larger bronchi ; this is 
what always happens in them when rhonchus is present. Rhonchus belongs to the 
larger divisions of the bronchi exclusively ; and as these are often, for a time exclu- 
sively affected, so rhonchus may exist alone. It will be grave or deep in proportion 
to the' length and diameter of the tube in which it is produced. When the sound is 
grave and deep, the hand placed upon the chest may frequently perceive a trem- 
bhng or thrill communicated to its parietes. I believe that rhonchus is mostly occa- 
sioned by portions of viscid half soHd mucus, which adhere to the membrane and 
cause a virtual constriction of the air-tubes, and act as vibrating tongues while the 
air passes by them. I conclude such to be the case, because it seldom happens that 
the rhonchus cannot be got rid of by a vigorous cough. It will soon begin again, 
perhaps, or it will commence in some other part, but the effort of coughing, which 
detaches and removes the adhering tough mucus, dislodges also, for the time, the 
rhonchus. Yet, rhonchus in a given spot may be permanent : a tumour, or a tubercle, 
may flatten one of the air-tubes, and convert it into a musical instrunient. For the most 



PHYSICAL SIGNS. 



531 



part, you will find what I have told you holds true : you may suspend the rhonchus by 
getting the patient to make a hearty cough. Now in the natural state of the chest, 
we do not, except in particular 'spots, hear the transit of the air through the larger 
bronchi. V/hatever sound it makes is damped by the spongy lung, or covered by the 
vesicular breathing. But rhonchus, in its turn, may overpower the vesicular murmur, 
and render it inaudible. It does not prevent it, but it outroars it, as it were. Yet 
this is seldom the case : you hear the rhonchus, and, if you listen attentively, you 
may in general hear, mingling with it, the vesicular murmur also. Recollect, then, 
that rhonchus belongs to the larger divisions of the air-tubes ; that it denotes their 
partial narrowing ; that it is a dry sound ; and that the condition of which it is ex- 
pressive implies usually no danger : there is no material obstacle to the passage of 
the air through these larger tubes to the vesicular structure beyond them. 

I must further admonish you, that in your earlier essays in auscultation you will 
be apt to deceive yourselves in respect to the exact place in the lung in which the 
rhonchus which you hear is produced. It is so loud a sound, that when it proceeds 
from a single bronchial tube it may be plainly audible over the whole of that side of 
the chest ; and sometimes, more obscurely, over the other side too. 

When air is driven with a certain degree of velocity through a small pipe, it 
gives rise to a hissing noise. It is by forcing air through a cylinder perforated by a 
slender tube, that Professor Wheatstone obtains the sound of the letter S in the 
talking machine which he has constructed, after Kempelon's model. Precisely this 
condition we have in the smaller bronchial ramifications, when the inflammation in 
catarrh or bronchitis has reached them, and rendered the membrane lining them 
tumid. And sibilus is the result of this change. Now sibilus, like rhonchus, may 
exist alone ; and, inasmuch as the sibilus proceeds from the smaller air-tubes, adjacent 
to the pulmonary vesicles, it abolishes the natural respiratory murmur. It does not, 
like simple rhonchus, merely drovi^n it, but it takes its place. If you hear the res- 
piratory murmur minghng with sibilus, you may be sure that some of the lesser air- 
tubes are narrowed, and some free : you cannot have both sounds at once from the 
same ramifications of the bronchi. Sibilus is a sound of more serious import, there- 
fore, than rhonchus ; it bespeaks a condition of greater danger. It belongs to the 
smaller air-tubes and vesicles, and denotes that they are in the first stage of inflam- 
mation, which has diminished their natural calibre, by rendering the membrane 
tumid. It is a dry sound, but you cannot cough it away. 

I say rhonchus may occur alone, and sibilus may occur alone ; but very often 
indeed they both occur together; and maybe heard in various parts in different 
degrees : causing a strange medley of groaning, and cooing, and chirping, and whist- 
ling, and hissing, mixed, it may be, here and there, with the natural respiratory 
murmur. When you hear sibilus over the entire surface of the chest, the mucous 
membrane is universally affected, and the case is a severe one, and attended with 
considerable hazard. 

It is just possible that a sibilant sound may proceed from a large air-tube, when 
its bore has been narrowed to a very minute sht or orifice ; but this possibility 
does not interfere with the general distinctions that I have been endeavouring to 
point out. 

Now in these cases we neither obtain nor require any information from percus- 
sion, except of a negative kind. Supposing the inflammation confined to the mu- 
cous membrane, the resonance on percussion will not be sensibly diminished ; the 
lung is everywhere spongy still, and air reaches every part of it, though not with the 
usual freedom. 

There is one exception to this. Occasionally, though rarely, a piece of tough 
phlegm may seal up, as it were, the very entrance of one of the principal bronchial 
tubes, and so prevent the air from passing to or from the portion of lung to which 
that tube conducts. When this happens, it is very likely to puzzle the auscultator 
for a time. There is air in the sealed-up portion of lung, therefore percussion gives 
a natural sound; but the air is at rest, therefore no sound of respiration is audible. 
An effort of coughing unstops, perhaps, the bronchial tube ; and then the air is again 



532 



CATARRH. 



heard to enter and to depart from that portion of lung. I shali advert to this sort 
of accident again. 

Finally, 1 may remark, that these dry sounds, rhonchus and sibilus, are heard 
during the breathing : they have no relation to the voice or to the cough. 

After a while, the inflamed membrane begins again to pour out fluid ; but it is 
not the thin, bland, moderate exhalation of health ; it is a glairy, saltish, transparent 
liquid, like white of egg somewhat ; and if it be expectorated only after much cough- 
ing, it will be frothy also, i. e., it will contain many bubbles of air entangled in it. 
It is a stringy, tenacious fluid, and the more so in proportion to the intensity of the 
inflammation. With this new condition of the membrane, we have new sounds — 
sounds which result from the passage of air through a liquid ; sounds which are 
occasioned by the formation and bursting, in rapid succession, of numerous little air- 
bubbles. These sounds are called crepitations. This process may take place in 
the larger air-tubes, or it may take place in the smaller, or in both. In the larger 
tubes the bubbles will be larger, and the ear can readily distinguish this ; we have 
large crepitation. In the smaller air-tubes, we have, in the same way, small crepi- 
tation. There is no difference between these sounds, except in degree ; and they 
graduate insensibly into each other. But there is a considerable difference in the 
nature of the intimations which their well-marked varieties convey. If there be 
merely large crepitation, without any other morbid sound, it is produced in the 
larger tubes. Air passes, notwithstanding, into the vesicular structure beyond the 
accumulated hquid ; and vesicular breathing exists, though perhaps it cannot be 
heard, on account of the crepitation. But the state of the patient is not a state of 
peril. On the other hand, small crepitation has its seat in the smaller air-tubes and 
cells; it supersedes the vesicular breathing,. and, if extensive, it bespeaks considera- 
ble danger. ... 

Rhonchus and large crepitation are respectively the dry and moist sounds that 
belong to the larger bronchi ; sibilus and small crepitation the dry and moist sounds 
of the smaller branches. When the latter sounds are heard over a considerable part 
of the chest, there is, I say, usually a good deal of distress, dyspncea, and cough ; 
and the fever which attends the local inflammation is at its height. By and by the 
expectoration becomes opaque, and more consistent, and of a greenish or yellowish 
colour; it is brought up with move ease; the crepitation, great and small, dimi- 
nishes ; perhaps rhonchus reappears : but at last the parts return to their original 
condition ; and the natural, smooth, equable rustle of the breathing is again every- 
where audible. 

These are all the morbid sounds to which active and recent inflammation of the 
mucous membrane of the air-passages ever gives rise : rhonchus and sibilus ; large 
and small crepitation. Having once described their nature and causes, I need not 
repeat the description if we find them accompanying other diseases : but their ijn- 
port may be different. I may mention here, that as crepitation results from the 
passage of air amongst and through liquid, from the rupture of the little air-bubbles 
so produced, the kind of liquid may vary. If the air, in going and returning, meets 
with serum, or with pus, or with blood, it will occasion exactly the same bubbling 
noise. Hence the French term for what I have been calling crepitation, viz., mu- 
cous rattle, is very objectionable. From the sound itself, we cannot tell whether it 
proceeds from mucus or from some other liquid present in the air-passages ; and 
from this objection the word crepitation, whatever exception may be taken against 
it on other accounts, is free. 

Having thus embraced the occasion of explaining these auscultatory signs, I will 
now resume the history of catarrh. It implies inflammation of the mucous mem- 
brane of the air-passages; and it receives different appellations, according to the dis- 
trict of that membrane which it chiefly plagued : gravedo, in the frontal sinuses ; 
coryza, in the Schneiderian membrane of the nose ; bronchitis in the trachea and 
lungs. 

Catarrh is the commonest of all disorders : — ^not one man in ten thousand passes 
a winter without having a cold of some sort. And this name points to its ordinary 
cause : cold somehow appHed to the body. It does not always or often result, I 



CATARRH. 



533 



apprehend, from cold air brought into contact with the membrane itself, in the pro- 
cess of breathing ; but from cold, and especially from cold and wet, applied to the 
external integument. It is unnecessary for me again to go over the circumstances 
under which the application of cold is most hkely to prove injurious. Catarrh is 
usually a trivial disorder, and runs its course in a few days, if abstinence be observed 
with respect to animal food and stimulating liquor, and if the patient remains in an 
equable temperature, and avoids re-exposure to the cause of his malady. I am now 
speaking of the milder forms of catarrh. We are not often consulted for this com- 
plaint. Every man, in regard to a cold, thinks himself qualified to be his own doc- 
tor. But if you are consulted, keep your patient in the house, or even in bed ; let 
him live upon slops ; give him a gentle aperient, and then some of those medicines 
which are esteemed to be diaphoretic: small doses of James's powder; three drachms 
of the liquor ammonias acetatis, with a drachm of the spiritus setheris nitrici, and an 
ounce of camphor mixture ; or a saline draught with an excess of alkali, and a few 
grains of nitre, or a little antimonial wine ; three or four times a day : and let him 
take four or five grains of Dover's powder, and put his feet and legs into a warm 
bath, just before he goes to bed. In this way you may conduce to his recovery ; 
and he may be simple enough to believe that you have cured him. 

Yet I believe catarrhs rtiay sometimes be cured ; and the natural recovery from 
them may be, sometimes, accelerated. If you practise the old maxim, which says, 
" venienti occurite morbo," you may occasionally stop a cold on the threshold, as it 
were, by an opiate. And to persons who are habitually troubled with slight catarrhs, 
this piece of practice may prove of the greatest value. A medical man who resides 
in this neighbourhood, and with whom I was a fellow-student, is exceedingly subject 
to what he calls a snivelling cold. For many years he used to bear this as he best 
might ; and that, to say the truth, was very ill and impatiently. On one occasion, 
almost by accident, he took twenty drops of laudanum just as one of his colds was 
beginning to torment him, and he found that the initiatory symptoms ceased. Since 
that time he has constantly had recourse to the opiate under similar circumstances ; 
and whereas he used formerly to be very miserable for three or four days, he now is 
quite well and comfortable in the course of half an hour. And this is not a solitary 
case. It is worth trying, if you experience the feelings of an incipient catarrh, to go 
to bed, and to take a beaker of hot wine negus, with a tablespoonful of the syrup of 
poppies in it. This will not suit every person ; but if it fails on the first trial, it 
need not be repeated, and no great harm, beyond an increase of headache, will be 
done by it. I would not recommend this plan, however, to a plethoric person ; nor 
to any one having a tendency to inflammatory disease ; for when it does not cure, it 
makes the complaint worse. 

There is also a period in catarrh which has gone on unchecked, when you may 
accelerate its departure — " speed the going guest" — by a good dinner, and an extra 
glass or two of wine. But this pleasant method is scarcely to be advised for persons 
of delicate habits ; or in whom any pthistical tendency is suspected to exist ; or who 
are prone to inflammation. And it is not to be tried with any one till the fever is 
over, and the expectoration thick and loose. 

I must not omit to mention the dry plan of cure ; although (I confess it with some 
shame) I have never yet tried it either upon myself or upon others. Dr. C. J. B. 
Wilhams, who invented it, I believe, has a high opinion of its efficacy. It certainly 
has the merit of simplicity, for it consists merely in abstinence from every kind of 
drink. No hquid, or next to none, is to be swallowed until the disorder is gone. 
The principle here concerned is that of cutting off' the supply of watery materials to 
the blood. The wants of the system exhaust, from the circulating fluid, all that can 
be spared for the natural evacuations ; and there is nothing left to feed the unnatural 
secretion from the inflamed mucous membrane. Its capillary vessels cease to be 
congested ; the morbid flux is diverted, and the inflammation starved away. Such 
is the theory. Habitual topers might hold the remedy to be worse than the disease ; 
but Dr. Williams assures us that the necessary privation is not very hard to bear ; 
and that it achieves a cure, upon an average, in forty-eight hours. He allows, with- 

2u2 



534 



ACUTE BRONCHITIS. 



out recommending, a tablespoonful of tea or milk for the morning and evening meals, 
and. a wine-glass of water at' bed-time. 

One great advantage of this plan is, that it does not require confinement to bed, or 
to the house. The man whose business calls him abroad, may, with appropriate, 
clothing, pursue his customary employment, and his cure is all the while going on. 
In fact, exercise, inasm.uch as it promotes perspiration, helps the recovery ; whereas 
the system of warm drinks and diaphoretics renders the body more susceptible to 
atmospheric vicissitudes ; and, to be effectual, imphes restrictions which are often- 
times extremely inconvenient. 

Dr. Williams observes, that while this dry treatment is serviceable in catarrhal 
bronchitis, it is most successful in coryza, the snivelling cold in the head.^ It must 
be put in force in the very commencement of the disorder. 

You may often do much by way of prevention, for persons who are unusually 
liable to take colds. I have remarked before upon the great value of the shower- 
bath for that purpose. I could mention several instances in which persons have got 
rid of the tendency to catch cold by the habitual use of this aspersion. It should be 
begun in the summer, and made tepid at first ; but in a short time quite cold water 
may be emploj^ed ; and being once begun, the practice may be continued through 
the winter. I stated formerly, that the effect of exposure to cold was, casteris pari- 
bus, in proportion to the intensity and the duration of the sensation of cold that it 
produced. The intensity of the sensation of cold under the shower-bath is consider- 
able, but the duration of it is mom.entary. It operates as a prophylactic in this w^ay : 
it inures the surface to a lower temperature than it is likely to be subjected to at any 
other part of the day. The lesser degrees of cold have then no injurious effect, un- 
less they are long protracted. For those who cannot procure a shower-bath, or who 
cannot bear its shock, cold sponging will be found exceedingly salutary. 

But inflammation of the membrane lining the air-passages may be, and often is, a 
very acute and dangerous disorder, i. e., the inflammation may be both intense and 
diffused; it may descend into the vesicular texture, and occupy the whole surface 
of the membrane on one side of the chest, and then it may prove a very grave dis- 
ease ; or it may involve the whole lining membrane of both lungs, and then it is 
always attended with considerable peril. 

This inflammation Avill sometimes, when it is thus general over the whole mem- 
brane, hnger for a considerable period in its first stage ; and it may even, after so 
Hngering, subside again without ever passing beyond the first stage. By the first 
stage, I mean the stage of dryness. Very httle notice of this modification of bron- 
chitis has been taken by authors. Dr. Latham has given a distinct and graphic 
description of it, to the accuracy of which I can testify from my own experience. 
You will find cases of it detailed in his book. Since they were pubhshed, some 
striking instances of this form of the disease have occurred to myself. One, which 
happened lately, I will relate by way of example. I was asked by an old pupil of 
the hospital to see a lady, his patient, in Gordon Square. I found her feverish and 
in a state of extreme dyspncea, sitting up in bed from inability to lie down, labouring 
for her breath ; her face turgid and rather hvid, her nostrils working, her shoulders 
elevated. She could scarcely speak, but expressed, in what she did say, a dread of 
imm.ediate suffocation. She had been in nearly the same state for a day or two. 
On listening at her back I could hear the air slowly wheezing and whistling into her 
lungs everywhere, and then leaving them still more slowly, with a prolonged growl, 
something like that of an angry cat. There was no true vesicular breathing ; there 
was no crepitation ; and there was no part into which the air did not, although with 
difficulty, find its way. The chest was everywhere resonant on percussion. There 
could be no doubt that the membrane throughout was tumid and dry, and in the 
earliest stage of inflammation. Depletion had already been employed in this case, 
and vv'e had recourse to the tartar emetic. This was given in free and repeated 
doses, till it produced nausea and sickness. Whenever it did so, the pulse dimin- 
ished in force, the face became blanched, and the breathing much easier ; and the 
medicine was then suspended until these efiects had gone off, when it was repeated 
in the same manner. The disease was not, however, brought at once to an end by 



ACUTE BRONCHITIS. 



535 



this treatment ; it was kept at bay for a day or two longer, and then a copious 
secretion from the membrane took placej with great rehef to all the distressing 
symptoms. Then, of course, crepitation became universally audible. Except 
the debihty which it left behind, the patient soon recovered of the bronchial inflam- 
mation. 

But in the great majority of instances the inflammation does not thus linger in its 
first stage ; the membrane soon begins to pour forth glairy mucus ; so that we do not 
often meet with sibilus, without finding at the same time, in some part of the same 
lung, that there is also small and large crepitation. It is of some importance to 
attend to the characters of the mucus that is expectorated. It is transparent and 
adhesive. If you pour it from one vessel into another, it flows out in one mass of 
extreme tenacity ; it will draw out sometimes hke melted glass ; and the degree of 
viscosity is a tolerably accurate measure of the degree of the existing inflammation. 
Upon the surface of the viscid mucus there is usually more or less froth, the quantity 
of it depending on the facility or the difficulty with which the sputa are brought up. 
If the patient does not expectorate till after a long fit of coughing, during which air 
has been many times inspired and expired, and has thus got intimately mingled with 
the mucus that fills the air-passages, the expectoration will contain numerous little 
air-bubbles ; will be very frothy. Sometimes also, during this stage of the com- 
plaint, the sputa are marked with streaks of blood. 

While the expectoration possesses the characters I have been describing, the 
inflammation is still intense, and the fever and dyspnoea considerable. This cor- 
respondence between the general symptoms and the matters spat up was well known 
to the ancients, who said that such expectoration was still crude. But in proportion 
as -the inflammation approaches to resolution, the appearance and qualities of the 
sputa are changed ; the mucus loses by degrees its transparency, is mixed with 
masses that are opaque, and of a yellow, white or greenish colour : and these masses, 
few at first, increase more and more in number, until they constitute the whole of 
the sputa. Such expectoration asi this is commonly accompanied by a marked re- 
mission in the different symptoms of the bronchial inflammation ; it announces that 
the inflammation is terminating in resolution. It is such as the ancients spoke of as 
being concocted, or ripe. However, the characters of the opaque sputa expecto- 
rated towards the end of an attack of acute bronchitis are subject to much variety. 

It will oTten happen that the expectoration, after having thus become opaque, and 
parti-coloured, will go back again to its former condition of transparency, and sticki- 
ness, and froth : and that is a very certain index of a return or increase or extension 
of the inflammation ; so that the character of the matter expectorated exhibits, in a 
certain degree, the progress of the inflammation ; and consequently constitutes one 
point of guidance to our treatment. The nature of the expectoration forms also an 
important particular in our means of distinguishing bronchitis from pneumonia; as I 
shall further explain when I speak of the latter disease. 

I have described acute bronchitis as it appears when it terminates favourably : in. 
such cases the inflammation generally begins to abate, somewhere from the fourth to 
the eighth day of the disease. But acute bronchitis may terminate unfavourably. 
When the inflammation is universal and intense, the fever high, and the labour of 
respiration great — if the symptoms do not yield to the treatment employed, or if judi- 
cious treatment has not been adopted, or has been too long delayed, signs of im- 
pending suffocation begin to show themselves : the hps and cheeks, and tongue, 
assume a purplish colour; a livid paleness takes the place of the former red flush; 
the expression becomes more and more anxious : delirium comes on, and rapid sinking. 
These indicate, you know, the circulation of blood that is in a great measure venous 
through the arteries ; and the venous blood acts as a poison when it so circulates. 
Profuse, cold, clammy sweats ensue ; and the patient dies of apnoe. His breathing 
is choked by the morbid secretion which occupies the bronchial tubes, small as well 
as large, and which he has not strength enough left to cough up. 

Accordingly, when we examine the thorax after death so produced, we find, in 
the first place, that the lungs do not coUapse upon the admission of the pressure of 
the atmosphere to their external surface. We next find the trachea, and bronchi, and 



536 



ACUTE BRONCHITIS. 



their ramifications, blocked up by a frothy adhesive mucus, resembling that which 
during life had been expectorated ; and the membrane which hues them is red and 
thickened. 

The treatment proper for these acute and dangerous forms of bronchitis is a matter 
of some nicety. Blood-letting, as I formerly stated to you, has not that decided 
power over inflammation of the mucous tissues which it possesses over the adhesive 
inflammation that takes place in the serous membranes. If there be much fever, a 
hard pulse, and great oppression of the breathing, and particularly if these symptoms 
present themselves in a young, strong, and robust individual, we must bleed him 
from the arm. And you will always find blood-letting relieve the symptoms; even 
when its ultimate effect may be' injurious. The patient's distress arises from his 
inability to supply air enough to arterialize the venous blood which is transmitted to 
his lungs ; and by diminishing the quantity of blood sent to those organs, you will, 
pro tanto, mitigate his uneasiness. But a great part of the danger to be apprehended 
in the advanced periods of the disease, is that the patient may not have muscular 
power enough to disembarrass his air-passages af the phlegm that overloads them ; 
to draw a strong breath, and to achieve a vigorous cough. We must not bleed 
therefore to syncope, and again and again, as we are often justified in doing in cases 
of pneumonia. Sixteen ounces will be a moderate bleeding at first for an adult, but 
more or less than that must be taken, and the bleeding must be repeated or not, 
according to the condition of the pulse : for the pulse affords a better measure of the 
propriety of pushing the abstraction of blood, than is furnished by the local symp- 
toms. 

Great relief is often obtainable by topical blood-letting ; by cupping over the sur- 
face of the chest, or between the scapulae. If you distinguish sibilus in one portion 
of the lung more than in another, take the blood rather from that part of the surface 
which corresponds to the place of the sibilus. 

After the bowels have been cleared by a mercurial purgative, calomel and jalap, 
for example, you will find the tartar emetic a very valuable medicine in these acute 
cases of bronchitis. It should be given in such doses as will excite nausea : and if 
vomiting be occasioned, you may still go on with the medicine after the sickness has 
subsided. The depression which this substance produces is great, but it is tempo- 
rary, and it is effected without expending blood. With the antimony — I mean 
during the same period— mercury may and ought to be given : to this combination I 
should be inrlined to trust more than to any other internal treatment. 

If symptoins of sinking and debility have begun to show themselves, it will be 
necessary to administer stimulating expectorants. I presum.e that the carbonate of 
ammonia, which is often extremely useful in such cases, acts as an expectorant, by 
giving a filhp to the muscular powder. But it is supposed by some persons to exer- 
cise some specific influence upon the bronchial membrane. However this may be, 
five or six grains of it, given in solution every four or six hours, are often followed 
by free expectoration and a marked improvement. 

One of the circumstances of which patients are much disposed to complain, is 
the violent or importunate cough ; and another is, the want of sleep and of rest ; 
indeed, the one of these is often, in a great measure, the cause of the other; — the 
urgency or frequency of the cough prevents the patient from sleeping. Now there 
is nothing so well calculated to allay cough, and to procure sleep, as opium ; and 
you will be strongly tempted to give these patients opiates, and you will probably 
be encouraged to do so by the success which Avill follow that practice in many 
cases. The good effects of a full narcotic at bed-time are sometimes very striking. 
Patients who for previous nights have been perpetually harassed by cough, and 
who are worn out by the disturbance of their rest, will sleep tranquilly, and in the 
morning expectorate largely and freely, and declare themselves wonderfully the 
better for their opiate. Yet opium is a ticklish remedy in these cases. Many a 
patient — some within my own knowledge — labouring under general or extensive 
bronchitis, have been put so soundly to sleep by a dose of opium on going to bed, 
that they have not waked again. I beheve 5'ou may receive it as a golden rule in 
these cases not to give opium — I mean in a full dose, so as to force sleep — if you see 



PERIPNEUMONIA NOTHA. 



537 



any venous blood mingling in the general circulation, — if the complexion be dusky, 
and the lips in any degree blue. The circulation of half-arterialized bJood through 
the brain is in itself a powerful cause of coma ; and if you add the influence of an 
opiate, the coma may easily be made fatal. While the cheeks and lips remain florid, 
and when the first violence of the disease has abated, an opiate will do capital ser- 
vice. It is a common practice to combine it with antimony or some other expecto- 
rant. Twenty minims of laudanum, with the same quantity of the liquor antimonii 
tartarizati ; or a third of a grain of the acetate of morphia, with a drachm of oxymel 
of squills ; are convenient forms. 

Counter-irritation is frequently of great use, as an auxiliary measure, in the treat- 
ment of acute bronchitis. Sensible relief of the cough, and of the oppressed breath- 
ing, often follows the rising of a large bhster laid across the front of the chest. When 
the dyspnoea is extreme, and a more speedy counter-irritant is required, you may 
have recourse to the mustard pouhice. Inhalation of the steam of hot water is also 
very soothing and useful. It is one of the best expectorants I know of when it 
answers at all ; but to some persons it proves irritating, and they derive no comfort 
from it. 

I have been speaking of acute bronchitis, uncombined with any other pulmonary 
disease ; and it is curious how little disposed the inflammation often seems to be to 
extend itself from the mucous membrane to the neighbouring tissues. The reason, 
doubtless, is, that this membrane is furnished with a distinct set of blood-vessels, 
the bronchial arteries, and veins : while the substance of the lungs is supplied by 
the pulmonary. We could not tell, merely by attending to the general symptoms, 
whether the inflammation was hmited to the inner membrane or not ; but by making 
use of the sense of hearing, we are able to determine this. If the inflammation 
should spread to the parenchymatous texture of the lungs,~i. e., if the bronchitis 
should pass into pneumonia, — this circumstance would be disclosed by physical 
signs, which I shall in due time prescribe and explain ; and it would demand certain 
modifications of our plan of t reatment. 

I shall have to speak of some varieties of chronic bronchitis ; but there is a mixed 
form of pulmonary disease that requires to be noticed, in which acute or subacute 
inflammation engrafts itself w\)on changes that are chronic and abiding. Sydenham 
calls the disorder to which I no^w refer peripneumonia notha — bastard peripneumony. 
Catarrhus senilis is another of its names. It may be considered as chronic bron- 
chitis, occurring in old persons, and very apt to be converted into pneumonia, or to 
be greatly aggravated in degree during winter, or upon any accidental exposure. 
This is the common complaint of persons advanced in fife. I mention it here in 
comphance with the usual custom, and because this is as convenient a place for its 
introduction as any. But it would be an error to regard it as exclusively a disease 
of the mucous membrane of the lungs. An habitually congested state of that mem- 
brane, marked by some shortne^ss of breath, and some expectoration, and by the 
constant presence of some degree of crepitation in the lower parts of the lungs, — 
these are circumstances which Eire of daily occurrence as consequences of disease 
of the heart ; and it is in persons whose habitual health is of this kind, that what is 
called peripneumonia notha, which implies a diffused inflammation of the pulmonary 
mucous membrane, with sometimes an enormous secretion from its surface, is most 
apt to supervene. Almost all such persons will tell you that there are periods at 
which they experience slight febrile attacks, and exacerbations of their complaints : 
they have pain in the breast or side, headache, heat, and thirst ; and at these periods 
the cough and expectoration are always aggravated, and continue for some time to 
be more than commonly severe. " The disease (says Cullen, who, following Syden- 
ham, has given a good description of its general symptoms) has often the appearance 
only of a more violent catarrh ; and after the employment of some remedies, is 
entirely relieved by a free and copious expectoration. In other cases, however, the 
feverish and catarrhal symptoms are at first very moderate, and even slight ; but 
after a few days these symptoms suddenly become considerable, and put an end to 
the patient's life, when the indications of danger were before very little evident." 



538 



PERIPNEUMONIA NOTHA. 



The truth is, (and we learn the truth by the evidence of auscultation,) that in 
these cases pneumonic inflammation is often suddenly set up. There is no security, 
as Dr. Latham observes, that the portions of lung which yield small crepitation to- 
day may not be solid and impervious to-morrow. Dr. Latham is of opinion that in 
this disease the inflammation is apt to travel over the bronchial membrane from place 
to place, as erysipelas is seen sometimes to wander over the surface of the body. I 
know not how this may be ; but certainly death is often produced in these persons 
by the sudden spoihng of even a moderate portion of lung. In their ordinary con- 
dition, the patients have just enough, and no more, of the respiratory apparatus in 
an eflectivp state, whereby to subsist ; and when a fresh part of it is rapidly rendered 
sohd, they quickly perish. But they die also from another cause. The nicety of 
treatment which I spoke of as being required in certain stages of acute bronchitis, is 
still more apparent and necessary here. We are placed in this dilemma. If we do 
not take blood in these attacks, we run a risk of losing our patient from the effects 
of the unchecked inflammation ; and if we do bleed, we are in danger of losing 
him by producing a degree of weakness which will render him unable to expecto- 
rate the effused mucus, and so liable to perish by suffocation. Leeches and bhsters, 
and what are called expectorants, are the remedies to which we must chiefly trust. 
Medicines, which are at the same time diuretic are also serviceable — the spiritus 
setheris nitrici, the preparations of squill, and of digitalis. 

Even in younger patients, in whom the bronchitis is idiopathic, not engrafted upon 
any previous disease of the chest, and in whom the disorder had not appeared severe, 
extreme difficulty of breathing will sometimes most "unexpectedly arise, and some- 
times it will rapidly lead to the extinction of Hfe. Now both Andral and Laennec 
have pointed out one cause (to which, indeed, I have already adverted in the pre- 
sent lecture) of this sudden change for the worse. It is a cause which was not 
likely to be even guessed at before the discovery of the method of auscultation. 
Occasionally it happens, they say, that during the course of an attack of bronchitis, 
we cease altogether to hear, in a certain extent of the lung, either the natural respira- 
tory murmur, or any of the modifications of rhonchus, sibilus, or crepitation, that 
have been mentioned ; yet over this same portion of lung, in which no sound, 
healthy or morbid, is heard by the ear applied to the thorax, percussion gives the 
natural hollow sound. At the same time the patient becomes affected with urgent 
dyspncea. This sudden suspension of ah sound of respiration they attribute to the , 
temporary, or, in some cases, the permanent, obstruction of one of the bronchi, the \ 
ramifications whereof are distributed to that portion of lung in which the respiration 
is no longer audible. In such cases it generally happens that at the end of a strong 
fit of coughing — the effect of which is to expel, or at least to displace the tenacious 
plug of mucus obstructing the bronchus— the sound of respiration is re-estabhshed 
as suddenly as it had previously disappeared ; and the dyspnoea also ceases. In | 
some rarer cases, however, the noise of the pulmonary expansion does not return, \ 
the difficulty of breathing increases, suffocation becomes imminent, and death by i 
apnffia rapidly takes place. The slightest attack of bronchitis may in this way be t 
suddenly transformed into a most serious and quickly fatal malady. 

Andral relates two instances of death from this cause ; one of which was the fol- 
lowing. A coachman, fifty years old, had been several times a patient in La Charite, 
for obstinate pulmonary catarrh, with slight dyspnoea, and puriform expectoration. 
Every time he went away relieved, but not cured. On both sides of his chest could 
be heard all the varieties of rhonchus. In one spot the column of air which pene- 
trated the bronchi imitated the snoring of one in a deep sleep ; in another spot it 
was like a duU and prolonged groan ; in a third, a sound resembhng that made by 
bellows; and in a fourth the cooing of a turtle-dove was exactly simulated. On the 
last occasion of his entering the hospital, his respiration was still tolerably free. One 
morning he was found in a state of unusual anxiety. In the middle of the night, 
after a violent paroxysm of cough, his breathing (he said) had suddenly become very 
much oppressed. It was discovered, on auscultation of his chest, that no air pene- 
trated into the upper lobe of the right lung ; yet that part sounded well on percus- 
sion, even lo'ider than the corresponding part of the other side, which was morbidly 



INFLUiaJZA. 



539 



dull. The difficulty of breathing went on augmenting, and the man was soon 
dead. 

Besides other marks of disease in the lungs, the primary bronchus leading to the 
upper lobe on the right side was closed up completely by tough mucus, and exhi- 
bited the appearance of a full cylinder. 

In the other case, also, the obstructed bronchial tube supplied the upper lobe of 
the right lung. 

It may seem strange that the interruption of the access of air to so small a portion 
of the lungs should be attended with such serious consequences, when we know that 
the greater part of each lung may be impermeable by air, and yet the patient live a 
long time, and often without any great dyspnoea. The explanation of the apparent 
difficulty seems to be, that in the one case the prevention of the arrival of air in the 
I part affected is sudden, in the other gradual. Moreover, the remaining portions of 
I the lungs are performing their functions imperfectly. 

I When once attention has been awakened to the kind of accident just mentioned, 
the diagnosis would not seem to be difficult. We may suspect obstruction of one of 
the bronchi when considerable dyspnoea comes on suddenly during the continuance 
of simple bronchitis: and our suspicion will be confirmed if at the same time respi- 
ration ceases to be audible in a certain portion of the lung, while the sound given by 
percussion over the same part remains unaltered. Emphysema of the lung (which 
I shall explain hereafter) is the only other condition which could give rise to a similar 

' set of symptoms. 

j Andral judiciously suggests the employment of emetics, and the inhalation of 
' steam, in such cases. 



LECTURE XLIX. 

Influenza. Symptoms and progress. Conjectures as to its cause. . Treatment, 
Hay asthma. Chronic Bronchitis. Its varieties. Morbid anatomy of these 
affections. 

Catarrh, which was the principal subject of the last lecture, occasionally prevails 
far and wide as an epidemic disease. -I speak, indeed, (February 4, 1837,) during 
the immediate presence of one such visitation, although the extreme violence of the 
complaint that has been raging among us is now fast subsiding. You can hardly 
be without curiosity to know what has been learned respecting an influence which 
has thus, on a sudden, before your eyes, disturbed and sickened a whole community. 

I have here used, without thinking of it, the very word by which, in a foreifjn 
version, the disorder is denominated. It has receivei^, however, various names ; for 
it has been known and noticed from remote antiquity. Cullen calls it catarrhus e 
contagio : and under that head, in his Nosology, you will find a copious reference 
to recorded accounts of epidemic catarrh, as it has been observed to spread over 
great portions of the world. In France the disorder thus prevailing is styled the 
grippe. The Italians, putting the cause for the effect, called it influenza, the influ- 
ence: and this last term, influenza, has now become naturahzed in our language. 
Since Cullen wrote there have been four or five more of these epidemics. One in 
1782, which extended over all Europe, visiting every country therein, affecting more 
than one half of its inhabitants, and proving fatal to very many of them. You will 
find, in the third volume of the Transactions of the College of Physicians, a good 
account of the disease as it then showed itself in this country. In the spring of 1803 
another instance of it occurred ; and of this the history, as compiled from the testi- 
mony of a hundred and twenty-four observers, is preserved in the ninth and tenth 
volumes of the London Medical and Physical Journal. In the month of April, in 
the year 1833, the influenza again made its appearance, and prevailed extensively, 
both here and elsewhere : and of the influenza of 1837 you have had, and you still 
have, the opportunity of being observers. A very good and instructive sketch, of 

1 



540 



INFLUENZA. 



this epidemic malady, compiled by Dr. Hancock, is to be found in the Cydopsedia 
of Practical Medicine. To that article, to the publications I just now mentioned, 
and to the works enumerated by Cullen, I may refer you for much which is curious 
and interesting in the history of the disease ; but which would not be so well adapted 
to our immediate purpose in this place — nam.ely, that of seizing upon the practical 
facts which have been ascertained respecting influenza. 

One characteristic feature of this species of catarrh, as distinguished from the ordi- 
nary sporadic disorder, is the sudden occurrence, in the outset, of more decided 
febrile disturbance. The first two patients whom I saw in the epidemic of 1833 had 
just the symptoms which frequently mark the commencement of an attack of conti- 
nued fever; and I did not know, at my first visit, what was about to happen to them. 
The symptoms, taking them altogether, are somewhat as follows. The patient is 
chilly, and perhaps shivers ; presently headache occurs, and a sense of tightness 
across the forehead, in the situation of the frontal sinuses ; the eyes become tender 
and watery ; and sneezing and a copious defluxion from the nose ensue, followed or 
accompanied by heat and uneasiness about the throat, hoarseness, a troublesome 
cough, and oppression of the breathing. In short, the symptoms are the symptoms 
of catarrh ; including in that term all the varieties thereof that are sometimes met 
with separately — gravedo, coryza, bronchitis : and with these symptoms a sudden, 
early and extraordinary subdual of the strength; and, most commonly, great depres- 
sion of spirits. The debility which comes on at the very outset of the complaint, is 
one of its most singular phenomena, taking place, in some cases, almost instantly, 
and in a much greater degree than would seem proportioned to the other symptoms 
of the malady \Vhich it thus ushers in. Indeed, this rapid and remarkable prostra- 
tion of strength is more essentially a part of the disorder than the catarrhal affection, 
which sometimes (though rarely) is absent, or imperceptible. It is upon the mucous 
membranes, ho\A'ever, that the stress of the disease generally falls ; especially upon 
the internal lining of the air-passages. Those of the alimentary canal seldom escape 
entirely ; but they suffer in a less degree. The tongue is white and creamy, the 
palate loses its sensibihty, the appetite fails, nausea and vomiting are not uncommon, ' 
and sometimes there is diarrhoea. The pulse, in the uncomphcated disease, is soft, | 
and generally weak. The patients complain also of pains in the hmbs and back, I 
and of much soreness, a bruised, fatigued, or tender feel, along the edges of the ribs 
and in various parts of the body. 

In its simple form and ordinary course, the disease abates of its violence after two, \ 
three, or four days, and the patient is usually convalescent before the termination of ' 
the week : but cough and much debility are apt to survive the other symptoms, and 
while these continue, the complaint is very easily renewed. Pre-existing disease, ; 
and peculiar constitutional habits and tendencies, modify considerably the character 
of the influenza, as it affects different persons. I do not attempt to represent its va- 
rious phases ; they are fit subjicts of study for yourselves. 

I have remarked that Cullen makes this species of catarrh to proceed from conta- 
gion. But the visitation is a great deal too sudden and too widely spread to be 
capable of explanation in that wa}^ I will not say that the disease may not be in 
some degree infectious ; for there is reason to beheve that other epidemic disorders, 
having many points of analogy with the influenza, are somehow imparted from one 
individual to another, although they are mainly produced by some influence which 
resides in the atmosphere. There are points in the history of influenza which fur- 
nish a strong presumption that the exciting cause of the disorder is material, not a 
mere quahty of the atmosphere ; and that it is at least portable. The instances are 
very numerous, too numerous to be attributed to mere chance, in which the com- 
plaint has first broken out in those particular houses of a town at which travellers 
have recently arrived from infected places. But this great and important question 
of contagion I hope to examine with you more rigorously on a future occasion. 
What I wish to point out now is the fact that the influenza pervades large tracts of 
country in a manner much too sudden and simultaneous to be consistent with the 
notion that its prevalence depends exclusively upon any contagious properties that 
it may possess. You are aware that it has recently seized upon all parts of this 



INFLUENZA. 



541 



; metropolis — and I believe I may say of nearly the whole kingdom — within the space 
] of a very few days. It has been observed to occur also, at the same time, on land, 
and on board different ships which have had no communication with the shore, nor 
with each other. Thus it is slated in the Transactions of the College of Physi- 
cians, that on the 2d of May, 1783, Admiral Kempenfelt sailed from Spithead with 
j a squadron, of which the Goliah was one. The crew of that vessel were attacked 
I with influenza on the 29th of May ; and the rest were at different times affected, and 
j so many of the men were rendered incapable of duty by this prevailing sickness 
I that the whole squadron was obliged to return into port about the second week in 
I June, not having had communication with any shore, but having cruised solely be- 
! tween Brest and the Lizard. This happened in one part of the fleet. In the begin- 
! ninq- of the same month, another large squadron sailed, all in perfect health, under 
' Lord Flowe's command, for the Dutch coast. Towards the end of the month, just 
I at the time, therefore, when the Goliah became full of the disease, it appeared in the 
! Rippon, the Princess Amelia, and other ships of the last-mentioned fleet, although 
I there had been no intercourse with the land. Similar events were noticed in the 
I epidemic of 1833. One or two curious instances of the sudden sickening of consi- 
^ derable bodies of men in different places at the same time, were related to me on 
i good authority. On the 3d of April in that year — the very day on which I saw the 
j first two cases that I did see of the influenza, all London being smitten with it on 
j that and the following day — on that same day the Stag was coming up the channel, 
and arrived at two o'clock off Berry Head, on the Devonshire coast, all on board 
j- being at that time well. In half an hour afterwards, the breeze being easterly and 
' blowing off the land, 40 men were down with the influenza ; by six o'clock the 
! number was increased to 60, and by two o'clock the next day to 160. On the self- 
same evening a regiment on duty at Portsmouth was in a perfectly healthy state, 
but by the next morning so many of the soldiers of that regiment were affected by 
the influenza, that the garrison duty could not be performed by it. 1 make no doubt 
that facts of a like nature have occurred during the present epidemic, and will be 
made known in due time. They illustrate several important points in respect to the 
I disease : viz., the impossibility of accounting for its prevalence upon the principle 
of mere contagion — the suddenness of its invasion — and the early and extreme pros- 
tration of strength with which it is attended. 

The occurrence of epidemic catarrh, as well as of most other epidemics, is un- 
questionably connected with some particular state or contamination of the atmosphere. 
What that state is, or what may be the kind of contamination, no one knows. The 
present epidemic followed hard upon the sudden thaw that succeeded the remarka- 
ble snow-storm of the last week of the last year. A similar coincidence between 
the breaking out of the same disorder, and a sudden elevation of the temperature 
of the atmosphere, happened at St. Petersburgh in the epidemic of 1782. " On a 
cold night (Maertens says), the thermometer rose 30° of Fahrenheit ; the next morn- 
ing 40,000 people were taken ill with the influenza." Now if every epidemic had 
been preceded by similar changes in the weather, we might resolve the universal 
prevalence and sudden accession of the complaint, into the effect of the cold and 
damp state of the air, produced by the thaw. But it is not so ; for, as Dr. Hancock 
observes, there has not been any uniform connection between any one sensible quahty 
of the atmosphere as to the heat or cold, rain or drought, wind or calm — and the 
invasion of the epidemic. " Et tempore frigidiori et calidiori, et flante lam Austro 
quam Borea, et pluvioso et sereno caelo, peragravit hasce omnes Europse regiones, 
et omnia loca indiscriminatim." Irregularities and great vicissitudes of weather 
have, however, gone before the disease in very many instances : but sometimes one 
condition of the atmosphere, and sometimes another, has been its immediate fore- 
runner : and the epidemic has frequently been observed to fail partially and caprici- 
ously : as a blight falls upon a field or district. Short, in his chronological history 
of the weather, says that thick ill-smelling fogs preceded, some days, the epidemic 
catarrh of 1557. Jussieu states that the grippe of the spring of 1733 appeared m 
France immediately after offensive fogs, " more dense than the darkness of Egypt." 
So also in 1775, Petit informs us that in France the disease was ushered in by thick 



542 INFLUENZA. 

■aoisome fogs. In the same year it visited the shire of Galloway in Scotland, where, 
we are told, " a continual dark fog and particularly smoky smell prevailed in the 
itmosphere for five weeks, the sun being seldom seen." Dr. Darwin has recorded 
hat, in 1782, " the sun was for many weeks obscured by a dry fog, and appeared 
ed as through a common mist :" and he supposes that " the material which thus 
•endered the air muddy, probably caused the epidemic catarrh which prevailed in 
iiat year." You will call to mind here the dark fog which brooded over this city in 
he midst of the raging of the distemper about ten days ago, and which was repeated 
0 a less degree, on Wednesday last (Feb. 1). 

It has been observed also, that shortly before, or during, or soon after, the preva- 
^nce of these epidemic catarrhs — epizootic diseases have raged ; various species 
of brutes, and of birds, have been extensively affected with sickness: while on 
some occasions prodigious swarms of insects have made their appearance. In 
short, a great variety of facts concur to render it probable that some pecuhar con- 
dition of the air existed, which, though it might be favourable to the multiphcation 
of some species of living creatures, such as the insects just referred to, operated 
as a poison upon the human body, and upon the bodies of many of the brute 
creation. 

It is a very curious circumstance in the history of epidemic catarrhs, and worthy 
of your reflection, that they travel; migrate as it were from one place to another: 
and moreover, that they hold, for the niost part, to certain courses, in spite even of 
opposite Avinds, and of variations of temperature. It has been noticed that the influ- 
enza general!}^ follows a westerly direction, or one from the south towards the north- 
west. In this remarkable properly it resembles, as you may perhaps be aware, the 
epidemic cholera. 

Although the general descent of the malady is, as I have said, very sudden and 
diffused, scattered cases of it, like the first droppings of a thunder-shower, have 
usually been remembered as having preceded it. The disorder is most violent at 
the commencement of the visitation ; then its severity abates ; and the epidemic is 
mostly over in about six weeks. Yet the morbific influence w-ould seem to have a 
longer duration. In a given place nearly all the inhabitants who are susceptible of 
the distemper suffer it within that period, or become proof against its power. But I 
strangers who, after that period, arrive from uninfected places, have not, apparently, } 
the same immunity. 

The locahty does not appear to be thoroughly cleared of the poison for some time : } 
or perhaps a more cautious statement of the fact would be, that the disorder generally j 
shows itself again in succeeding years, but in a milder and less general form. This i 
must depend either upon some remaining dregs, or possibly some revival, of the inju- 
rious influence ; or else upon some abiding predisposition impressed upon the bodies 
of men by its former visit. You may hear, every year, of Mr. So-and-so having 
the influenza. In many instances, no doubt, common sporadic catarrh is dignified 
by that narae ; but it is certain also that many of the colds, and bronchial disorders, 
of the seasons which immediately follow a period of genuine influenza, are_^ attended 
with much more languor, debihty, muscular aching, and distress, than belong to an 
ordinary attack of catarrh. i 

All this is very curious ; and very mysterious. All this, or much of it, is true 
also of all the diseases which are known to prevail occasionally as epidemics. The [ 
facts that have now been mentioned respecting the influenza, warrant, I think, the ! 
conclusion that it does i20t depend upon any mutations in the ordinary qualities of ' 
the atmospere ; upon any degrees or variations, I mean, of its temperature, its I 
motions, or its moisture ; upon what is expressed in the single word weather. Con- j 
cerning a calamity so generally felt, and so obscure in its origin, conjecture, you may 
well beheve, has not been idle. One hypothesis assigns the complaint to some change J. 
in the electrical condition of the air : to its becoming negatively electric : or to its [' 
being such as to cause an excessive accumulation of electricity in the animal econo- 
my. The facts adduced in support of these views are of this kind. Meat, sent up 
by means of a kite, high into the atmosphere, during the prevalence of the disease, j 
has returned plitrid. Large heavy separate clouds, in a state of negative electricity, 



INFLUENZA. 



543 



have been observed just before the setting in of an epidemic. Thunder-storms, and 
tumults of the atmosphere, have occurred at the same periods. During the raging 
of one epidemic, 800 women engaged in coal-dredging at Newcastle, and wading all 
day in the sea, escaped the complaint. It has been thought that this exemption 
4night be accounted for by supposing that the almost constant immersion of the body 
. in a conducting medium prevented any undue collection of electricity. 

Again, it has been fancied that the tolerably definite course of the epidemic, in its 
migrations, might be somehow connected with magnetic currents. 

Another hypothesis, more fanciful, perhaps, at first sight, than these, yet more 
easily accommodated to the known phenomena of the distemper, attributes it to the 
presence of innumerable minute substances, endowed with vegetable or with animal 
life, and developed in unusual abundance under specific states of the atmosphere, in 
which they float, and by which they are carried hither and thither. Myriads of 
these animalcules, or of these vegetable germs, coming in contact with the mucous 
membranes, and especially with that of the air-passages, irritate (it is imagined) these 
surfaces, and exercise a poisonous influence upon the system. Now, the sporules 
of certain fungi, which ruin the health, and destroy the vitality of larger plants, on 
which they prey, are inconceivably small. I shall prove to you, presently, that 
vegetable effluvia are capable of producing, in the human body, symptoms not very 
dissimilar from those of influenza. Again, that the waters of this globe swarm with 
living creatures, which are invisible by our unaided eyes, the microscope has taught 
us. Others, too small even to be estimated by that wonder-showing instrument, in 
all probability exist. We cannot doubt that the gaseous fluid which surrounds this 
planet, equally teems with hving atoms. We know that multitudes of insects, and 
of cryptogamous plants, infinite in number in respect to our finite powers of compu- 
tation, are sometimes suddenly hatched or developed, in places which were pre- 
viously free from them. It is easy to conceive that atmospheric infusoria (so to 
speak) may rapidly congregate, or vivify, in masses sufficient to render deleterious 
the very air we breathe. If this be so, we can understand how such a cause of dis- 
ease may first act here and there, and presently overspread large districts ; how it 
may move, or be wafted from place to place, or be carried about by persons ; how 
its course and operation may be circumscribed and definite ; and how some germs 
or ova may remain after the visit, retaining their vitality, and ready in future seasons 
again to start into hfe and activity under favouring circumstances. Taking the 
insect hypothesis, and knowing as we do that some animal poisons (that of small-pox, 
for example), have the singular property of multiplying themselves in the human 
body, like yeast in beer, we may conceive that diseases, produced by animalcules^ 
may thus infect the fluids of the body, and become contagious in the fullest sense of 
that term. Lastly, the uniform duration of these epidemics has been supposed to 
add probability to the hypothesis that they result from the operation of some organic 
principle, which has its definite periods of growth and of decay. All this is sheer 
hypothesis ; but it is as good an hypothesis as I am able to offer you ; and you 
must be content to conceive of it as being possibly the true one, until a better shall 
be proposed. 

The character of debility which is so conspicuously impressed upon this disease, 
bears closely upon the treatment required for its cure, or its safe conduct. As in all 
other epidemics, the severity of the complaint is extremely variable in different per- 
sons. In some it proves a very trifling malady, which soon passes off, and requires 
httle or no assistance from medicine. In others it is a very distressing affection, and 
lays the foundation for other and still more serious, though more chronic diseases; 
and in some, and more especially in the old and the unsound, it shows itself a very 
fatal disorder. The absolute mortality under the recent epidemic has been immense ; 
the daily newspaper obituaries have been unusually long ; and you may have re- 
marked, that the ages of the persons whose deaths they announced were in almost 
all cases great. ' The funerals have been so frequent, that difficulty has been found 
m performing them without indecent hurry and confusion. One undertaker of whom 
I was informed had at one time seventy-five dead bodies to inter — above ground, as 
he expressed it ; and mourning coaches and black horses could not be procured in 



Ill i 

544 INFLUENZA. j 

sufficient numbers to meet the demand for them. The absolute mprtahty, therefore, 
I say, has been enormous ; yet the relative mortality has been small. You will hear 
people comparing the ravages of the influenza with those of the cholera, and infer- 
ring that the latter is the less dangerous complaint of the two ; but this is plainly a 
great misapprehension. Less dangerous to the community at large (in this country i 
at least) it certainly has been; but infinitely more dangerous to the individuals | 
attacked by it. More persons have died of the influenza in the present year than ' 
died of the cholera when it raged in 1832; but then a vastly greater number have i 
been affected with the one disease than with the other. I suppose that nearly one- 
half of those who were seized with the cholera perished ; while but a very small . 
fraction indeed of those who suffered influenza have sunk under it. The only fatal I 
cases that I have seen have been in persons advanced in hfe, or in persons whose i 
lungs were previously known to be unsound. ] 

Now, the treatment of the influenza is pretty welJ understood. The chief risk ^ 
of mistake is that of being too busy with the lancet. Certainly those affected by this j 
disorder do not well bear active depletion. Of course no one would think of blood- | 
letting except the symptoms were severe, and the distress great ; but, even in such | 
cases, much caution is requisite in adopting that remedy. If you find that the in- | 
flammation has extended to the pleura, or to the substance of the lungs, it may be : 
necessarj' to open a vein, or to apply cupping-glasses over the chest ; but this is a 
very unpleasant necessity. Such is the result of all that I have seen, and heard 
from others, of the present epidemic ; and such is the result of the recorded expe- ' 
rience of nearly all previous epidemics. You will find abundant evidence of this col- j 
lected into a summary view by Dr. Hancock. In 1510, Dr. Short says bleeding and ' 
purging did harm. In 1557, bleeding was said to be so fatal, that in a small town i 
near Madrid, two thousand persons died after it in the month of September. Ii\ 
1580, Sennertus, after stating that, where blood-letiing was omitted, the mortality I 
was not greater than one in one thousand, adds, " Experientia enim hoc comprobavit, i 
omnes fere mortuos esse quibus vena aperiebatur." Dr. Ash observes that, in 1775, 
it was never necessary to bleed at Birmingham ; and that, in a neighbouring town, 
three died who were bled, and all recovered who were not bled. And a great deal 
more evidence to the same purpose you may find in the article I have referred to. j 

I believe the best plan of management — as far as any general plan can be laid 
down — is to keep the patient in bed, and, after clearing the bowels by a mild ape- 
rient, to give a couple of grains of James's powder every six hours, with a sahne 
draught, and slops, till the first brunt of the disorder is over ; and then, if the cough 
be troublesome, and the breathing laborious, and much rhonchus, or sibilus, or crepi- j 
tation, is audible in the chest, to apply a blister, and to give expectorants and diure- j 
tics. What I prescribed a great many times was something of this kind : half a j 
drachm of oxymel of squills, a drachm of the sweet spirit of nitre, and sometimes | 
another drachm of paregoric, in almond emulsion. With respect to fufl doses of 
opium, when the feverishness is abated and the headache gone, I should recommend \\ i 
the same practice which I described in the last lecture. If there be any lividity of ! 
the skin, or of the mucous membranes, it is dangerous to give a full dose of opium. ' 
On the other hand, if there be no visible indication in the complexion that venous ; 
blood is circulating in the arteries, opium given at bed-time will sometimes have a j 
magical effect in relieving, distress, and (by giving rest and refreshing sleep) in 
recruiting the strength also. In cases in which the powers of the system are pros- i 
trate, and the face and hps are livid, and the patient is tugging to expectorate the ' 
mucus that is filling up his air-passages, you should have recourse to ammonia, to | 
nourishing broths, and it may be to wine and water: and when all danger from the j 
disease is over, but the patient remains feeble, languid, and out of spirits, then is the | 
fit time to administer tonic medicines; and although snake-root and cascarilla are ; 
well-spoken of by many practitioners, I know no tonics so good as the sulphate of | j 
quina, or of iron, for such patients. | 

As to external applications, mustard poultices, blisters, and the like — and to the ; 
inhalation of the steam of hot water, — these may each and all be very useful ; but I j i 



HAY-ASTHMA. 



545 



have nothing to add concerning the time and manner of their employment to what I 
said upon the same subject in the last lecture. 

There is one point in the treatment which I must not omit to notice, although I 
cannot tell 3^ou much about it from my own experience. Dr. Thomas Davies, an 
accurate observer, and one well qualified to form a judgment in the matter, states 
that he found a mercurial treatment answer well in severe cases, in the epidemic 
of 1833. He perceived that active depletion was not well borne, and discovering 
that in the bad cases there was always crepitation in the lower lobes of the lungs, 
he thought mercury was one of the most proper remedies to subdue the inflamma- 
tion, and to occasion absorption of the fluid etfu^ed into the air-cells. He had severe 
cases to deal with. He says that it happened to be his duty to admit the patients 
into the London Hospital during the week the epidemic was at its height, and that 
thirty-two beds which were placed at his disposal were all soon filled with individuals 
labouring under the severe forms of influenza ; so severe, that he behoved the greater 
number of them would have perished if they had been allowed to wander about the 
streets, or even to have remained at their own homes, with the insufficient attention 
they could there have obtained. Only one or two of these patients were bled, but 
they were all put under the influence of mercury. This treatment commenced on 
Thursday, and all who, by Saturday night, vvere affected in the usual way by the 
remedy, safely and gradually recovered, with the exception of two ; and one of these 
had hypertrophy of the heart, and diseased aortic valves. His object was not to 
sahvate, but merely to make the gums tender. It was of course necessary that the 
action of mercury should be prompt; and he found that the most quick and effica- 
cious way of obtaining it was by rubbing in the linimentum hydrargyri. 

There is another kind of catarrh described as depending upon a peculiar local 
cause, and therefore requiring to be briefly noticed. 1 have seen only one instance 
of it ; but it has been observed and described by several medical men. Dr. Bostock, 
in the Medico-Cliirurgiccil Transactions^ gives an account of this complaint as it is 
apt to attack himself. It is called the catarrhus scstivus, and by some the hay-fever, 
or the hay-asthma. In Dr. Elliotson's lectures, also, as published in the Medical 
Gazette, there is a good deal of curious information upon this malady, contained in 
letters addressed to him from practitioners in various parts of the country, in conse- 
quence of some previous remarks he had made upon it in a clinical lecture, which 
had also been printed. Dr. Elliotson speaks of it as a combination of catarrh and- 
asthma. It consists in excessive irritation of the eyes, nose, and the whole of the 
air-passages ; producing, in succession, itching of the eyes and nose, much sneezing 
occurring in paroxysms, with a copious defluxion from the nostrils ; pricking sensa- 
tions in the throat; cough, tightness of the chest, and difficulty of breathing, with or 
without considerable raucous expectoration. This complaint affects certain persons 
only, and in them it always takes place at the same period of the year, in the latter 
end of May, or in June, when the grass comes into blossom, or when the hay-making 
is going on. It seems, in fact, to be produced by some kind of emanation from cer- 
tain of the grasses that are in flower at that season, of the irritating qualities of which 
emanation some persons only, — and a very few persons in comparison with the en- 
tire population, — are susceptible. The disorder happens only at that one particular 
season ; and it then attacks persons who are not remarkably subject to catarrh at 
other times, nor from the ordinary causes of catarrh ; and if they avoid meadows and 
hay-fields, and the neighbourhood of hay-stacks, they escape the malady. Hence 
going to the sea-coast, and especially to those parts of the coast that are barren of 
glass, offers a means of protection ; and when this cannot be done, such persons ob- 
tain refuge, in some measure, from the cause of the irritation, by remaining within 
doors, and shutting out as much as possible the external air, during the hay-crop. 
One lady, who suffered annually from this strange affection, states that a paroxysm 
has been brought on by the approach of her children, who had been in a hay-field ; 
and once this happened when the hay-season had been for some time over, upon 
their joining her at tea, after playing in a barn in which the hay of that year had 
been deposited. She was in the habit of flying to Harwich, or some other part of 
35 2v3 



546 



HAY-ASTHMA. 



the coast, as the dangerous season came on. On one occasion, while walking on the 
shore at Harwich, she was suddenly attacked by the complaint, to her great surprise, 
as she was not aware of any grass being in the neighbourhood ; but the next day 
she discovered that hay-making was in progress upon the top of the cliff at the time 
she was walking under it. In another year, she being at Cromer, and an attack that 
she had suffered having quite subsided, and all the hay-making thereabouts being 
over, she was suddenly visited by the well-known symptoms, and on going into her 
bed-chamber, perceived that they were building a large stack of hay in a yard near 
the house, having transferred it from a field five miles distant. 

Very lately I was asked by Mr. Cheyne to see with him the wife of a stable-keeper 
near Regent street. I found her suffering under what is popularly called " a crying 
cold pain in the situation of the frontal sinuses, streaming eyes, sneezing and de- 
fiuxion from the nostrils, and very urgent dyspncea, which was accompanied by loud 
wheezing. Symptoms of this kind had come on, suddenly, some days before : and 
her distress was then so great, that her husband proposed to drive her in a gig to 
consult a medical friend of his who lived at Islington. On their way thither, every 
symptom disappeared, and she felt at once quite well. She subsequently stayed a 
night or two, in comfort, with some relations in the city. Immediately upon her re- 
turn home the same symptoms recurred, with all their former severity, and resisted 
the means adopted for their relief by Mr. Cheyne, who had now been called in. He 
was soon led to suspect the cause of the attack, and of its obstinacy. There was a 
strong odour of hay in the house. The husband told him that his lofis were filled 
with a lot of hay which had recently arrived, and which had an unusually powerful 
smell. We learned that our patient was always worse at night, when the house was 
shut up ; and better in the morning, when a free current of air blew through the 
open windows. We advised a temporary change of residence : but our advice was 
not followed until two days afterwards, the disorder meanwhile continuing, and in- 
creasing in intensity. Then the patient removed to lodgings not one hundred yards 
distant ; and immediately all the catarrh and distress again ceased, and she passed a 
perfectly tranquil night. Afterwards she went into the country, and did not return 
till the odoriferous parcel of hay had been consumed, and a new stock laid in. She 
was however revisited by some slight cough, and occasional dyspnoea — neither of 
which troubled her much or long. 

Avoidance, then, of the ascertained source of the complaint is the best thing that 
can be recommended to these persons. You may read almost every year in the 
newspapers that one of our English dukes has gone to Brighton to escape the hay- 
fever. But it is not in the power of every one to leave home for that purpose ; and 
it has been found that the sj'Stem is capable of being fortified in some degree against • 
the pernicious effects of these vegetable effluvia. Mr. Crordon of Welton, in York- 
shire, had communicated some interesting observations to the profession on this 
subject, before those of Dr. Eiliotson were published. You may find Mr. Gordon's 
paper in the fourth volume of the Medical Gazette. He supposes that the aroma I 
of the sweet-scented vernal grass, the anthoxanthum odoratum, is the principal I 
exciting cause of the complaint. He found the symptoms more speedily and effectu- i 
ally removed by the tincture of lobelia inflata, than by anything else that he had tried ' 
at that time ; and he recommended the cold shower-bath as the best preservative | 
against the attack. But in a subsequent communication to Dr. Eiliotson, he states | 
that the sulphates of quina and of iron given in combination, had proved completely 
successful in emancipating from their tormenting disorder the two patients, from ■ 
whose cases he had principally drawn up his account; although they had, in spite | 
of all previous treatment, suffered an annual return of it for fifteen or twenty years. 

The susceptibility of this troublesome affection of the mucous membrane, from a 
pecuhar cause, which, to most people, occasions no uneasiness, appears sometimes 
to run in families : and this is nothing more than one might expect. 

Dr. Ehiotson, thinking it possible that the chlorides which have the power of 
decomposing, and disarming of their noxious qualities, certain animal effluvia, might 
exert a similar control over the vegetable emanations that excite the hay-catarrh, 
suggested to one of the sufferers a trial of the chloride of lime or of soda. He 



CHRONIC BRONCHITIS. 



547 



desired him to have it placed in saucers about his bed-chamber : to have rags dipped 
in it and liung- about the rooms of the house; to wash his hands and face with it 
night and morning ; and to carry a small bottle of it with him to smell repeatedly in 
the course of the day ; and this plan gave so much* relief, — either by destroying the 
emanations, or by lessening the irritability of the mucous membranes, — that it was 
tried in other cases; and, though it did not succeed in all, it did in most of them. 
Three patients out of four derived advantage from it. This expedient, therefore, is 
worth carrying in mind. 

There is another vegetable substance, better known to us, which produces in some 
few individuals symptoms like those of the hay-asthma ; I mean the powder of ipe- 
cacuanha. I recollect a servant employed in the laboratory of St. Bartholomew's 
Hospital, Vv^hen I was a pupil there, who had the pecuhar ill luck to be hable to this 
affection. Whenever that drug was under preparation, he was obliged to fly the 
place. This idiosyncrasy is not very uncommon. A very small quantity of the 
ipecacuanha dust is sufficient in such persons to bring on a paroxysm of extreme 
dyspnoea, wheezing, and cough, with singular anxiety and great weakness. The 
distress usually terminates by a copious expectoration of mucus. 

These effects of a powdered root, and of certain emanations from grass or hay, lend 
weight to the hypothesis which ascribes the influenza to subtle vegetable matter 
floating in the atmosphere. 

I would suggest a trial of the Respirator, as a defence against the particles of 
ipecacuanha, and against the volatile exciting cause (whatever it may be) of hay- 
asthma. 

Catarrh is very often met with in a chronic form ; in other words, the mucous 
membrane of the air-passages is very liable to be affected with chronic inflammation, 
The accounts which you may read of this are exceedingly puzzling. Authors have 
endeavoured to draw nice distinctions between different species of chronic catarrh ; 
sometimes according to varying qualities in the matter expectorated : thus you have 
chronic mucous catarrh —pituitous catarrh — chronic pituitoiis catarrh — and dry 
catarrh, which, after all, is not dry, but only accompanied by less expectoration than 
some of the others ; and then again there is symptomatic catarrh. Yon will find all 
these enumerated by Laennec; and the majority of writers since his time have trod- 
den with too submissive reverence in his footsteps. There are by no means such 
differences in the symptoms or in the proper treatment of the several varieties of 
chronic inflammation of the membrane in question, as to make these numerous sub- 
divisions of any pmctical utility. Chronic or moderate catarrh is often a sequel of 
acute bronchitis ; it is a very common accompaniment of disease of the heart ; it fre. 
quently arises during the course of the febrile exanthemata ; it is seldom entirely 
absent in cases of continued fever ; and it is a form of complaint that is full of 
interest on this account, if on no other, that it has so often been mistaken, and is so 
hable to be mistaken still for tubercular consumption ; of which indeed it is very fre- 
quently the companion. 

The constant symptoms of chronic catarrh, or bronchitis, are cough, some short- 
ness of breath, expectoration of altered mucus. The ?;«na6/e symptoms, those which 
are oftentimes of the most importance, as determining the slight or the serious character 
of the disorder, consist in the quantity and quality of the matters expectorated, and 
the presence or absence of wasting, and of hectic fever. ^ 

You will continually be meeting with cases of this kind. A person advanced in 
years has what he calls a slight cold, in the winter. He coughs, and expectorates a 
certain quantity of gray or transparent mucus. In the summer his cough diminishes, 
or ceases altogether. The next winter the same thing happens again ; and each suc- 
cessive return of the colder seasons of the year brings back in increasing severity 
the cough and the expectoration : and if you listen to the breathing of such persons, 
while the cough is on them, you will find crepitation at the lower part of their lungs. 
Now these are examples, I beheve, of a chronic state of shght inflammation of the 
membrane,— or it may be of passive congestion and effusion, — depending upon 



548 



CHRONIC BRONCHITIS. 



slowly advancing cardiac alterations. Peripneumonia notha is veiy apt to super- 
vene on this condition. 

But chronic bronchitis may take place at any age, as a sequel to the acute : just 
as active inflammation of other parts of the body is liable to degenerate into the 
chronic form ; and such cases are sometimes very equivocal and deceptive. Several 
years ago, a lady became my patient, having cough, expectoration of puriform 
matter, night-sweats, and diarrhoea. She had had hooping-cough a short time 
before ; but though the hooping, and other symptoms proper to that disease had 
ceased, she continued to cough, and to waste. Gradually she got thinner and 
weaker, her pulse became like a thread, and beat 120 times in a minute ; she took 
to her bed, the diarrhcea was scarcely restrained by astringents and opiates, and I 
thought she could not live a week. And, upon being pressed by her brother for my 
opinion, I said so. She had scarcely allowed me to hsten to the sounds in the 
thorax : but I had once done so fairly, and I could find no morbid sounds, except at 
the lower part of the lungs. If I had trusted to that circumstance alone, I should 
have said that she had not tubercular consumption ; but I had not then so much faith 
in the indications afforded by auscultation, nor in my accuracy of ear in such matters, 
as I might have now; and I concluded that she was dying of tubercular phthisis. 
Almost on the day, however, on which I ventured to give this prognosis, some slight 
amendment began : and she did gradually recover, and is ahve and quite well at this 
time. Now it is in cases of this kind that cures are performed by those who boast 
of curing consumption. 

In truth, chronic bronchitis is, in some cases, as incapable of recovery, and as 
surely and progressively fatal, as tubercular phthisis itself; and even more so than 
some of the forms of phthisis. So long, however, as no organic change has taken 
place in the air-tubes, or in the mucous membrane lining them, these chronic forms 
of bronchitis that simulate phthisis in their general symptoms, are within the reach 
of cure. They are to be treated by counter-irritants to the chest — and by such 
measures as are calculated to relieve the most urgent symptoms. Opiates for cough, 
or for diarrhea. Sometimes the patients bear steel well, and then it is almost sure 
to have a beneficial effect. Sometimes sarsaparilla appears to do good ; but, as far 
as T have observed, one of the most effectual restoratives in these cases is to be found 
when the weather and the strength permit, in frequent change of air and place ; in 
gentle gestation in a carriage, or in a boat; and in a nourishing but bland and un- 
stimulating diet. When the membrane, and the tubes which it lines, become aliered 
in structure, and pour forth a fluid which has all the qualities of pus, hectic fever 
generally is present, and the chronic disease tends, slowly perhaps, but surely, to 
death. 

There are certain cases of chronic bronchitis which are especially remarkable, on 
account of the great abundance of the bronchial secretion : so great that the patients 
appear to die principally from the daily exhausting drain thus made upon the sys- 
tem. There are sometimes no other evident signs of inflammation ; so that, as 
Andral observes, one might be led to separate these fluxes from the truly inflamma- 
tory affections. They differ from them, apparently, in their nature, and certainly in 
the treatment which they require. Andral has detailed two or three instances of this 
kind in his Clinique Medicate. The patients expectorated every day large quanti- 
ties — a pint or more — of frothy fluid, resembhng weak gum-water in colour and con- 
sistence. They had no fever ; neither frequency of pulse nor heat of skin ; but they 
were exceedingly pale, like persons blanched by hemorrhage, and their emaciation 
and weakness were also extreme. Yery little appreciable deviation from the healthy 
state was detectible when the lungs and heart were examined after death. 

It does occasionally happen that even larger quantities — three or four pints daily — 
are, for a considerable period, spat up, Avithout much wasting. 

Andral asks, whether, in such cases as these, which certainly occur, though they 
are not very common, the first indication of treatment should not be to check and 
diminish the excessive bronchial secretion ; to treat it as you miight treat a gleet of 
the other mucous membranes, with balsams, administered either by the stomach, or 
in the shape of vapour. He conjectures that it might have been in cases of this 



CHRONIC BRONCHITIS. 



549 



nature that the vapour of tar, and tar-water, were once thought to be so useful. 
Probably the creasote would be well adapted to such cases. Certainly I have 
seen the excessive expectoration diminish, and the patients gain strength, under the 
use of the balsams; the compound tincture of benzoes, for example; a form of 
medicine much employed formerly, and too much neglected, I apprehend, at present. 

[Balsam Copaiba will be found a very valuable remedy in these cases. — C] 

Another remedy, from which I have derived great advantage in some cases of the 
same kind, is the sulphate of iron, given in two or three-grain doses, in the compound 
infusion of roses, thrice daily. When there is any fever present, these remedies are 
apt to augment it : but when the pulse is quiet, and the skin cool, 1 am quite sure 
that they are often of the greatest service ; and this you will find to be the opinion 
also of various practical authors. 

There is another very remarkable condition of the pulmonary mucous membrane, 
constituting also, I imagine, a species of chronic inflammation, and characterized 
chiefly, like the last, by the matters expectorated. I mean that state in which a firm 
substance, resembling a false membrane, forms in the smaller bronchi and their rami- 
fications, and is coughed up, from time to time, in fragments. T mentioned in a 
former lecture that the false membrane of croup sometimes descends a long way into 
the bronchi; even to their extremities. But I am speaking now of a different and 
less acute form of disease, in which, the trachea being unaffected, concrete masses, 
evidently moulded in parts of the hollow bronchial tree, are spat up ; somewhat like 
bunches of worms, or the roo:s of a small plant. This I presume to be uncommon ; 
for I have met with it twice only in my life. It has been described, however, by 
several observers. The first, Dr. Warren, has a paper upon it in the first volume 
of the Medical Transactions, where he gives representations of the substances 
coughed up, vv'hich he calls bronchial polypi. Dr. Paris has told me that a patient 
of his coughed up considerable quantities of these branching casts of the ultimate air- 
tubes, now and then, for a long period. An interesting paper of Mr. North's, on the 
same subject, was read at one of the evening meetings of the College of Physicians. 
That gentleman possesses some beautiful specimens of these miscalled polypi. Dr. 
Carswell gives a figure representing them. When the affection is extensive, it is 
attended with great distress, and dyspnoea, and violent fits of coughing; and the 
symptoms are wonderfully calmed upon each expulsion of the sohd matter. The 
surprise is that such patients skould ever recover ; but I have never heard of an 
instance in which the complaint proved fatal. 

The two examples of it which have fallen under my own observation, were 
invested, by the circumstances attending them, with a peculiar interest. They 
occurred, within less than a twelvemonth of each other, in the persons of two brothers, 
of middle age, the one a barrister, the other well known to you all as one of my most 
valued colleagues in this place. Both of them were, and are, remarkably stout, 
strong, and heakhy men. In both cases the expulsion of the so-called polypi was 
preceded by haemoptysis, which came in considerable gushes, and was repeated at 
intervals of a few days, until the sohd matters began also to be expelled, and then 
hemorrhage soon subsided. 

The barrister, after having been annoyed for nearly a year by some huskiness of 
the voice, spat up, all of a sudden, a small quantity of bright blood ; and soon after- 
wards expectorated several ramifying masses of tolerably firm consistence, resembling 
fibrinous coagula of blood, deprived of most of its colouring matter. Some of them, 
which I saw and examined, were sohd ; others, I understood, were hollow. I found 
slight circumscribed crepitation in the lower and posterior part of his left lung. This 
trivial degree of haemoptysis, with the expulsion of what looked like casts of the inte- 
rior of a bronchial tube, was once or twice repeated within a few days. He had no 
fever — no dyspnoea. Mercury, inter alia, was prescribed ; but as the patient did 
not feel in any way ill, I believe he soon became tired of physic, and of medical 
restraint. Whenever I have since seen him, he has appeared to be in perfect 
health. 

Of the professor's illness I saw more. In the midst of health which had been 



550 



CHRONIC BRONCHITIS. 



uninterrupted, save by a solitary fit of the gout some 5^ears before, he also spat some 
mouthfuls of florid blood. He had no cough, but the hsemoptysis was accompanied 
by a ratthng sensation in the right side of his chest. 

For about three weeks he continued, at intervals varying from three to six days, 
to expectorate blood in gushes. " The smallest quantit}^ brought up on any one 
occasion was two ounces ; the largest, eight. Just above the right nipple, the respi- 
ratory murmur was mingled with large crepitation, which was always sensibly 
increased, and quite perceptible by the patient himself, during the attacks of he- 
morrhage. In the intervals between them his breathing and his pulse were per- 
fectly tranquil and regular. 

With the florid blood came up, in general, some black coagula : and at the end 
of three weeks, or thereabouts, in these black masses, ragged shreds of a different 
and firmer material began to be visible : and presently afterwards, complete branch- 
hke casts of the ramifying air-tubes were expelled ; and the bleeding ceased. 

Of these casts there were two kinds; the one soHd, somewhat coloured, evidently 
fibrinous, and resembling the branching coagula that ma}^ somethnes be drawn out 
of the arteries in the dead body ; the other white, membranous, tubular, but rami- 
fying also. None of them were of very firm consistence. 

Till these substances made their appearance, our anxiety about the' patient was 
extreme, and he underwent some rigorous discipline at our hands. He was con- 
fined to bed, forbidden to speak, kept strictly to the slenderest slop diet, several 
times bled, and extensively blistered. Lumps of ice were given him to swallow, and 
pounded ice was applied to his chest whenever the blood broke forth afresh. He 
took mercury till his gum5 were tender, and afterwards the acetate of lead, and other 
reputed styptics. 

To most of this I was a consenting party ; but, looking back upon the case now 
that its nature and result are known, I must confess that the treatment, though fairly 
justifiable at the time, was unnecessarily active. 

Mr. North, in the paper to which I have alluded (you may see it in the twenty- 
second volume of the Medical Gazette), draws a distinction, of which he gives the 
credit to Dr. Cheyne, between the hollow, membranous concretions, expelled without 
any blood ; and the sofid branching masses which accompany or succeed haemopty- 
sis, and are obviously mere coagula of blood moulded in the smaller air-tubes, where 
it had stagnated. He points out the comparatively harmless character of the cases 
in which the first occur ; and the far more serious import of the second : the hemor- 
rhage denoting the presence of some organic mischief within the thorax, and the 
" polypous concretions" being simply an accident of the hemorrhage. 

I doubt the accuracy of this distinction. The brothers of whom I have spoken 
continue to be, as they were before, free from any symptom or suspicion, either of 
cardiac or of pulmonary disease. Moreover, in hsemoptysis depending upon tuber- 
cles in the lungs, or upon organic disease of the heart, these concretions are very 
rarely observed. I have never seen them in such cases, common as such cases are. 
The barrister had a husky voice, and the professor was noticed to have been often 
"clearing his throat" for some time before the first eruption of blood: from which 
circumstance I infer a previous unhealthy state of the mucous membrane. Upon the 
whole I incline to the views expressed by Dr. Todd, with whom I had the advantage 
of consulting in the latter case — that a chronic and limited inflammation of certain 
of the bronchial tubes first occurred ; disclosing itself by no marked symptoms, but 
leading to the formation of tubular membranes : that, afier awhile, these membranes 
began to be detached: that hemorrhage resulted, and continued till the separation 
was complete : and that, at the same time, some of the extra vasated blood coagulated 
in, and took the shape of, the air-tubes, and was afterwards expectorated. 

I understand that the barrister has since had a recurrence of this strange complaint, 
which he treated very lightly, and soon got rid of. 

He entertained a fixed behef that his attacks were attributable to the presence of 
one of Dr. Arnott's stoves, in his chambers ; the heated atmosphere of which ahvaj's 
produced a shght feeling of constriction and distress within his chest. Whether 
this notion be well or ill founded I cannot pretend to say : but it is curious that the 



MORBID ANATOMY OF THESE AFFECTIONS. 



551 



professor also had been using a similar stove, whicii, placed in his sitiiiig-roon}, 
warmed both it and his bed-room adjoining. 

A word or two, before we separate, as to the morbid anatomy of these tissues. 

Chronic inflammation of the aerial mucous membrane may lead to changes in its 
colour ; or to thickening of the membrane ; or to ulceration ; or to dilatation of the 
bronchi, and their ramifications. And it is proper that you should be informed re- 
specting these morbid conditions. 

In general, when chronic inflammation has existed during life, the mucous mem- 
brane is found to be red : but it is not a bright redness ; it is rather a livid, or violet, 
or brownish tint. And what is very curious, in some ipstances in which all the 
symptoms of inveterate bronchitis, with puriform expectoration, had been present, 
the inner membrane of the air-passages has been found scarcely ros}' — or even per- 
fectly white- — ^throughout its whole extent. Of course we are not to infer from this 
that there has not been infuimmalioa ; for the same thing is known to occur in the 
intestinal mucous membrane, in that of the bladder, and even in serous membranes. 
Where pus is poured forth there must have been inflammation. 

One effect of inflammation, as I formerly showed you, is a softening of the mem- 
brane ; but this is a much less common result of inflammation in the mucous mem- 
brane of the bronchi, than in that 9f the digestive organs, in regard to ulceration 
likewise there is a great difterence between the two mucous surfaces : in that of the 
air-passages it is comparatively rare. 

Thickening of the mucous tissue occurs also in various degrees : but the most 
remarkable change undergone by the membrane, and the tubes which it lines, is the 
dilatation of those tubes, and the consequent alteration of the membrane, which 
expands with them. 

There are two or three varieties of this dilatation. In the first of them, one or 
more of the bronchi present, throughout the whole or the greater part of their extent, 
an increase of capacity more or less considerable : so that tubes which result from the 
fourth or fifth, or even sixth division of the principal bronchus of each lung, may 
equal or exceed in diameter that bronchus itself. Tubes that ought not to be bigger 
than a crow-quill may become as large as the finger of one's glove. Sometimes this 
kind of dilatation is seen in a single branch only, sometimes in many. It may affect 
the bronchial ramifications of an entire lobe. It is more common in the branches of 
a bronchus than in the bronchus itself. 

It is not very easy to explain the manner in which this sort of dilatation is pro- 
duced. We might attribute it to simple distension of the bronchial parietes, were it 
not that these parietes are at the same time thickened, and the circular fibres hyper- 
trophic'd, as you may see in this preparation, and in Dr. Cars well's plate. But there 
is another form of bronchial dilatation to which the explanation just adverted to is 
easily applicable. Instead of the uniform dilatation of one or more bronchial tubes, 
throughout their whole extent, we find a bellying, or globular expansion, at the ex- 
tremity of one of them ; and the walls of the tube, instead of being thick and hyper- 
trophied, are wasted, and in a state of atrophy. The tissues composing the tube are 
often so thin, that when the cavity, for such it must be called, is laid open, the colour 
and structure of the pulmonary tissue may be seen through them. These cavities 
are generally found filled with a thick, tenacious, straw-coloured, muco-purulent fluid. 
Now it is easy to conceive how " the straining influence of repeated paroxysms of 
coughing" may cause dilatation of this kind. The primary branches are more easily 
cleared of the mucus that fills them : but the pressure which the lung undergoes 
under a forced expiration, operating on a portion of the same kind of mucus detained 
in the smaller branches, may be more than the elasticity of the tube is capable of 
resisting. And, in fact, all dilatations of the bronchial tubes must be, in part at least, 
owing to the same influence of centrifugal pressure by imprisoned mucus. They 
are seldom met with except after those affections which are characterized Dy con- 
siderable secretion from the membrane, and by much and repeated cough: as after 
some forms of chronic bronchitis, and after hooping-cough. 

A third variety of dilatation is that in which the same bronchus bellies out in dif- 



552 



HOOPING-COUGH. 



ferent places ; is dilated at intervals ; so as to present in its course a series of succes- 
sive enlargements and contractions. Here, again, the walls of tiie bronchi, though 
they may be traced in the parts dilated, do not appear to be thickened, but rather 
are diminished in thickness. We may suppose, therefore, that these small partial 
dilatations of the bronchi may result from mechanical distension, by mucus, in those 
places which offer the least resistance ; either on account of diminished elasticity, or 
of actual thinning. This variety of dilatation is more frequent in children than in 
adults. 

In whatever way the dilatation may take place, one of its obvious and necessary 
consequences is, the condensation of the pulmonary substance around the dilated 
tube, the obhteration of some of the cells, and a proportional abridgement of the func- 
tion of the lung. Accordingly, when it is extensive, dilatation of the bronchi is 
attended with habitual dyspncea. 

But the most important consideration arising out of this state of the bronchi, is 
this ; that the signs, both general and physical, by which it is accompanied, are 
apt to be exactly those which are most distinctive of phthisis. And it is on that 
account that I have now described these changes. I shall revert to them again 
when I come to the symptoms, revealed by auscultation, of tubercular disease of the 
lungs. 



LECTURE L. 

Hooping-cough: symptoms^ duration; complications; pathology; treatment. 
Pneumonia: its stages and morbid anatomy ; auscultatory signs, 

I HAVE yet to consider one very important disorder, which is usually classed among 
the catarrhal affections, but which is marked by features so peculiarly its own, as to 
distinguish it effectually from every other form of disease. I allude to hooping- 
cough ; a remarkable complaint, well known everywhere, I believe, and much 
dreaded by parents. It has received a variety of names : chin-cough ; kinkhoast ; 
coqueluche ; tussis convulsiva ; tussis ferina ; and pertussis. This last name, which 
Sydenham bestowed upon it, and which was adopted by CuUen, is the technical 
appellation of the disease in this country, as hooping-cough is the popular. 

The phenomena that characterize hooping-cough are, I say, remarkable. It begins 
with the symptoms of an ordinary catarrh arising from cold. The child (for it is 
most especially a disease of children) has coryza, and coughs ; and mothers and 
nurses are aware that the disease commences in this way, and express their appre 
hensions lest it may turn to the hooping-cough. After this, the catarrhal stage, has 
lasted eight or ten days, or a fortnight, or sometimes a day or two longer, that kind 
of cough begins to be heard which is so distinctive. It comes on in paroxysms, in 
which a number of the e:rpiratory motions belonging to the act of coughing are made 
in rapid succession, and with much violence, without any intervening inspirations ; 
till the little patient turns black in the face, and seems on the point of being suffo- 
cated. Then one long-drawn act of i/zspiration takes place, attended with that pecu- 
liar crowing or hooping noise, which denotes that the rima glottidis is partially closed, 
and which gives the disease its name. As soon as this protracted inspiration has 
been completed, the series of sh.ort expiratory coughs, repeated one immediately 
after the other till all the air appears to be expelled from the lungs, is renewed ; and 
then a second sonorous back-draught occurs ; and this alternation of a number of 
expiratory coughs, with one shrill inspiration, goes on, until a quantity of glairy 
mucus is forced up from the lungs, or until the child vomits, or until expectoration 
and vomiting both take place at once. During the urgency of the paroxysms, the 
face becomes swelled, and red or livid, the eyes start, the httle sufferer stamps some- 
times with impatience, and generally clings to the person who is nursing him for 
support, or lays hold of a chair or table, or of whatever object may be near him, to 



HOOPING-COUGH. 



553 



diminish (as it would seem) the shock and jar by which his whole frame is shaken. 
As soon as expectoration or vomiting have happened, the paroxysm is over. The 
chiJd may pant a httle while, and appear fatigued ; but commonly the relief is so 
complete, that he returns immediately to the amusements, or the occupation, which 
the fit of coughing had interrupted, and is as gay and lively as if nothing had been 
the matter with him. When the fit terminates by vomiting, the patient is in general 
^ seized immediately after with a craving for food, asks for something to eat, and takes 
it with some greediness. 

Each paroxysm may consist of several alternations of the gasping coughs, and the 
characteristic hoop or kink; but CuUen remarks, that the expectoration or vomiting 
usually takes place after the second coughing, and puts an end to the fit. 

The number of paroxysms that occur in the twenty-four hours is variable also; 
and they come on at irregular intervals. When the complaint is uncomplicated, the 
child, during the intermissions, appears to be quite well. This is another striking 
feature of the disorder. In the earher paroxysms the mucus expelled is scanty and 
thin ; and in proportion as this is the case, the fits are the longer and the more violent. 
By degrees the expectoration becomes more abundant ; and sometimes it is very 
copious : at the same time it is thicker, and more easily brought up; and on that 
account the fits of coughing are less protracted. 

The ordinary duration of the disease is from six weeks to three months; but it 
may run its course, I believe, in three weeks ; and it may continue for six months, 
or more. 

In an uncomplicated case, if you listen at the chest during the intermissions, you 
will probably hear the sounds that are proper to catarrh — some degree of rhonchus 
or sibilus : and in many parts there may be puerile respiration ; and if you percuss 
the thorax, you get the natural hollow sounds. But v/hat happens when you apply 
your ear to the chest during the paroxysms of coughing? Why, the information 
given us in this case by auscultation is very curious. You may perhaps hear, be- 
tween the short explosive shocks of the cough, some snatches of wheezing, or of 
vesicular breathing ; but during the long-drawn noisy inspiration that succeeds, all 
within the chest is silent. This is supposed to result from the slow and niggardly 
manner in which the air passes towards the lungs through the chink of the glottis, 
.which is spasmodically narrowed. It may also depend, in part, as Laennec sup- 
posed, upon a spasmodic condition of the muscular or contractile fibres of the bronchi 
and their branches. When the fit is at an end, the ordinary sounds of healthy, or 
of catarrhal respiration, are resumed. 

Children are very susceptible of this complaint ; and it is a complaint which 
spreads by contagion. Hence it follows that few children escape an attack of it. 
It is also one of those contagious maladies which do not in general affect the same 
individual twice ; and hence again it follows that it is rarely met with in adults. Such 
is the fact; and such, I apprehend, is the explanation of it. It is not that adults are 
insusceptible of hooping-cough ; for adults that have not had it during their child- 
hood are readily affected when exposed to the contagion. But it is that the disorder, 
with very few exceptions, protects the S3^stem somehow from its future recurrence ; 
and that most adults have had it when they were young, and for that reason do not 
take it afterwards. 

During the very early periods of infancy, i. e., within the first tvv^o or three months, 
hooping-cough is said to be rare : I mentioned a case, however, before — and I have 
read of others— in which the disorder appeared to have been contracted before the 
patient was born. My bed maker's daughter in Cambrid2:e had a child ill with 
hooping-cough in the house with her durmg the last weeks of another pregnancy, 
and the new-comer hooped the first day he came into the world. 

As long as this disease is uncomphcated — unmixed with inflammation, and there- 
fore unattended with fever, or only with that slight inflammatory condition proper to 
mild catarrh — it is not at all a dangerous disease. Probably it wilU under the most 
favourable circumstances, run a certain course. By degrees the violence and the 
frequency of the paroxysms diminish ; they occur only in the morning and the eve- 
ning, then in the evening alone, and at length they cease altogether. But for some 

2w 



554 

/ 



HOOPING-COUGH. 



time after the disorder has apparently come to an end, if the child takes cold, and 
gets a cough, it is apt to assume a spasmodic character, and to be attended with a 
hooping noise in inspiration. 

Unfortunately hooping-cough is, in a great many cases, not simple — not uncom- 
plicated. It becomes mixed up with other kinds of disease in the chest, or in the 
head. In the chest, severe bronchitis supervenes upon it, or inflammation of the 
substance of the lungs ; and then fever is lighted up, and permanent dyspncea is pre- 
sent. When the disorder has been long drawn out, and has at last terminated fatally, 
dilatation of the bronchi, such as I described in the last lecture, is often found upon 
dissection ; or, still more commonl)^, I believe, what is called emphyzema of the 
lungs — a change which I have yet to bring before you. 

That such effects should follow such violent and continued efforts of coughing, is 
no great matter for wonder. Neither can we be surprised that the disease frequently 
leads to cerebral disorder. During the fits, there is a great and visible determination 
of blood towards the head, or rather a detention of the blood in the veins that pro- 
ceed from the head ; — passive mechanical congestion : the transmission of the blood 
through the lungs being obstructed, and its return from the head being interrupted. 
Hence, the face becomes turgid, the eyes are prominent, the superficial veins full 
and projecting, the lips and cheeks turn hvid ; sometimes hemorrhage takes place 
from the nose or ears, or the eyes become blood-shotten, or the patient actually falls 
into convulsions ; nay, apoplexy is occasionally the result of the straining; and when 
life is not thus suddenly cut short, chronic mischief is apt to be set up in the brain, 
and the child ultimately dies hydrocephalic. 

All this is the more to be feared in proportion as the child is the younger. Head 
affections are particularly to be dreaded in scrofulous children ; and in any children 
during the first dentition. When the disease occurs Avithin the first two years of life, 
it is usually attended with convulsions : and many more die within that period than 
afterwards. And Cu lien's remark is undoubtedly true, that the older children are, 
the more secure they are, casteris paribus, against an unhappy event. 

Hooping-cough may be complicated also with a disordered condition of the bowels; 
and with infantile remittent fever. This complication is more accidental, and less a 
consequence of the hooping-cough than the former ; but it m.ay very materially add 
to its peril. 

Dr. Cullen was of opinion that the complaint may exist in even a milder form 
than that which I have called simple hooping-cough. He thought he had seen " in- 
stances of a disease, which, though evidently arising from the chin-cough contagion, 
never put on any other form than that of a common catarrh." Others again believe 
that adults may have it without hooping. But all this seems to me very doubtful. 
Catarrh is an exceedingly common malady ; and I should be slow to consider any 
case a genuine case of pertussis, unless the characteristic paroxysms of coughing, 
and the stridulous inspiration, were present. 

Divers opinions have been held respecting the seat, and respecting the nature, of 
hooping-cough. Some suppose it to have its seat in the brain ; and that it is essen- 
tially a spasmodic disease. Others maintain that it is situated in the air-passages of 
the lungs, and that it is always an inflammatory disorder. I do not pretend to strike 
the balance between these conflicting judgments. Certainly the simple form of the 
disease is often unattended with any appreciable fever : and that is a strong ground 
for believing that its pecuHar phenomena are not necessarily connected with inflam- 
mation. They who have ascribed the complaint to a morbid condition of the brain 
have deduced that opinion, 1 presume, from the cerebral symptoms that are some- 
times so plainly marked in hooping-cough. But these symptoms are oftener, to all 
appearance, the consequence, than the cause, of the paroxysms of coughing. I would 
suggest it as an interesting point for your future inquiry, whether the pathology of 
hooping-cough may not receive some elucidation from the researches of the late Dr. 
Ley, respecting the crowing inspiration of infants. You remember his suggestion, 
that mere inflammation of the mucous membrane of the air-passages might cause 
swelling of the absorbent glands of the bronchi or of the neck. This is a circum- 
stance which I have myself long thought probable, from having found enlargement 



PATHOLOGY. 



555 



of the cervical glands springing up during the existence of pulmonary irritation. 
Take notice that the spasmodic fits of hooping-cough are always preceded for some 
days by mere catarrhal symptoms. Observe further how the parts supplied by the 
pneumogastric nerve are affected in these paroxysms : the larynx, the lungs, the 
stomach. This conjecture, that the crowing inspiration of infants, and the crowing 
inspiration of hooping-cough — though quite distinct affections — may both depend 
upon irritation of the recurrent nerve, or of the pneumogastric nerve generally ; and 
that even the irritation might in both cases arise out of enlargement of the glands 
that lie in the course of that nerve : this natural conjecture had presented itself to 
Dr. Ley's mind ; for, towards the end of his book, I find this note : — " Recently four 
children have been brought to my house, labouring under hooping-cough. In all, 
the glandulse concatenatse near the trachea were very considerably enlarged. Is this 
(he says) merely an accidental combination ? or is there any essential connection 
between the two ? May it not be that an enlargement of these glands, from a specific 
animal poison, similar to that of the parotid glands in mumps, is, after all, the essence 
of hooping-cough ? The subject at least deserves inquiry, and further observation." 

In corroboration of this conjectural view of what may ultimately prove to be the 
true pathology of hooping-cough, I may remark that among the morbid appearances 
described as being met with after death from that disease, "an unusual swelling of 
the bronchial glands" is set down. It is also stated, by some of the Germans, that 
that portion of the pneumogastric nerve which lies in the cavity of the chest has been 
sometimes found red. Yet I should lay no stress upon this ; for others have asserted 
that they have looked in vain for this redness : and even supposing it to exist, it is 
no sure or safe token that there had been inflammation of the nerve. The nerve, all 
things considered, would be likely to become tinged of that .colour soon before, or 
even after, death, from the gorged condition of the lungs. In some cases, as you 
may well believe, serous fluid is met with in the ventricles of the brain, or in the 
meshes of the pia mater: in others the consequences of inflammation are traceable 
in the bronchi, the lungs, or the pleura. Portions of what is called hepatized lung 
are not unfrequently seen in the fatal cases. 

[The leading opinions in relation to the pathology of hooping-cough, may be referred to 
one or other of the following heads. 

1st. With some the disease is essentially a spasmodic affection of the air-passages, arising 
from a primary irritation, inflammatory or nervous, of the brain, or of one or other set of the 
respiratory nerves. This theory, variously modified, is that advocated by Hotfmann, Cullen, 
Hufeland, Jahn, Lobel, Holzhausen, Leroy, Goiter, Guibert, Breschet, Gardien, Bauer, Albers, 
Claras, Webster and Copland. Dr. Webster considers the affection of the respiratory organs 
as secondary, and dependent on a primary inflammatory irritation of the brain or of its 
membranes, or of both. Most of the advocates of the nervous theory regard the pneumo- 
gastric nerves as the primary seat of the afiection ; others, however, locate the irritation in 
tlie phrenic nerves — the principal of these are Jiiger, Lobenstein, Lobel and Leroy; others 
again, as Albers, of Bremen, Pinel, Laennec, Blaclie and Roe, refer the irritation to both the 
mucous membrane of the bronchi and the pneumogastric nerves. 

2d. Others consider the disease as an inflammatory affection of some part of the mucous 
membrane of the air-passages ^ this opinion numbers among its advocates, Darwin, Watt, Mar- 
cus Alcock, Dewees, Dawson, Pearson, Guersent, Fourcade-Prunet, Boisseau, Bjoussais, 
Eostan, and Duges. Dr. Watt believed it to be "in all cases, an inflammatory, w^iose chief 
seat is in the mucous membrane of the larynx, trachea, bronchi, and air-cells, possibly at- 
tended with a minute exanthematous eruption there."' He considers that, when mild, "this 
inflammation runs its course without materially disturbing the other functions of the body, 
or even the functions of that very membrane in which it is seated, and that whenever 
hooping-cough proves dangerous or fatal, it becomes so by the degree of inflammation in the 
natural seat of the disease, or by that inflammation extending or being translated to other 
parts." Most advocates, however, of the inflammatory origin of tlie disease, limit the in- 
flannnation to the trachea and bronchi — Dawson confines it, at first, to the larynx, or, strictly 
speaking, to the glottis — an opinion, by the way, not widely dilfering from that of Astrue, 
who of old describes the disease as an "inflammation of the superior part of the larynx and 
pharynx." 

3d. Many view the complaint as at first inflammatory, and afterwards spasmodic, or as 
a specific inflammation of the respiratory mucous membrane combined with irritation of the 
respiratory nerves, in consequence of which the muscles to which these are distributed are 
thrown into spasmodic action, which irritation continues after the inflammation has ceased. 



556 



HOOPING-COUGH. 



This doctrine, variously modified, is a favourite one with the writers on hooping-cough.—- 
Desnielles makes the disease to consist in a primary inflammation of the bronchi, compli- 
cated with a consecutive cerebral irritation, which, by its influence over the diaphragm and 
other respiratory. muscles, and over those of the larynx and glottis, changes the simple cough 
of bronchitis into one of a convulsive character. This opinion is the one adopted, also, by 
Dr. C. Johnson in his able article on hooping-cough in the Cyclopaedia of Practical Medicine, 
(Philadelphia Edition, vol. 2, page 453 :) other writers who admit the occasional presence of 
cerebral disease, consider them to be invariably secondary to the bronchial affection : of this 
opinion are Boisseau, Begin, Otto, and Vondembush. 

4th. By not a few, especially of the older medical writers, hooping-cough is referred to an 
irritation of the stomach and lungs. — Rosen, who supposed the disease to be produced by 
either an insect or a morbid poison, partly inhaled into the lungs and partly swallowed with 
the patient's saliva, considered that the stomach suffered more from the irritation than the 
lungs. Danz believed that the irritation' is seated primarily in the stomach and bowels, the 
affection of the respiratory organs being secondary — this opinion had been previously ad- 
vanced by Stoll, and is also that advocated by Chambon in his work " Des Maladies des 
Enfans." Tourtelle likewise describes the disease as a catarrhal affection of the lungs and 
stomach (^ajj^cdion pneumogastrique pituiteuse). Millot entertains a somewhat similar opinion ; 
he supposes, however, that the irritation of the stomach is secondary, and not so intense as 
that of the lungs and larynx. Opinions somewhat similar are maintained by Meltzer, Hol- 
defreund. Butler, Klinge and Strack. 

5th. The peculiar phenomena of the hooping-cough have been ascribed, by a few, to a 
physical or chemical irritant introduced into the larynx, either from without or after it has 
been engendered in the blood, or in the secretions of the respiratory organs. Under this 
head may be arranged the opinion of Linnteus, who referred it to the presence of minute 
insects ; that of Sydenham, who imputed it to a subtle and irritating vapour in the blood 
which affected the lungs, — that of Bohme, and Klinge, and also, partially, that of Rosen, 
who ascribed it to a peculiar miasm, acting chiefly on the nerves. Dr. Blaud, of the Hos- 
pital Beaucaire (^Revue ^edicale, March, 1831), considers the primary cause of hooping-cough 
to consist in an irritation, not inflammatory, of the mucous membrane of the bronchi, under 
which the glands and follicles of the membrane pour forth a specific secretion saturated 
with bydrochlorate of soda, the irritation caused by which, when it reaches the upper part 
of the trachea and larynx, throws the muscles of the glottis and of respiration into spas- 
modic action for its expulsion, in a manner exactly similar to any foreign body which acci- 
dentally enters the larynx. This theory of the disease Mr. Streeter. of London, in a paper 
read before the Physical- Society of Guy's Hospital, November, 1844, has adopted and zeal- 
ously advocated, "as the one most consistent with the phenomena observable in the symp- 
toms, loathology, and successful treatment of the disease," 

Mr. Streeter regards, however, the primary aff'ection of the bronchial membranes as in- 
flammatory, and believes that it will be found, on careful observation, to be attended by 
more or less fever of an analogous character to that which attends the influenza. 

The evidences of the truth of this theory upon which this gentleman places reliance are 
— "the testimony of adults, who have been attacked by the disease, to the unusual and ex- 
cessive saline taste of the exi^ectoration so long as the paroxysms are severe — the resem- 
blance of the expiratory eflbrts in the hooping-cough to those made by the excito-motory 
system for the expulsion of a foreign body from the larynx — the very adequate explanation 
it affords, both of the extraordinary and spasmodic muscular actions which accompany the 
cough, and of its occurrence in paroxysms after intervals of uncertain duration — and, lastly, 
the key which it furnishes to the chaotic host of apparently opposite remedies that have ob- 
tained professional or popular reputation in its treatment. Of these remedies, we find one 
group adapted to lessen the original bronchial affections, and favour the expulsion of the 
offending mucus — as emetics, antimonials, and counter-irritants applied over the chest; an- 
other which acts b}'' altering the quality of the secretion, as the alkaline carbonates, ammo- 
nia, and sulphuret of potass, so strongly recommended by Dr. Blaud himself; another, by 
exciting a new action in the bronchial membrane, and, by constringing the vessels, to put a 
stop to the secretion, in a manner perfectly familiar to the physician in chronic bronchitis, 
and to the surgeon in purulent ophthalmia — as the super-acetate of lead, alum, common 
resin, tine, cantharid., bals. copaiba, tar vapour, and even the inhalation of nitrous vapours, 
&c. Others, again, as musk, both native and artificial, camphor, arsenic, conium, belladonna, 
opium, and hydrocyanic acid, are more especially adapted for the nervous lesions; while 
antiphlogistic measures meet the inflammatory lesions of the third or cou^iplicated stage. 

" When, he remarks, the convulsive hooping is fully established, it very commonly hap- 
pens that symptoms which mark the third, or what may be appropriately termed the com- 
plicated stage, are developed, and continue to mark the varying and formidable phases of 
the disease which mostly attract attention in practice." These tertiary phenomena usually 
manifest themselves " 1st — as special lesions of the nervous and muscular systems — An 
exalted sensibility and morbidly susceptible state of the membrane of the larynx the pha- 



Hooping-cough. 



557 



vynx, the epiglottis, under which death from asphyxia may snddenly occur — Morbid associa- 
tion of the action of tlie muscles of the glottis and respiration, in consequence of which the 
cough continues from mere habit, or is reproduced by the most trivial irritation of the air 
passages — reflex irritation often passing into inflammation of the nervous centres of the 
pneumogastric nerves, involving those of the phrenic nerves also; and, Anally, tliese reflex 
affections may extend to the whole of the brain, or to the medulla oblongata and their 
meninges, and prove fatal by inducing general convulsions or hydrocephalus. All these, be 
it observed, are pathological conditions of the nervous system which have been so constantly 
put forward in high relief, by the advocates of the nervous theory, as proximate causes of 
the disease itself" A second class of tertiary phenomena include "the various congestive 
and inflammatory aflections that result from the mechanical disturbance of respiration and 
circulation, and the extension of the primary bronchial inflammation to the trachea, larynx 
and pharynx, and to the tissues of the lungs themselves. Epistaxis, haemoptysis, and fatal 
emphysema from extensive rupture of the air-cells, have occurred within my own expe- 
rience, and have apparently resulted from the mechanical violence of the cough acting upon 
tissues previously weakened by disease." A third class of tertiary phenomena "include 
fever and cachexia," which are ''present in individual cases in every conceivable variety of 
combination.'" — "In the absence of cerebral or pulmonary inflammation, the fever of the 
third stage is always asthenic, and often assumes a remittent type when the cachexia is of a 
marasmie character." 

For an account of the various lesions met with in the bodies of those who die of hooping- 
cough, the reader is referred to Condie on Diseases of Children, page 327. — C] 

The object of rational treatment in hooping-cough, supposing the disease to be 
simple, is to keep it simple: to keep it mere hooping-cough: to obviate serious 
inflammation or mischief in the chest and head : and, if possible, to mitigate the 
severity and shorten the duration of the fits of coughing. I have no notion that 
anything we can do in the beginning will materially abridge the duration of the com- 
plaint as it appears in its unmixed form. It wi/l, I say, in all probability, run a 
certain course ; and our business is to conduct it evenly and safely to the end of its 
course. For this purpose the diet must, in the first place, be regulated and reduced. 
The child should not be allowed to eat meat : the bowels should be kept moderately 
open; and the patient in cold weather should be confined to the equable tempera- 
ture of the house, or protected by warm clothing. You will find different persons 
employing and praising different plans of treatment ; the object in all cases, how- 
ever, being the same, viz., to ward off inflammation and to quiet irritation. One 
very good plan, as I believe, is that of giving a grain, or a grain and a half, of ipeca- 
cuan, three or four times a day. This generally keeps the bowels sufficiently open, 
and seems to have a beneficial operation on the mucous membrane of the air-pas- 
sages also. Or a few grains of rhubarb and ipecacuan may be given every night : 
and if the cough be very troublesome and urgent, small opiates may be administered : 
syrup of poppies : or the extract of hyoscyamus ; as many grains per diem as the 
child has years. There is a method recommended many years ago by a namesake 
of mine, which some people swear by. Sir William Watson's prescription was one 
grain of tartarized antimony and twenty drops of laudanum in an ounce of water. 
A teaspoonful, or a dessertspoonful, of that mixture was given every evening, or 
every other evening. I have heard the late Dr. Gooch say that his mother became 
famous as a village doctress by the help of that prescription. Foihergill's method 
M^as to give an emetic every day ; or three or four times a week : and this plan 
answers best, I believe, when the expectoration is scanty, and brought up with diffi- 
culty, and after much coughing. The best emetic substance in such cases is, doubt- 
less, ipecacuan. Mr. Pearson — who has had, I fancy, many imitators — used to give, 
after the operation of an emetic, one drop of laudanum, five drops of ipecacuan 
wine, and two grains of carbonate of soda, in a draught, every fourth hour, for 
several days. Under some such treatment as this, the disease will reach its termina- 
tion in from six to twelve weeks : and it frequently happens that when the child is 
quite well in all other respects, it still continues to cough. The cough would almost 
seem to be kept up by the mere influence of habit. Now, under these circum- 
stances, change of air will often remove the cough, as if by magic : and the shower- 
bath, and iron in some shape, will sometimes succeed, if change of air be not 
practicable. 

2w3 



558 



HOOPING-COUGH. 



There is a great variety of medicines lauded as specifics against hooping-cough : 
but they are not to be trusted to. Many persons think highly of the prussic acid, as 
a remedy for the paroxysms of coughing. Others employ and laud the extract of 
belladonna. But these are gigantic remedies to employ in such young subjects. If 
you give them at all, you must give them in very small quantities, and watch their 
effects. The artificial tincture of musk is another substance which some have found 
useful. Three or four minims of it may be given in the outset, and the dose in- 
creased till some sensible effect is produced ; and then the dose that has been so 
reached should be persisted in without further augmentation. I have been assured, 
by a most intelligent practitioner, that he had got considerable credit by prescribing 
this medicine, after other persons, with other modes of management, had failed. 
Digitahs, and cantharipes, are other, and I think, hazardous remedies. Safer drugs 
recommended, and, for aught I know, equally efficacious with these poisons, are 
cochineal, oil of amber, musk, camphor, and the meadow narcissus. Of late the 
carbonate of iron has been greatly praised by some of the continental physicians. 

[Horst recommends the flowers of sulphur as ahuost a specific in hooping-cough. He 
gives it throughout the disease, from its onset until its termination. Schneider, Roffy, Rand- 
han, Riecken, and others, confine its use to the more advanced periods of the attack. Jade- 
lot is said by Barthez and Rilliet to have derived the best effects from the sulphur as a 
remedy in hooping-cough, as well as in bronchitis unattended with fever. The sulphur is 
given to children between two and four years of age in the dose of from 6 to 8 grains, two 
or three times a day, and to older children in doses of from 15 to 20 grains, — in both cases 
the dose being gradually augmented. 

Assafoetida will be found a very excellent remedy in the spasmodic stage of hooping- 
cough. Dr. Lombard states that he has often known frictions to the spine with the tincture 
of assafoetida of great service, and we have found a plaster of assafcEtida applied to the 
chest promptly to relieve the cough, which is liable to remain after the more acute symp- 
toms have subsided. 

It is stated that M. Berger has found the following plan of treating hooping-cough jDarticu- 
larly successful. In the first stage, a moderate course of antiphlogistic remedies, jjurgatives, 
and repeated emetics of ipecacuanha in combination with tartar emetic. In the spasmodic 
stage, in which the indication is to quell the existing nervous irritation, being dissatisfied 
with the remedies ordinarily employed, he was induced to administer the nitrate of silver, 
from which he has obtained results singularly beneficial. He administers it in doses 
of from a sixteenth to a twelfth of a grain, at first three times, and afterwards four times a 
day. Of course the remedy should not be administered in cases where the state of the diges- 
tive organs contra-indicates its employment (^Annuaire de Therapeutique, 1846), 

Dr. Golding Bird remarks (^Guy's Hospital Reports, April, 1845), that, in the second or ner- 
vous stage of pertussis, after all inflammatory symptoms have subsided — and when, with a 
tolerably cool skin and clean tongue, the patient is still severely distressed by the more or 
less copious secretion of viscid mucus from the bronchi — each attempt to get rid of which 
produces the exhausting and characteristic cough — no remedy will be found to act so satis- 
factorily, or to give such marked and often rapid relief to the child as alum. He has not yet 
met with any other remedy which is equally eflicacious. Dr. Bird generally gives the alum 
in doses of from two to six grains to children of from one to ten years of age, repeated every 
four or six hours. For a child of tv/o or three hours he employs generally the following 
formula : — 

R. Aluminis gr. xxv ; extr. conii gr, xij ; syrup, rhasdos. ^ii j anethi ^iij. m. Dose a 
medium sized spoonful, every sixth hour. Dr. B, has never met with any inconvenient 
stringent eflTects on the bowels during its exhibition ; on the contrary, in more than one in- 
stance it produced, he says, diarrhoea. The only obvious efiects resulting from its use were, 
diminished secrection, and of a less viscid mucus, with a marked diminution in the fre- 
quency and severity of the spasmodic paroxysms. — C] 

External applications are also much in fashion in the treatment of hooping-cough. 
Frictions to the spine and to the chest ; and as counter-irritants, they probably are of 
some service. The tartarized antimony is the least innocent of these applications. 
It will often cause foul and very troublesome sores upon an adult skin : and till I am 
better advised than 1 am at present of its certain efficacy as a remedy for hooping- 
cough, no one (however authorized professionally liidere corio kwnano), should rub 
it upon a child of mine. Mothers are many of them fond of using Roche's Embro- 
cation for the hooping-cough. This (Dr. Paris tells us) consists of olive oil, mixed 
with half its quantity of the oils of cloves and of amber. 



PNEUMONIA. 



559 



Such is the plan of management which you will do well to enforce — -and such are 
the expedients which you may, if you please, make use of as auxiliaries to that 
plan — when the disease is mere hooping-cough. But when it becomes complicated 
with symptoms of inflammation wilhin the chest, or with head symptoms — (and for 
such symptoms you must jealously watch) — then you must employ antiphlogistic 
remedies (in addition to the antiphlogistic regimen) adapted to the circumstances of 
the case. Now we know that the bronchi, or the lungs, are affected with inflamma- 
tion, when we find that the child has fever, and that there is permanent dyspnoea 
between the paroxysms of spasmodic cough. In such a case we must have recourse 
to the treatment required in such inflammation : leeches to the surface of the chest, 
bleeding even from the arm, if the child's age and strength should warrant it, tartar 
emetic, small doses of nitre, the warm bath, and blistering; and to these measures, 
modified and combined according to the particular emergency, it will be well to add 
small and repeated doses of mercury : of the hydrargyrum cum creta, or of calomel; 
the state of the bowels determining which. Some have recommended friction with 
the tartar emetic ointment to the chest in such cases : but I have the same objection 
to it there, in such young patients, as to the spine. 

When any head symptoms come on, threatening hydrocephalus — such as squint- 
ing, convulsions, stupor — those remedies must be adopted which 1 endeavoured to 
describe to you when I spoke of that disease; leeches to the head, cold applied 
there, purgatives, the warm bath : but except in very young children, I believe there 
is more danger of fatal pulmonary changes in this disagreeable, and sometimes in- 
tractable disorder, than of cerebral mischief. 

I might pass, by a very natural transition, from the consideration of hooping-cough, 
to that of spasmodic asthma. But this last complaint is found to exist in connection 
with various organic changes within the chest, few of which have yet been treated 
of in these lectures. I shall, therefore, postpone what I have to say respecting 
asthma, till I have gone through some other thoracic diseases. And I now proceed 
to pneumonia, or inflammation of the substance of the lungs. Questions have been 
raised as to the precise part and texture in which the inflammation begins ; and to 
these questions I may briefly advert as we go on: but I hold that in pneumonia all 
the textures composing the pulmonary substance in the part inflamed are involved in 
the inflammatory process. 

Now of pneumonia it is especially true, that we ascertain its extent, its situation, 
and every step of its progress, by means of the ear. All the symptoms that give us 
the most sure information respecting the nature of the disease, the event to which it 
tends, and the remedial treatment which it requires, spring out of the actual changes 
wrought in the pulmonary substance itself; and these changes are disclosed to us by 
the method of auscultation. It is necessary, therefore, that you should understand, 
first of all, what those changes are which are produced by inflammation of the sub- 
stance of the lungs : that you should know the morbid anatomy of pneumonia, as 
an indispensable groundwork for a knowledge of its pathology. 

There are three well-marked, and very constant conditions of the lung, correspond- 
ing to different decrees and periods of its inflammation. I will describe them in 
succession, in the order in which they take place. 

The first stage or condition is that of engorgement : all modern observers agree, 
I believe, both as to the nature and as to the name of this condition. The substance 
of the lung is gorged with blood, or bloody serum. It is of a dark red colour ex- 
ternally, and crepitates less under pressure than sound lung does. We feel that 
there is more hquid than air in its cells. It is heavier also than natural, and inelastic, 
and retains, in some degree, the impression of the finger. When the engorged por- 
tion is cut, we find it red, and we see a great quantity of a reddish and frothy serum 
flow from it. Its cohesion is at the same time diminished ; it is more easily torn ; 
more, in that respect, like the spleen ; and accordingly the term splenizatioii of the 
lung has been given to this stage of its inflammation, as hepatization has to that 
which succeeds it. In this state of engorgement the mucous membrane of the 
small bronchial ramifications is of a deep red colour. The portions most engorged, 



560 



PNEUMONIA. 



althougii their specific gravity is increased, will nevertheless almost always float on 
water. 

Now it is necessary to caution you, in the outset, against a very frequent source 
of fallacy in respect to this condition of inflammatory engorgement. Such a state 
of the pulmonary substance as I have been describing, you will meet with in half, 
at least, of the dead bodies which you may have to examine ; and you must not 
necessarily infer therefrom that the persons deceased had injlammaiion of the lungs. 
There is almost always some degree of mechanical engorgement of the back part of 
the lungs ; or of that part which has been undermost during the last hours of life, or 
after death ; and the two kinds of engorgements can scarcely be distinguished from 
each other by their anatomical characters alone. Andral at one time held, indeed, 
that if the engorged part were more friable, more easily torn or broken down under 
pressure than natural, that was a sufficient evidence of its inflammation; but he 
afterwards saw reason to change that opinion. We judge by the situaJion of the 
engorgement sometimes : if it be not in a depending part of the lungs, it is surely 
inflammatory. We judge also by the antecedent symptoms. 

If the inflammation continues, the lung undergoes a further alteration, and presents 
the following characters. It is still red — externally and within : but it crepitates no 
longer under pressure ; and it sinks in water: it contains in fact no air. Its cut 
surface presents sometimes a uniform red colour; sometimes a slightly mottled or 
variegated appearance, produced by intermixture of specks of the black matter of the 
lung, and of the interlobular areolar tissue, which is less red than the other parts, and 
more than naturally obvious to the sight; but the spongy character of the organ is 
lost; it is evidently solid ; and the cut surface very much resembles the cut surface 
of the liver. Hence Laennec, and after him most other writers, have applied to 
this altered condition of the lung the term hepatization. There still flows out, 
under pressure, from the surface, when a fresh incision is made, some red fluid, but 
it is much less in quantity than in ihe former degree ; and it is not foamy ; and if 
the surface be gently scraped with a scalpel, you may often perceive in the red fluid 
so collected, some traces of a thicker and j'ellower matter, the first indication of 
commencing suppuration. The hepatized lung is denser and more solid than before, 
but it is also more friable ; more easily crushed and broken : and this results from 
the softening of the areolar tissue which holds its component parts together. 

If you tear a portion of hepatized lung, and examine the torn surface with a mag- 
nifying glass, the pulmonary tissue will appear to be composed of a crowd of small 
red granulations, lying close to each other. These are, I presume, the air-vesicles, 
clogged up, thickened, and made red, by the inflammation. As no air is contained 
in the lung in this stage of the inflammation, it follows that if the entire organ be 
involved in the disease, it will not collapse when the thorax is laid open ; and will 
therefore appear to be increased in bulk. It is swelled, in fact — ^just as other in- 
flamed parts are swelled — by the congestion of its vessels, and by the eflusion of 
blood, or of some of the constituent parts of the blood, into its hollows and inter- 
stices. The marks of the ribs are frequently visible on the surface of the distended 
lang. The texture of the lung in this condition is sometimes so rotten, that a mode- 
rate degree of pressure between the fingers will suffice to reduce it to a state of 
pulp ; and this diminution of consistence has made Andral quarrel with the term 
hepatization : and he proposes to call this second stage of pneumonia, red softening, 
ramollissement rouge. All this is very unimportant, provided that you recollect the 
sense in which either nomenclature is employed. But as Laennec and iVndral are 
both great authorities, and both have their disciples in this country, it is well thai 
you should understand their language. 

I have been speaking of pneumonia as it is apt to attack the whole, or the larger 
portion, or a considerable portion, of the lung on one side : but it is a curious cir- 
cumstance that the changes I have been describing are sometimes exactly hmited 
to certain of the pulmonary lobules ; and this state is called, accordingly, lobular 
pneumonia. 

In a degree still further advanced, the pulmonary tissue, dense, sohd, and imper- 
vious to air, as in the last stage, undergoes an alteration of colour ; it pre.sents a red- 



PNEUMONIA. 



561 



dish yellow, or straw, or drab, or stone colour ; or it is of a grayish hue, sometimes 
mottled with red, or with the black pulmonary matter. The httle granulations which 
I just now mentioned are whitish or gray, instead of being red ; and the texture of 
the lung is still more rotten and friable than before. It is full, in fact, of puriform 
matter, which is sometimes so abundant that it oozes out plentifully when incisions 
are made into the lung : or it may be made to exude by gentle pressure. The gray 
pus shows itself upon the cut surface in the form of minute drops. The more the 
pulmonary texture is soaked or drenched with this fluid, the softer and more friable 
it becomes. When crushed between the thumb and fingers, it is reduced to a yel- 
lowish gray pulp, exactly like the fluid itself, only rather more consistent. And by 
gently forcing the finger into any part of the parenchyma in this state, a small cavity 
may be made which soon fills with pus, and which might readily be mistaken for a 
recently formed abscess. 

Laennec has called this third stage of the process of inflammation in the lung, 
gray hepatization, or purulent infiltration.. Andral denominates it gray soflening 
— ramollissement gris. In fact, it consists in diffused suppuration of the pulmo- 
nary texture. And it is a very remarkable circumstance, and one which the re- 
searches of modern times have brought to light, that, in the lung, inflammation going 
on to suppuration does not lead to the formation of a circumscribed abscess, as it 
does when it affects the areolar tissue, or the parenchymatous tissue, in other parts 
of the body. Abscess of the lung used to be spoken of as a very common thing ; 
but it is a very rare thing. Ih several hundred dissections of persons dead of pneu- 
monia, made by Laennec during a space of more than twenty years, he only met 
with five or six collections of pus in the inflamed lung. Once only did he find a 
large abscess of that sort. Once only has Andral seen a real abscess of the lung 
form as a consequence of pneumonia. You may find collections of pus in the lungs, 
sometimes, occurring in connection with the inflammation of veins. Several in- 
stances of that kind have happened very recently in patients who have died in the 
Middlesex Hospital. But these are not ordinary cases of pneumonia. I need 
scarcely caution you not to take tubercular vomicae and cavities, containing pus, for 
genuine abscesses of the lung. These, and the phlebitic deposits of pus, are not 
exceptions to the general statement : they arise from different forms of disease : and 
you will find a circumscribed collection of pus, surrounded by hepatized lung, as a 
consequence of common pneumonia, to be an exceedingly rare- event. 

Can we account for this in any way ? I do not know that any satisfactory expla- 
nation of the fact has ever been offered. But I would submit to your consideration 
what has occurred to my mind on this subject. When I was speaking of inflamma- 
tion in general, I pointed out to you the remarkable influence which the presence 
of atmospheric air in contact with the inflamed part has in accelerating, or deter- 
mining, the event of suppuration. In a recent cut, the admission or exclusion of 
the air to the cut surface will make all the difference between the adhesive and the 
suppurative inflammation ; and so in other cases which I then mentioned, and will 
not now trouble you by repeating. Now it seems to me that the same principle 
obtains in inflammation of the lung. First, there is an effusion of serum and blood, 
then of lymph and blood ; but the air passing into the surrounding sounder tissue, 
and mingling for a time even with the inflamed portion itself, causes the suppurative 
process to supersede the adhesive ; and so no wall of circumvallation is formed by 
the coagulable lymph, as is the case in areolar tissue which is not accessible by the 
air. Whether this be a sufficient explanation of the/ac^ (all explanations being the 
resolving a given fact into a certain class of other facts more general and compre- 
hensive) ; I say whether it be a reasonable and satisfactory explanation, you will 
judge : at any rate it may serve to impress upon your memory that fact which it 
endeavours to elucidate. 

Gangrene is sometimes, but very seldom, *he result of acute inflammation of the 
lung. It is almost as uncommon as the formation of an abscess. Yet it certainly 
does now and then occur, as a consequence of acute inflammation of the pulmonary 
substance. It is somewhat more common (though under any shape rare) as an inde- 
pendent and primitive affection. Sometimes it occupies a large portion of the lung, 



562 



PNEUMONIA. 



and is un circumscribed ; and sometimes it is more limited. The colour of the part 
which has thus perished under inflammation is dark, of a dirty olive, or greenish-brown 
colour. The gangrenous portion is moist and wet ; sometimes of the consistence of 
the engorged lung; more commonly softer, and even diffluent; and it stinks most 
abominably. This horrible odour is in truth, during life, the most distinctive cha- 
racter of gangrene of the lung. It sometimes renders the room in which the un- 
happy patient is lying, scarcely endurable. I should have stated before that the 
puriform infiltration of the third stage of pneumonia is attended with no fetor. 

There are some other points, connected with, or learned from investigating, the 
morbid anatomy of pneumonia, which I may as well take this opportunity of tell- 
ing you, before we go on to consider the symptoms, physical and general, of that 
disease. 

There are two lungs, just as there are two tonsils, and two eyes ; and in the one 
case as well as in the other, inflammation may affect both organs at once, or it may 
affect one of them alone. Technically speaking, pneumonia may be either double 
or single. Again, the inflammation may occupy a part of one lung, or the whole 
of it : in other words, it may be partial or general ; but it does not affect all parts, 
or both sides, indifferently or capriciously. In the first place, it is (why I know not) 
greatly more common on the right side of the body than on the left. I will give 
you some statistical statements collected by Andral, in respect to this point. Of one 
hundred and fift3^-one cases of pneumonia, noticed at La Charite, ninety were of the 
right lung alone ; thirty-eight only of the left alone ; seventeen of both sides at once ; 
and in six the situation was uncertain. He v/as at the pains of collecting the parti- 
culars of fifty-nine other examples of pneumonia, from different authors, so fully de- 
scribed as to leave no doubt about the nature and situation of the disease. Among 
these, the inflammation existed in the right lung alone in thirty-one patients ; in the 
left alone in twenty ; and in both sides at once in eight. Hence, taking both series 
of observations together, we have two hundred and ten cases of pneumonia; and 
there were one hundred and twenty-one in which the right side was solely the seat 
of the disease ; fifty-eight in which the left ; twenty-five in which the pneumonia 
was double ; and six in which the seat was uncertain. So that, at this rate, pneu- 
monia is more than twice as common on the right side as on the left ; and does not 
occur on both sides together so often as once in eight times. 

Again, with regard to the part of the lung which is most obnoxious to inflamma- 
tion, there are remarkable differences. It is w^ell known, and it is a very important 
fact in respect to diagnosis in some cases, that the lower lobes are more hable to 
inflammation than the upper. I speak, of course, of active idiopathic inflammation. 
But this circumstance, much insisted on by Laennec, and quite true in the main, has 
perhaps been somewhat exaggerated. I have not had leisure to frame any numeri- 
cal statement of the cases that have come under my own observation, but the general 
impression which they have left upon my mind is in favour of the correctness of 
Laennec's statement — that pneumonia generally commences in the lower lobes, and 
spreads upwards frequently to the superior lobes. But I may adduce Andral's sta- 
tistical representation in respect to this question also. Of eighty-eight cases of pneu- 
monia, he found that the inflammation affected the inferior lobe forty-seven times, the 
superior lobe thirty, and the whole lung at once, eleven. 

Inflammation of the bronchi constantly accompanies inflammation of the paren- 
chyma. The mucous membrane presents a red colour, both in the large and in the 
small brartches of the air-passages. And when a single lobe is inflamed, it has 
been observed that the redness of the mucous membrane existed in those bronchial 
tubes alone which were distributed to that lobe. You may have bronchitis without 
pneumonia ; but pneumonia without a corresponding extent of bronchitis is perhaps 
never seen. 

The majority of cases of pneumonia are attended also with a degree of inflam- 
mation of the investing membrane of the lung: there is some pleurisy. So fre- 
quently indeed is this the case, that certain writers, Andral among others, call the 
disease by the compound name pleuro-pnmmonia. However, pneumonia may 
and does sometimes occur Avithout any concurrent pleurisy. Of the latter complaint 



PNEUMONIA 



563 



I must speak by itself; and I merely notice now the frequent combination of 
the two— the occurrence of a slight degree and extent of pleuritis in most cases of 
pneumonia — that you may the better understand some of the general symptoms of 
pneumonia. 

Now such being the changes which the lungs undergo when inflammation affects 
the pulmonary texture, we may next inquire what signals of its existence the inflam- 
mation holds out ; and how far we, not having the power of seeing what is going on 
within the cavity of the thorax, may nevertheless ascertain the important processes 
which are there transacted. 

If the ear be apphed to the surface of the chest, with or without the intervention 
of the stethoscope, and the portion of lung subjacent to that surface happen to be in 
the first stage of inflammation, that of engorgement, what does the lung, so sufTer- 
ing, say? what audible notice does it give of its morbid condition? Why, it speaks 
very plainly. You hear a peculiar crackling sound ; the smallest and finest-possible 
kind of crepitation : which has been happily illustrated by saying that it resembles 
the multitudinous little crackling explosions made by salt when it is scattered over 
red-hot coals. Andral has another resemblance for it, and not a bad one ; he says 
the noise is often like that which is produced by rumpling a very fine piece of parch- 
ment. Dr. Williams observes that a pretty correct idea of this sound may be 
obtained in a ready way, by rubbing between the finger and thumb a lock of one's 
own hair, close to the ear. Laennec calls this crepitant rhonchus : I would speak 
of it as minute crepitation ; or the crackling of pneumonia. This may be heard 
in a very hm.ited spot in the beginning. And what an important sound it is ! " It 
is a direct symptom, having immediate reference to the structure of the part. And 
(says Dr. Latham) if we consider what the part is, and what the disease ; the part 
the lungs, and the disease inflammation : we cannot too highly value this single 
symptom (simple and mean as it may seem), which gives the earliest and surest inti- 
mation that such a disease has begun, as tends to disorganization, and the inevitable 
loss of fife, unless quickly arrested by its counteracting remedy." 

At first, when you catch the inflammation in its earliest stage, this minute crepita- 
tion, which announces commencing engorgement of the part, is heard mingled with 
the ordinary vesicular breathing. This obscures the natural sound, though it does 
not yet entirely cover it — but as the inflammation advances, the crackling becomes 
more and more pronounced, until at length it totally supersedes it. So long as the 
natural vesicular breathing prevails over the crackhng, we may conclude that the 
inflammation is shght : and if the crackhng should, in its turn, become predominant, 
if it should ultimately mask the murmur of respiration entirely, that infallibly de- 
notes the progress of the pneumonia, and teaches us that it tends to pass from the 
first into the second degree. But the crackhng sound does not long remain in any 
part. As the case proceeds, the sound is less and less heard, and at length is not 
heard at all, in that spot; and it may be succeeded by one of two very diflerent 
things. Its place may be taken by the natural respiratory murmur again. When 
this is so, it denotes the resolution of the inflammation. But the crackling may 
cease, and either no sound at all be heard in its stead, or another morbid sound 
which I shah presently describe : and this teaches us with absolute certainty, that the 
disease is growing more severe and serious ; that the lung is becoming, or has be- 
come, hepatized. 

Let us inquire, for a moment, before we go any further, what is the nature and 
the seat of this minute crepitation, so characteristic of the commencement of pul- 
monic inflammation. With respect to its seat, I apprehend, there can be no question. 
It proceeds from the very smallest ramifications of the bronchi, and the air-vesicles 
themselves. The common opinion is, and such, I confess, is mine, that the sound is 
the same in cause and kind, only different in degree, with the large and small crepi- 
tation described in a previous lecture : that it results from the passage of air through 
liquid ; from the formation and bursting in quick succession of a multitude of httle 
air-bubbles. The bubbles are necessarily minute, for they are formed, and they ex- 
plode, in very slender tubes. This is Andral's view of the matter. Laennec does 
not appear to have -formed very clear notions on the subject. But a diflerent expla- 



\ 



564 



PNEUMONIA 



nation has been offered by a well-known and able writer on the auscultatory sigTis 
of disease, in this country : I mean Dr. Williams. He holds that the distended 
blood-vessels, and the interstitial serous effusion, press upon the minutest bronchial 
ramifications, and obstruct, without wholly preventing, the passage of the air through 
them : that these small tubes are lined by a viscid secretion, such as is expectorated, 
and such as I shall have to describe : that the sides of the tubes stick together in 
consequence of the presence of this viscid matter ; and that it is the separation of 
these adhering sides by httle portions of air which successively pass in and out, that 
gives rise to the characteristic sound. However, what it is important to remember 
is, that the crackling sound proceeds from the minutest divisions of the air-tubes, and 
from the ultimate vesicles of the lungs. 

Sometimes, I say, when this crackling ceases, the ear apphed to the corresponding 
surface of the chest, feels it heave up in inspiration, but catches no sound at all. 
Much more commonly, however, a new sound reaches the ear. It is not the vesi- 
cular rustle ; it is not the minute crepitation : but a whiffing sound is audible, like 
that produced hj blowing through a quill. Little gusts of air are puffed in and out ; 
most distinct, often, at the termination of a slight cough or hem. This is the sound 
to which the term bronchial respiration has been given: and the name expresses 
well the fact. I mentioned before that in the healthy state we do not hear the air 
pass through the larger bronchi during inspiration and expiration : the sound doubt- 
less is made, but it is obscured and hidden by the smooth rustle of the vesicular 
breathing, which comes from the spongy lung surrounding the large divisions of the 
bronchi, and intervening between them and the ear. But that spongy structure is 
now filled up. The hepatized lung admits air to pass through the larger bronchi, 
W'hich are still patent, but it admits none into the vesicles and smaller tubes. It cre- 
pitates not when pressed between the thumb and finger: in fact, it is converted into 
a sohd substance, and conducts the sound, in the living body, as any other solid sub- 
stance might do : and therefore the whiffing, blowing, gusty sound of the breath, 
as it enters and departs from the larger bronchial tubes, which still remain open, is 
conveyed to the ear, and bronchial respiration is heard. At the same time, and in 
the same place, another auscultatory phenomenon generally arises, and admits of a 
similar explanation. The voice of the patient descends into the pervious bronchi, 
and is conveyed to the ear of the listener through the solid lung: and it is quite 
altered by that circumstance. The tone of it is modified ; it sounds hke the voice 
of one speaking through a tube. It is totally different from the same voice heard 
through the healthy lung at the corresponding point on the other side. It approaches 
in distinctness and quaht}^ but it does not reach, the sound heard in -speaking, when 
the stethoscope is placed over the trachea. A humming and muttering are audible, 
but the words are not distinctly articulated into the ear. It is hard to describe these 
things in words. Three minutes, at the bedside of a patient in whom the bronchial 
breathing and the bronchial voice were tolerably well marked, would put you in 
possession of them for ever. They are striking sounds : requiring no fine tact to 
distinguish : and exceedingly informing sounds. But I must resume this subject 
when we meet again. 



LECTURE LI. 

Pneumonia continued; its general symptoms ; pain, dyspnoea, cough, expectora- 
tion. Course of the disease. Prognosis. Treatment. 

I WAS describing, at the close of the last lecture, the auscultatory signs which lead 
us to the knowledge that the inflamed lung, in a case of pneumonia, has passed from 
the first into the second stage of inflammation, and become sohd, or hepatized. The 
altered condition of the organ gives rise to altered sounds. Instead of the vesicular 



PNEUMONIA. 



565 



breathing, which is the natural sound, or of the minute crepitation, which is the 
sound belonging to the first stage of the inflammation, we either hear no sound at 
all, although we feel the chest heave up against our ear, or we hear what I described 
under the denomination of bronchial respiration; that is to say, a puffing sound 
which is conveyed to the ear from the larger and still pervious branches of the bron- 
chi, through the sohd portion of the lung around them, and through the sohd walls 
of the chest. This is what the listener hears when the patient breathes. And when 
he speaks, his voice is heard, much more resonant than is natural, much more reso- 
nant than in the corresponding spot on the opposite side of the chest, entering the 
same open air-tubes, and conducted to the ear by the dense and sohd lung. We thus 
become acquainted with two entirely new sounds ; sounds which are never heard in 
the healthy state of the lur^s ; bronchial respiration, and bronchial voice, or bron- 
chophony ; and you will do well to remember these two sounds, and to familiarize 
your ear to them; for they speak a most significant language in other pulmonary 
diseases, as well as in pneumonia. 

But I say, sometimes we hear these morbid sounds, in the case in question, and 
sometimes we hear no sound at all during the breathing. How is that? Why, the 
existence and degree of the bronchial respiration, and bronchial voice, vary accord- 
ing to the place and extent of the inflammation. These morbid sounds are most 
plainly marked, where the number and size of the bronchial tubes involved in the 
hepatization are the greater. They are most distinct, therefore, when the inflamma- 
tion occupies the upper part of the lung ; or the central parts, what are called the 
roots of the lungs : and when it extends thence to the surface : but when the lower 
portions alone are inflamed, or the inflammation is merely superficial or partial, they 
may not be heard at all. Again, if the hepatization should be so general and com- 
plete as to prevent the chest, on the affected side, from expanding, you will, in that 
case, hear no bronchial respiration ; for the air in the large bronchi must be stagnant. 
Bronchophony, however, may remain. 

When we have the bronchial respiration, usually also we have dullness on per- 
cussion. The degree in which this is present will depend upon the circumstances 
of the case. If a portion of crepitant and permeable lung, even a thin portion, should 
intervene between the inflamed parts and the walls of the chest, there will still be 
resonance, though it will not be exactly the natural resonance, on percussion. If the 
hepatized part come close up to the ribs, the sound elicited by mediate percussion 
will be flat, or dtad. With all this, you will generally hear, in the sound lung, if 
the whole of the other be engaged in the inflammation — or in those parts of the 
inflamed lung that are healthy — you will hear, I say, puerile respiration ; and this 
is a strong confirming symptom that a part of the breathing apparatus is spoiled, and 
that the remaining part is endeavouring to compensate for its deficiency. 

Now, this period in pneumonia, when no sound but bronchial breathing is audible 
during respiration, is a period of anxious and painful interest. We cannot tell whe- 
ther the lung will revert gradually to its healthy state, or whether it is passing into 
the third stage ; that of purulent infiltration. But taking first the most favourable 
of these two suppositions — what happens ? Why, there, where for a while we heard 
nothing but bronchial respiration, a slight crepitation begins again to be distinguish- 
able, especially at the end of each act of inspiration: gradually this increases in ex- 
tent and intensity, and, as it increases, the bronchial breathing and the bronchial 
voice become proportionably less distinct, in consequence of the texture of the lungs 
becoming again permeable by air, and therefore a worse conductor of sound. By 
degrees, the bronchial breathing and the voice disappear akogether ; the vesicular 
murmut begins again to mix with the crepitation, and at length supersedes it ; and 
the lung is restored to its previous fitness for the purposes of respiration. The same 
symptoms therefore recur, over again, but in a reversed order ; the returniiig crepi- 
tation is, however, coarser and larger, and less regularly diffused, than that of the 
advancing pneumonia : and even when nothing is heard in the ordinary condition 
ef the breathing but the natural vesicular rustle, some crepitation is found for some 
little while to mingle with it, towards the end of a full inspiration. This is beheved 
to depend upon an oedematous state of the pulmonary texture, left after the active 

2x 



566 



PNEUMONIA. 



inflammation has been displaced. Next, let us take the worst of the two supposi- 
tions. Auscultation has traced the disease through its stage of engorgement, and 
into its stage of hepatization. Can it trace it further ? I believe not, with any cer- 
tainty. We cannot say vv'hether the lung remains in the state of hepatization (as it 
may remain), or whether it has passed into the third stage. But at last, if the struc- 
ture of the lung breaks down, and a portion of it is expectorated, air finds its way 
into the vacant spot, and gives rise to large gurgling crepitation. But the other signs 
sometimes come to our aid when this state has been reached. 

We often find, after death, the three degrees of pneumonia existing in different 
parts of the sam.e lung; and therefore it is not to be wondered at that the different 
parts of the chest should during life yield sounds indicative of each of those degrees, 
or at least of the first two ; minute crepitation here, brotichial breathing, and bron- 
chophony, and dullness on percussion there, and in another spot no sound at all, or, 
on the other hand, puerile respiration. 

Again, it must be confessed — and I am desirous of confessing it, for I am sure that 
the method of auscultation is brought into undeserved suspicion and disrepute by 
attempts made to assert its all-sufiiciency in all cases — it must be confessed that, in 
some instances, although pneumonia exists, the ear is able to collect nothing of it ; 
nothing indicative of its situation, or of its extent, or even of its existence. The 
pulmonary expansion is clear, all over the thorax; nay, much more strong than is 
natural : and this circumstance justifies the behef that, from some cause or other, 
not necessarily from pneumonia, a portion of the lung has ceased to discharge its 
function, and the other portions have taken it up. This failure on the part of aus- 
cultation happens when the inflammation occupies only a small portion of the lung, 
and that portion central, or deeply situated — at a distance from the walls of the chest. 
For this reason, auscultation miay give little or no account of lobular pneumonia. 

Such are, then, the physical signs that accompany and reveal the successive 
changes of texture, destructive and reparatory, which take place in inflammation of 
the lungs. I do not know whether I have made them clear to you ; but I know that 
no very long apprenticeship, if I may so speak, in the wards of a hospital, will be 
sufficient, with a httle guidance, to render you master of them. There are indeed 
varieties, and modifications, and exceptions, which nothing but such an apprentice- 
ship can ever teach you. Of these it would be idle and unprofitable for me here to 
speak : and I go on to consider the general signs of pneumonia ; some of which, 
either in themselves, or in combination with the physical signs, afe of no less im- 
portance than these. 

In the majority of cases the commencement of inflammation of the lung is marked 
by shivering, followed by heat and increased frequency of pulse ; in one word, by 
inflammatory fever ; and at the same time, or presently after, a stitch in the side 
comes on, with cough, and a sense of oppression in the chest. In other instances 
the disease steals on more insidiously, and succeeds to bronchitis ; the inflammation 
appearing to propagate itself by httle and little from the larger to the smaller 
bronchi, and ultimately to reach the air vesicles themselves, and the interstitial tex- 
tures ; and this may be accomplished with or without the sharp pain or stitch in the 
side. At first the cough may be dry, but it soon is attended with a very characteristic 
sort of expectoration. The dyspnoea is sometimes but slight in the outset ; some- 
times severe. 

Apart, therefore, from the physical signs, we may say that the usual symptoms 
of pneumonia are pain, more or less severe, on one side of the chest ; dyspnoea ; 
cough ; a peculiar expectoration ; and fever. 

The pain in pneumonia appears to exist only in those cases in Avhich the inflam- 
mation of the lung is accompanied by some degree of pleurisy. But these are the 
most numerous cases. It is most commonly experienced on a level with, or a little 
below, one or other breast ; but it may exist in almost any other part of the thoracic 
parietes. Generally it is most severe at the beginning, dechnes by degrees, and 
ceases altogether for some time before the pneumonia ceases. It is aggravated by 
cough ; by a full inspiration ; often by sudden changes of posture ; by pressure made 
upon the ribs or intercostal spaces ; or by percussion of that part. For the same 



PNEUMONIA. 



567 



reason the patients cannot lie on the painful side. Andral declares that in all the 
individuals in whom he had noticed this pain, and who died, he found the pleura 
inflamed, and covered more or less with coagulable lymph ; and, on the other hand, 
that he had constantly known the absence of pain coincide with a sound condition 
of the pleura. When there is no sharp pain, there is, however, some morbid sensa- 
tion, of trouble, or tig-htness, or weight, or heat on the affected side. He quotes, with 
approbation of its justness, the ancient observation respecting pneumonia: — " Affert 
plus periculi quam doloris." When I come to speak of pleurisy as a distinct and 
substantial affection, I shall revert to this pain. 

It is, or it was, a common doctrine, that one of the general symptoms of pneu-. 
monia relates to the posture which the patient assumes ; that the decubitus, to speak 
technically, is on the side affected. The truth, however, is as I have just now stated 
it. The breathing, indeed, is more oppressed when the patient lies on the sound 
than when on the diseased side ; but, in point of fact, patients labouring under this 
disease almost all lie upon their backs: the decubitus is dorsal. The difficulty of 
breathing deserves some notice. _ In general it bears a direct proportion to the extent 
and severity of the inflammation. But there are many exceptions to this. In some 
persons the inflammation of even a very small portion of one lung will embarrass the 
respiration greatly. In others, who have a much larger portion of the pulmonary 
tissue intensely inflamed, the dyspnea is but slight. So that the degree of difficulty 
of breathing is not a certain measure of the seriousness, or rather of the extent and 
the degree, of the inflammation. It is probable, that if we knew of what kind was 
the ordinary breathing of the individuals thus differently affected, we should find that 
they whose respiration is generally indistinct, or noiseless, who do not seem to ivant 
all their lung for the purpose of breathing, would best bear to have a part of it in- 
flamed ; diuA vice versa. Cseieris paribus, inflammatfon of the upper lobe causes 
greater dyspnoea than inflammation of the lower. I may observe further with respect 
to dyspnoea in general, that you must not trust implicitl}'- to what patients tell you 
on that head. They will often deny that they have any shortness of breath, when 
one may see them respiring with unnatural rapidity, or observe that, in their dis- 
course, they pause between every three or four words to take breath. 

However, the dyspnoea produced by pneumonia varies greatly in its degree in 
different cases. Sometimes it is so slight that the patient is not conscious of it, and 
the physician scarcely perceives it: sometimes it is so extreme, that the patient, 
entirely regardless of what is going on about him, seems wholly occupied with 
respiring; is unable to lie down ; can scarcely speak ; his face becomes hvidly red 
or pale, and is expressive of the utmost anxiety ; his nostrils are expanded, and in 
full action : the respiratory movements are very frequent and very short or shallow, 
as if the air was not able to penetrate beyond the primary divisions of the bronchi. 
From this state of extreme dyspncea few patients recover : and between this, and 
the slightest hurry or embarrassment of the breathing, there are of course many 
degrees. 

Delirium is a symptom which very frequently occurs in the course of an attack 
of pneumonia ; and a very ugly symptom it is. It denotes that the due arterializa- 
tion of the blood is largely interfered with by the pulmonary affection. It measures, 
in one sense, the quantity of mischief which is going on within the thorax : and it is a 
direct evidence that the pectoral mischief is telling, through the circulation of venous 
blood, upon the brain. 

The cough, in pneumonia, has no particular character, and affords but little infor- 
mation. It does not usually take place in paroxysms; and its severity and frequency 
are not always proportioned to the intensity and extent of the inflammation. It is 
usually dry in the outset ; but in a few hours it is accompanied by the expectoration 
of peculiar sputa, which constitute one of the most certain indications of the pre- 
sence of pneumonia : and as this is a symptom vvhich every one can easily recog- 
nize, I will describe this characteristic expectoration, and endeavour to explain the 
cause of it. 

The expectoration of pneumonia, when well marked, consists of transparent and 
tawny or rust-coloured sputa, uniting, in the vessel containing them, into one jelly- 



m 



PNEUMONIA. 



like and trembling mass ; and of such viscidity that the vessel may be turned upside 
down, and strongly shaken, without their being detached from its bottom or sides. 
It cannot be said that when there is no such expectoration as this, there is no pneu- 
monia : but it may be affirmed that where we do find such expectoration, there almost 
certainly w^e have pneumonia. At the outset of the disease, either nothing is spat 
up, or simply some bronchial mucus : but on the second or third day generally, the 
matters expectorated assume the characteristic appearance : i. e., they come to be 
composed of mucus, intimately united and combined with blood. It is not that the 
sputa are streaked with blood, as often happens in bronchitis: nor have we the un- 
mixed blood of haemoptysis. But the blood and the mucus are amalgamated toge- 
ther ; and in proportion to the quantity of the former, the sputa become of a yellow 
colour, or of the colour of rust, or of a decided red : and at the same time they be- 
come glutinous and tenacious : they adhere together, so as to form one transparent 
homogeneous mass. So long as this mass flows readily along the sides of the vessel 
when it is tilted, so long have we reason to hope (judging from that circumstance 
alone) that the inflammation of the lung does not pass its first degree. But, as I said 
before, the sputa often acquire an extraordinary degree of viscidity: so as no longer 
to separate themselves from the vessel when it is inverted : you cannot even shake 
them out. When this happens, we are obliged to fear that the pneumonia reaches 
its second degree. In fact, when the sputa become thus rusty and very viscid, the 
stricken chest almost always returns a duller sound, and the vesicular breathing is 
abolished, and bronchial respiration takes its place. The pneumonia is ther; at its 
acme ; and the expectoration remains for some time stationary. At length, if the 
inflammation recedes, the sputa become again less tenacious, less red or yellow, and 
more hke the expectoration of mere catarrh. But if the disease goes on from bad to 
worse, the rust-coloured sputa may continue to the end. Commonly there is less 
expectoration in that case, or even none at aH. Not that the mucus ceases to be 
secreted, but that its excretion is no longer possible : either on account of its extreme 
tenacity, or on account of the patient's debility. The sputa then accumulate in the 
bronchi, trachea, and larynx, in succession : they fill up the air-passages, and suffo- 
cate the patient. In some instances the expectoration, in the advanced stages of the 
disease, consists of a fluid having the consistence of gum-water, and of a brownish- 
red colour: like (as Andral says) liquorice-water, or plum-juice. He states that the 
mere occurrence of this kind of expectoration has led him to announce the existence 
of the third stage of pneumonia ; and that the subsequent examination of the dead 
body has seldom failed to justify his diagnosis. Sometimes again, during the third 
sta^e, very perfect pus is excreted. 

That the colour of the sputa peculiar to pneumonia depends upon an intimate 
union of blood with the altered mucus, is perfectly obvious when that colour is deep. 
And even when this transparent mucus is yellow, you may satisfy yourselves by the 
following simple experiment that the source of the colour is the same, and that the 
yellowness does not result, as some have fancied, from an admixture of ^i/ewith the 
matter expectorated : — If to water, rendered viscid by dissolving a certain quantity 
of gum in it, you add blood, drop by drop, you will obtain, in succession, all the 
shades of colour that are presented by the pneumonic sputa: first a yellow tinge; 
then a tawny yellow U'hich loses itself in a red, and comes to represent the colour 
of the rust of iron; and lastly an intense red. The sputa may indeed, sometimes, 
but I believe that does not often happen, be -coloured by bile ; but bile is not the 
source of the yellowness which they assume in cases of pneumonia. 

Sputa composed of very red mucus, indicate pneumonia less surely than such as 
are tawny. The very red masses, in which there is more blood than mucus, often 
belong to pulmonary apoplexy. 

Although these rust or orange-coloured sputa are commonly present during the 
more active period of pneumonia, and, as far as my experience goes, are pecuhar to 
that disease, you ought to be aware that they do not constantly accompany it. Some- 
times the matters expectorated are like those of catarrh : and sometimes there is 
scarcely any expectoration at all. 

When the pneumonia passes into gangrene — which I repeat is an exceedingly 



PNEUMONIA. 



rare consequence of inflammation in that organ, — the expectoration becomes of a 
greenish, or reddish, or dirty gray colour ; and exhales a fetid smell, resembling that 
which proceeds from gangrene of the external parts. 

I have now described, seriatim, the main symptoms, general and physical, which 
mark the existence and the progress of pneumonia. And in order to give you a just 
notion of each, I have spoken of them separately. But they exist together ; and 
they must be studied together : and some will be found to confirm or to correct the 
indications that might be drawn from the others. I must briefly therefore run over 
the phenomena of the disease we have been considering, as it actually presents itself 
in most cases. 

The first symptom felt is commonly pain in the side, which may or may not have 
been preceded by rigors. At the same time the breathing is constrained; and the 
patient coughs without expectorating. At this period, the ear may generally detect 
"a slight degree of minute crepitation, which is not strong enough to mask entirely 
the vesicular rustle; and the stricken thorax still sounds well : and there is fever 
withal. This assemblage of phenomena constitutes the first period of the disease. 
From the second to the third day, new symptoms appear. The expectoration, 
hitherto absent, or merely catarrhal, becomes characteristic ; being at first moderately 
viscid, and having a degree of colour proportioned to the variable quantity of blood 
which it contains. The minute crepitation increases, and drowns or supersedes the 
natural respiratory murmur: the clear sound produced by percussion begins to 
diminish on that side on which the crackling is heard and the pain is felt ; and that 
pain is commonly less sharp than in the beginning. The dyspnosa increases, as is 
quite apparent from the short and frequent inspirations made by the patient. If the 
pain be acute, he cannot he, on that account, on the side afiected ; neither can he 
place himself on the sound side, because in that position his respiration becomes 
more laborious ; he remains, therefore, almost constantly, lying upon his back. 

In this condition of pneumonia, though the disease may be severe, the inflamma- 
tion is as 3''et in its primary stage. It often remains stationary for a while, and then 
recedes, and terminates by resolution. The dyspnoea diminishes, the slight dullness 
of sound disappears, the crackling is gradually displaced by the natural murmur of 
the pulmonary expansion, the sputa again become those of simple bronchitis, the 
fever subsides, and ceases ; and all is well again. 

At other times, instead of retrograding towards resolution, the pneumonia becomes 
more intense, or rather more extensive, without passing beyond its primary stage ; 
and the patient may die while it is still in that stage. But this is unusual. Ordma- 
rily, if the inflammatory engorgement does not cease by resolution, and the symptoms 
that announce it are exasperated, we must expect that the second stage will be 
estabhshed. And we may be certain that it exists w^hen we observe the following 
phenomena: — the breathing becomes more and more constrained, short, accelerated; 
the speech ceases to be free ; the patient can do no more than pronounce a few in- 
terrupted words in a panting manner. The sputa acquire such a degree of viscidity, 
that they can no longer be detached from the vessel by shaking it ; the sound afforded 
by percussion, on the side affected, is decidedly dull: at first we still hear a little of 
the minute crepitation, without the admixture of any pure vesicular breathing; then 
that little crepitation ceases, and either no sound at all is perceived by the ear, or, in 
the part where the percussion is dull, bronchial respiration is heard, and this is 
almost always accompanied with bronchophony. The patient continues to lie on 
his back. 

In this degree of the disease the prognosis is always uncertain. The patient often 
sinks rapidly, and dies from apncra. Yet even in this degree resolution may still 
take place. In that case the dullness on percussion diminishes ; the bronchial 
breathing disappears ; we hear afresh the small crepitation, at first alone, then mixed 
with the natural respiratory murmur, which, in its turn, becomes alone audible. The 
sputa return to their catarrhal character. In the meanwhile the dyspnoea and fever 
diminish, and then cease entirely. 

It would doubtless be very interesting to determine, in a given case, whether the 
lung of our patient was in the second or the third stage of inflammation. But there 

2x^3 



570 



PNEUMONIA. 



are no certain means for making this distinction. We may guess that the third 
stage is estabhshed if the face becomes exceedingly pale and corpse-like : we may 
be more confident of it if the prune-juice expectoration should occur ; and our pre- 
sumption wilJ be strengthened if the disease has existed for a certain time. How- 
ever, this last circumstance will not help us much ; for sometim.es the lung has been 
found to be in a state of suppuration on the fifth day of the disease, and sometimes 
it has been found in a state of red hepatization after fifteen or twenty days. 

Whether, when the lung has reached this third stage, it is still susceptible of 
repair, is a question which no one can answer. We have not the materials for 
its solution, inasmuch as we have no sure sign of the existence of this third stage 
during life. I should think that recovery from diffused suppuration of the lung is 
not possible. The rarer form of circumscribed abscess certainly is not of necessity 
fatal. 

The duration of pneumonia may be laid, upon an average, at ten days. In a 
table collected by Andral for another purpose, viz., to determine whether there were 
any fixed critical days in respect to the termination of the disease (a question which 
I shall not now discuss), the duration, in 112 cases, varied from four days to six 
weeks. But one only was thus protracted ; 23 cases lasted each seven days ; and 
only 15 of the 112 instances continued longer than a fortnight. 

I have very little to add to what I have stated already of the morbid anatomy of 
pneumonia. Of the changes which the lung itself undergoes you are now I hope 
fully apprized. The pleurisy, which often attends the disease, is seldom accom- 
panied by much effusion ; indeed, when the whole of one lung is solidified by in- 
flammation, it fills the cavity of the pleura, and prevents much effusion. The heart 
is found to be in that condition which I formerly described to you, as being both a 
consequence, and an index, of death by apncea. Its right cavities especially are dis- 
tended by black coagulated blood ; and a remarkable degree of venous congestion is 
frequently met with in the liver, and spleen, and intestines. The amount of this 
varies according as the process of dissolution — what the French calf the agony — has 
been more or less protracted, and the breathing more or less difficult. 

Neither need I enter upon any formal discussion of the causes of pneumonia. 
Sometimes no cause can be traced ; sometimes the disease is clearly the consequence 
of exposure to cold ; especially under those circumstnces which were formerly de- 
scribed as aiding the injurious operation of cold upon the human body. Why, in 
one person, such exposure causes peritonitis, in another pleurisy, and in a third in- 
flammation of the substance of the lungs, we can give no satisfactory account. 

It remains, then, only that I should speak, first of the prognosis, and secondly of 
the treatment, of pneumonia ; and of the first of these matters, of the prognosis, I 
have already, incidentally, told you nearly all that is made out, or worth knowing. 
It is almost superfluous to say that the first degree of the disease is less dangerous 
than the second, and the second than the third. There is no doubt that pulmonary 
inflammation may still undergo resolution, although a great part of one lung should 
be hepatized ; but there are no facts which prove — indeed there is no possibility of 
proving — that the lung may recover from the state of purulent infiltration — the third 
degree. 

Something w^ill depend upon the extent of the inflammation ; I mean that pneu- 
monia in the first degree and of great extent, is generally as serious as pneumonia 
in the second degree but much more circumscribed. Inflammation of the upper 
lobes is also more perilous than inflammation, to the same extent and degree, of the 
lo"wer. • 

Of the general sym\)ioms, those which we learn independently of auscultation, the 
respiration, as a prognostic sign, is the most important. Considerable dyspnoea, 
whatever may otherwise be the condition of the lung, is always a bad omen. We 
get less help from the state of the pulse. If, however, a feeble pulse goes along with 
great diflicuky of breathing, and if it does not develop itself after the first bleeding, 
we must conclude that the inflammation is intense, and form therefore an unfavourable 
prognosis. The supervention of delirium is also a discouraging circumstance. You 
will have inferred already the information which may be gleaned from the character 



PNEUMONIA. 



571 



of the expectoration, in respect to the probable issue of the disease. Great viscidity 
of the sputa, and a deep rusty colour, announce intensity of inflammation : their 
return to the catarrhal condition indicates that resolution is going on. Watery and 
brownish sputa, more or less like plum-juice, should induce us to suspect suppura- 
tion of the lung, and are therefore of bad augury. 

The great instruments to be employed in the treatment of inflammation of the 
lungs, are the same which have so often been recommended by me, in other inflam- 
matory affections, before: blood-letting, tartarized antimony, mercury. Of these, 
blood-letting is the chief. Both reason and experience attest the especial power of 
bleeding upon acute pneumonia. In the first place it tends to restrain or extinguish 
the inflammation as inflammation. But, in the next place, it has the effect of re- 
lieving the particular function of the lungs. The more blood is sent to them in 
excess, the more dyspnoea must there be, the more venous blood passing into the 
arteries, as well as the more risk of the effusion of lymph and the obliteration of the 
cellular texture of the organ. When we bleed, therefore, in pneumonia, we kill 
two birds (as a phrase is) with one stone. We do that for the lung, which we do 
for an inflamed eye when we darken the room, or for an inflamed joint when we 
keep it absolutely at rest ; i. e., we do all that we can to spare the exercise of the 
organ, and to prevent aggravation of the inflammation from that cause. And the 
result of the free abstraction of blood in this disease, fully vindicates the value of a 
practice which has been pursued for ages. The late Dr. Gregory, of Edinburgh, 
v/as in the habit of saying, in his lectures, that provided he was called early to a case 
of pneumonia, he would be contented to dispense with all other aids than those of a 
lancet, and water-gruel. I am far from desiring you to believe that blood-letting is 
the only expedient required ; but certainly the amount of the best experience, ancient 
and modern, is strongly in favour of its free, and I might almost say, prodigal, employ- 
ment. Very lately, one most distinguished French writer, PvL Louis, has endeavoured 
to show that venesection has not much control over the progress or event of pneumonia ; 
and I advert to his opinion on this subject merely to caution you against being misled 
by it ; as you might otherwise be, considering his well-merited reputation as an exact 
and faithful observer. 

1 can only lay down general rules and indications with respect to the manner and 
amount of blood-letting in this disease, or in any other disease. The abstraction of 
blood will be effectual, ceteris paribus, in proportion as it is early ; during the first 
stage — the stage of engorgement — and before the spongy texture of the lung has 
been obliterated. The patient should be bled in an upright position, by a large orifice 
and in a full stream ; and the. bleeding should be continued until some sensible im- 
pression is made upon the system : until the pulse becomes softer ; or, if it were con- 
tracted, until it becomes fuller until the sensation of constriction is abated, and the 
dyspncea relieved ; or until syncope appears to be at hand. 

Bleeding, in this early stage, often gives very speedy relief, both to the pain and 
to the dyspnoea. Sometimes the pain does not cease at once, but goes off" a few 
hours afterwards ; but I believe that if the breathing be not at all relieved at first, the 
case generally (though not always) ends ill. However, you are not to expect that 
one blood-letting will suffice, even when it is performed early in the disease. Such 
a favourable case may happen, but not often. The patient should always be seen 
within four or five hours from the period of the first venesection, that a timely repe- 
tition of it may take place, if the relief has not been complete, or has not been per- 
manent. Many fatal cases have probably been fatal from want of this attention ; from 
too long an interval having been suffered to elapse between the bleedings. A vein 
may be opened, if necessary, two or three times in the twenty-four hours ; and 
the ultimate loss of strength, and even loss of blood, will be less under such treatment 
than if the blood-lettings were repeated at longer intervals ; and the necessity of the 
repetition must be judged of from the circumstances of the case. As an auxiliary to 
the lancet, f am much in the habit of taking blood from the surface of the chest itself, 
by means of cupping-glasses, or of a large number of leeches. I beheve that much 
good is done by this local emptying of the blood-vessels. It is particularly indicated 
if there be pain ; and the part to which the leeches or cupping-glasses are applied 



572 



PNEUMOxNIA. 



should be determined by the situation of the inflamed portion of lung, when that 
' is ascertained by the ear. I scarcely need say that the whole of the antiphlogistic 
regimen must be rigidly enforced ; that the patient must keep his bed ; and that all 
superfluous exertion of his lungs in speaking must be forbidden. 

When the inflammation has advanced into the second stage, w^e cannot expect that 
the removal of blood will have so decided an influence upon the inflamed and solid 
parts; but even then, if duly moderated, it will have these good consequences: it 
will diminish the force of the heart and arteries, and so tend to prevent the exten- 
sion of the inflammatory process ; it will lessen the whole quantity of blood circu- 
lating through those portions of the lung which are still pervious, and thus reHeve 
dyspncEa ; and it will put the system at large into the condition most favourable for 
the reabsorption of the lymph by which the air-tubes and vesicles of the affected 
parts have been blocked up. 

But a time arrives when bleeding is no longer of use, or when it is positively 
hurtful ; when it ceases to have any good influence on the local disease, and has an 
injurious influence on the whole system ; reducing the patient's strength, and inca- 
pacitating him for bringing up, and ridding his lungs of, the tenacious mucus 
exhaled by the bronchial membrane. This is what takes place in those cases in 
which the expectoration is said to be stopped by a bleeding. I have mentioned Dr. 
Gregory's reliance on blood-letting for the cure of pneumonia; and I ought to tell 
YOU at the same time what I have been informed respecting the result of his prac- 
tice. He " used to bleed to the verge of convulsion. His colleague. Dr. Rutherford, 
seldom went beyond three bleedings, and generally accomplished his object by two, 
judiciously timed and measured. His patients recovered quickly ; Dr. Gregory's 
very slowly." 

We want some remedy, therefore, to assist the lancet, or to employ alone when 
the lancet can do no more ; and we have two such, in tartarized antimony, and in 
mercury. The tartar emetic plan I believe to be the best adapted to the first degree 
of the inflammation — that of engorgement ; and the mercurial plan to the second — 
to that of hepatization. 

I need not tell you that the tartarized antimony is not given in this disorder with 
the object of producing vomiting. It is a very curious thing that although, when 
administered in a considerable dose, its first effect is usually sickness, followed, per- 
haps, by purging, a repetition of the same dose is, in the m.ajority of cases, at length 
borne without any further vomiting. The stomach comes to tolerate the medicine, 
as our continental brethren say ; and then its beneficial influence upon the disease 
is no less marked than when nausea and retching take place. Some patients do not 
vomit at all; others, the majority in fact, vomit two or three times, and then tolerance 
is estabhshed. If the sickness and purging go on, they may be checked by adding 
a few drops of laudanum to each dose. Dr. Thomas Davies, who had tried this 
remedy largely, and, as he tells us, with great success, gives the following as his 
own plan of administering it, and perhaps it is as good as any. After free bleeding, 
he begins with one-third of a grain of tartar emetic in half a wineglassful of water, 
with a few drops of laudanum or syrup of poppies. Two doses of this strength 
he gives at the interval of one hour from each other. He then, if the patient does 
not vomit, omits the opium, but continues it if he does, doubling, however, the quantity 
of the tartar emetic, giving two-thirds of a grain for two successive hours ; and in 
this way he goes on, adding a third of a grain every two hours, until he reaches two 
grains every hour. This last quantity he has not exceeded, and he says that he has 
continued it for many days without producing any injurious consequences. 

Under this plan of treatment the symptoms will often undergo a marked change 
for the better, in three or four hours. Sometimes, however, the relief is not con- 
spicuous for twenty-four or even for thirty -six hours. He states, and this is accordant 
with my own experience of the remedy, that the tartar emetic always acts best when 
it produces no effect except upon the inflammation itself; i. e., when it does not 
cause vomiting, or purging, or a general depression of the powers of the system. 
This is an important practical remark, because many persons have supposed that it 
subdues the disease only when it previously gives rise to these symptoms. I con- 



PNEUMONIA. ' 573 

sider this testimony of Dr. Davies to the power of the tartarized antimony in con- 
trolling inflammation of the lung^ the more valuable, because he informs us, that 
before he had occasion to see its admirable effects in the first stage of pneumonia, he 
had been in the habit of trusting to the free use of mercury, after due depletion. 

When dyspnoea has been put an end to by antimony thus exhibited, the medicine 
may be intermitted ; and if the inflammation shows any disposition to rekindle, it 
must be again extinguished by a repetition of the tartar emetic. 

When, however, the inflammation has reached the second stage, that of sohdifica- 
tion, mercury is more worthy of confidence, in my opinion, than tartarized antimony. 
And I have little or nothing to add to what I formerly said in respect to the mode in 
which it ought to be administered. The object of giving it is to make the gums 
tender; and it is expedient to do this as speedily as may be. Small doses of calomel 
repeated at short intervals — a grain every hour, or two grains every two hours, or 
three grains every three hours — combined with so much of laudanum or of opium 
as may be requisite to prevent it from running off by the bowels — offer the most 
certain way of accomplishing our object. If the bowels are irritable under the calo- 
mel, blue-pill, or the hydrargyrum cum creta, may be substituted for it with ad van* 
tage : and if the internal use of mercury is any how contra-indicated, or if it appears 
slow in occasioning its specific effect, the hnimentum hydrargyri may be rubbed in, 
or the strong mercurial ointment. 

Many persons, I am persuaded, are saved by treatment of this kind, pushed to 
slight plyalism : the effusion of lymph, tending to spoil the texture of the lung, is 
arrested ; and the lymph already effused begins to be ajjain absorbed : and the ease 
and comfort of the patient, as well as the alteration for the better of the physical 
signs, attest the healing qualities of the remedy. 

After the inflamed lung has become solid and impermeable, the treatment must 
be regulated rather by the state of the system at large, than by the actual or pre- 
sumed condition of the lung: we must look more for guidance to the general symp- 
toms than to the physical signs. If the pulse continues steady and firm, wait pa- 
tiently the effect of the mercury. But when sunken features, a pallid face, coldness 
of the surface or extremities, a tendency to delirium, and (above all) a feeble or 
irregular pulse, proclaim that the vital powers are giving way, it will be requisite, 
as in other cases vi^here death is threatened by asthenia, to administer cordial and 
stimulant medicines ; the carbonate of ammonia in a decoction of seneka ; wine : 
and to feed the patient well on milk, or beef-tea. 

Among what may be called the routine remedies of pneumonia, we must rank 
counter-irritation by means of blisters. When one is called, in consultation, to see a 
patient labouring under inflammation of the lungs, we may safely speculate upon the 
conclusion, that bleeding and blistering, and purging by calomel, have all been duly 
performed. And I beheve that blisters are often apphed to the chest much too early 
in such cases. In the outset, while there is yet considerable fever present, they add 
to the irritation, and distress the patient ; and probably tend to aggravate the existing 
inflammation. They are also attended with this inconvenience, that they interfere 
with the exploration of the lungs by the ear: and this is not a slight or fanciful dis- 
advantage ; for the information we receive, by the sense of hearing, of the state of 
the lung — whether the inflammation be making progress, or receding, or stationary 
— is of great use in directing the remedial management of the case. But of course 
this is a consideration not to be put in competition with the benefit which may be 
expected sometimes from a blister. When the fever is no longer high, and the skin 
no longer burning, but the expectoration is still difficult, the dyspnoea considerable, 
and a sensation of pain, or tightness, or oppression, is experienced in the chest, then 
a large bhster is often productive of very sensible benefit; but it should be a large 
one. The patient should have a w^aistcoat almost, or at any rate a breast-plate, of 
blistering-plaster. 1 have never seen such good effects from placing blisters upon 
distant p;irts in this disease, upon the thighs or arms for instance, as would lead me 
to plague the patient with them in those situations. 

Purgatives are of less certain value in pneumonia than in many other inflamma- 
tory diseases ; and less, especially, than in cerebral inflammation. Still, it will always 



574 



PNEUMONIA. 



be right to give an active aperient at the outset, and afterwards to take care that the 
bowels be unloaded at least once every day. A continued drain by purgation would 
not consist at all with the mercurial plan, which promises to be most useful when the 
inflammation has already reached the stage of hepatization. 

This, then, is the outline of the treatment which is most likely to save the life 
of those who are affected with acute idiopathic pneumonia. Different cases will 
require different modifications of it ; for which, I repeat, no particular rules can be 
laid down. 

All that I have hitherto been saying relates to acute pneumonia, occurring in a 
previously healthy person. But pneumonia having that character, and so occurring, 
is a much less common disorder than most persons appear to suppose, or than I for- 
merly thought it to be. I have been surprised to find how few cases of pure idiopa- 
thic inflammation of the lungs present themselves among my hospital patients. Five 
or six in the year are as many as I see there. Intercurrent pneumonia, however — 
pneum.onia engrafted upon some other pre-existing disease — is abundantly frequent; 
and requires, in general, a much less vigorous and more wary plan of treatment. 
Inflammation of the pulmonary substance is apt to supervene insidiously upon various 
disorders which are of e very-day occurrence : upon bronchitis, upon phthisis, upon 
disease of the heart, and upon fevers, especially the exanthematous fevers. In these 
cases, while the physical signs are necessarily the same as in the unmixed acute dis- 
ease, the general symptoms are often but slightly pronounced. During the progress 
of continued fever of a low type, inflammation may steal upon the lung, and run 
quickly through all its stages, and spoil the organ irrecoverably, without giving any 
notice of its presence ; unless, indeed, you suspect, and search for it with your ear. 
The pneumonia is said, in such cases, to be latent. It seldom needs, the associated 
disorder would seldom bear, any active depletion. Much benefit often follows the 
abstraction of small quantities of blood ; but they should be taken from the surface 
of the chest by the cupping-glass, and not by the lancet from the arm ; and it is often 
good practice thus to aim at reducing the local mischief with one hand, while with 
the other we support the patient's strength by means of ammonia, wine, and nour- 
ishing broths. Blisters are also of service ; more so than in the sthenic forms of pure 
pneumonia ; and they may be apphed at an earlier period. In conjunction with 
these remedies, I should advise the cautious employment of mercury. 

When the convalescence from acute pneumonia is decided and real, it is shorter 
than might have been supposed. From the period when the pulmonary inflamma- 
tion is fairly over, the strength returns with unexpected facility, even when large 
bleedings have been practised and repeated. But we have to guard, more perhaps 
in this disease than in most others, against false or merely apparent convalescences. 
A patient can never be pronounced perfectly secure so long as any trace of crepita- 
tion remains in the affected lung ; and this may often continue long : nay, it not 
unfrequentl}'' ceases only upon the supervention of another more surely fatal, though 
less rapid disorder, viz. : tubercular consumption ; of which, however, I must treat 
as a distinct disease. 

[PjTEtrMOJfiA IK CaiLDiiEif. ' — PneuiTionia is a veiy frequent disease of childhood ; and 
as it is then marked by some very important modifications in its general characters and 
results, it demands a separate consideration. 

The inflammation may be confined to the minute lobules of the lung, or it may attack the 
pulmonary lobes. The first constituting lobular, and the second lobar pneumonia. In both 
forms of the disease the inflammation may be confined to a small portion of one lung, or 
extend to nearly the whole of one or both. 

In very young children the symptoms of pneumonia, particularly at the commencement 
of the attack, are very obscure, and even v^^hen more distinctly marked, they differ but lit- 
tle from those of bronchitis. 

In infants the attack is very generally preceded by symptoms of a mild bronchitis, to 
which there usually succeeds a chill, differing in its severity and duration in different cases ; 
this is followed by increased heat and dryness of the surface, increased frequency of pui.-e, 
accelerated respiration, dyspncea, and a sliort dry cough. These symptoms quickly augment 
in intensity — the lips become of a bright red, the tongue of a florid hue. and somewhat dry, 
and coated along its centre with a thick white fur. Often there is from the commencement 
of the attack vomiting, and, in young children, diarrhoea. In many cases there is considera- 



PNEUMONIA. 



575 



ble agitation and anxiety, in others decided drowsiness, and more rarely convulsions ; these 
are sometimes violent and repeated, and often folioM^ed by an entire loss of consciousness. 
Convulsions, according to the observations of Rilliet and Bartliez, are confined to cases occur- 
ring in young infants, where the inflammation is seated at the summit of the lungs. 

In infants at the breast, in the early period of the attack, the breathing is no longer affected 
solely through the nose, but the little patient lies with the mouth partly open, and drawing 
in the air through it. The tongue becomes in consequence prfeternaturally dry, and the child 
sucks by starts — seizing the nipple with eagerness, sucking for a few moments with greedi- 
ness, and then suddenly dropping the nipple, and in most instances commencing to cry or 
moan. 

The inspiration in children affected with pneumonia, is marked by a peculiar abruptness, 
occurring suddenly before expiration is completed, and with a more or less dilatation of the 
nostrils. 

The frequency of the respiration is not always in proportion to the violence of the attack, 
and does not always increase with the progress of the disease. When pneumonia occurs in 
the course of chronic enteritis, there is often either a very slight or no acceleration of respira- 
tion; it may, also, be masked, by an accompanying aftection of the abdominal organs or of 
the brain. In cases of broncho-pneumonia, the dyspncEa is often so intense as to threaten 
suffocation. The dyspncea is always proportionate to the violence and extent of the pulmo- 
nary inflammation, and augments with the progress of the disease. It is often attended with 
great anxiety, and a sense of impending suffocation which renders a recumbent posture 
insupportable. 

The cough is at first frequent, short, dry. and painful, but soon becomes moist; when ex- 
pectoration occurs, which is seldom the case in young children, it is, at first, slight, and con- 
sists of a whitish, viscid mucus, which becomes subsequently reddish. It is rarely, however, 
rust coloured. As the cough becomes more moist, it gradually declines in violence until 
towards the eighth or ninth day, when it rapidly diminishes, and finally disappears. When, 
however, the pneumonia becomes more diff"used, or occurs in the course of some acute affec- 
tion, and in children not much debilitated, the cough is very frequent and intense, and is 
rarely attended with a free expectoration. The attacks of pneumonia that so frequently 
occur in the course of chronic enteritis, are seldom attended with much cough — occasionally, 
indeed, it is entirely absent. There is seldom any very decided pain of the chest — when 
present, it is generally acute, though occasionally dull, and is usually experienced at the ante- 
rior margin of the axilla — it is aagmented by the cough, and often disappears long before the 
other symptoms. 

The disease in these cases is so often destitute of leading symptoms, that its existence 
might be overlooked, were it not for the physical signs revealed by auscultation — the skin is 
pale and cool, the pulse small, and the face and extremities oedematous. 

In young children, or those under six years of age, pneumonia is frequently preceded by 
extensive bronchial inflammation. The inflammation of the lungs, which is probably pro- 
duced by the extension of the inflammation from the extreme branches of the bronchi to- the 
preliminary tissue, often comes on so gradually, that it is impossible to fix in most cases the 
exact date of its occurrence. Occasionally, at the period the pneumonia supervenes, there 
is a well-marked accession of fever and dyspnoea, and an aggravation of all the symptoms. 
The febrile symptoms are less than in the other forms of the disease, but the dyspnaa and 
distress are usually greater, and the face presents from the first a more livid hue. The 
cough is less hard, but often occurs in paroxysms which greatly distress the^ patient ; 'the 
respiration is more hurried and irregular; the irregularity coming on at an earlier period. 
Head symptoms are more frequent, the patient's rest is disturbed, and he often mutters in his 
sleep, and has far more restlessness and jactitation when awake. Convulsions and coma 
more frequently precede death, which occurs at an earlier period than in the other forms 
of pneumonia. 

Pneumonia in children is generally attended with loss of appetite and increased thirst, 
and a torpid state of the bowels ; v/hen the disease, however, is complicated with enteritis, 
profuse diarrhea may be present throughout the attack. In these cases furunculi or ecchy- 
moses occasionally cover the skin, while the blistered surfaces are liable to become ulcerated. 

In favourable cases of primitive bronchitis, the acceleration of pulse and respiration attain 
their greatest intensity generally by the end of the fourth, fifth, or seventh day, or, at 
the farthest, by the ninth day: when the he^it of the skin and the frequency of the pulse 
diminish, respiration becomes slower, and the inspiratory movement is unattended with dila- 
tation of the nostrils. . The cough becomes more free and moist, the fever quickly disap- 
pears, the face becomes paler, and the expression of the countenance more natural. The 
respiration finally assumes its normal rhythm, the cough rapidly diminishes, and in a few 
days convalescence is fully established. 

In the more severe and unfavourable cases, there is intense dyspnoea from the very com- 
mencement of the attack — intense anxiety, a pallid hue of the face, with a violet tinge of the 
lips and summits of the cheeks, an extremely small, rapid pulse, and a frequent, short, 



576 



PNEUMONIA. 



dry, painful cough. The general symptoms continue to augment in violence, and death may 
occur on the third or fourth day. In other cases, the symptoms, from the beginning of the 
attack, are less intense, and do not increase in severity after the fifth or sixth day, but remain, 
as it vs'^ere, perfectly stationary. Soon, however, in addition to the cough and dyspnoea, there 
occur pallor of the face, great emaciation, and constant diarrhcea: and, at the termination of 
from three to four weeks, the patient, being reduced to a state of the utmost debility, expires. 
In other cases, again, after all the prominent symptoms have declined, and a speedy conva- 
lescence is anticipated, from some accidental cause, the inflammatory action is re-excited in 
the lungs, the dyspnoea, cough, acceleration of the pulse, and fever, return with increased 
violence, and death speedily ensues. The fatal termination may also be hastened by the 
occurrence of pleurisy, measles, gangrene of the mouth, &,c. 

Acute pneumonia, occurring in the course of some other acute disease, is" generally of rapid 
progress, and terminates either in health or fatally, within a few days. 

The physical signs of pneumonia, occurring in children, are of primary importance. By 
them alone, in many cases, can a correct diagnosis be established — while it is only by them, 
also, that the extent and progress of the local disease can be determined. 

In simple primitive pneumonia of children, if of the lobar form, there are present, from 
the very commencement of the attack, crepitant ronchi, and often bronchial respiration on 
one side the thorax towards its base. The crepitus is generally larger than in adults. If 
for a short time it cannot be heard, it may be generally reproduced by causing the child to 
cough, when it is again to be distinguished, in the strong inspiration whicli -uoeeds the 
cough, the sound resembling the cracking of a whip. ' 

In the lobular form of pneumonia, the subcrepitant ronchi are more generally diffused, 
■while the bronchial respiration is seldom heard. The extent of the latter increases with the 
progress of the inflammation, while the ronchi decrease. When the acceleration of the 
respiration and pulse has attained its maximum, the bronchial breathing is very audible, and 
is accompanied with bronchophony, or with a resonance of the voice and extensive dulness 
of the chest. As the general symptoms decline, and the cough becomes more moist, the 
subcrepitant ronchi are very abundant, and the resonance of the voice extends over a greater 
space ; the bronchial breathing continues, but the dulness of the chest diminishes. Even after 
convalescence is established, a slight prolongation, as well as a difierent resonance of the 
voice, is still perceptible. The respiration continues feeble for several days, and only slowly 
recovers its proper vesicular tones. 

In more violent cases, humid ronchi are heard throughout the chest, intermixed with others 
of a drier character, or with bronchial expiration and a difiused resonance of the voice. 
Bronchial breathing is always a very grave sign. In eleven out of twenty cases in which 
it was detected by Dr. West of London, the disease had a fatal termination. 

The mucous ronchus is heard in most cases of broncho-pneumonia in children, and in 
cases of lobar pneumonia, in the neighbourhood of the subcrepitant ronchus, and occasionally 
whero distinct bronchial respiration exists. It often persists for a long time after every other 
sign of disease has disappeared. 

In the lobular pneumonia of young children, the physical signs are at first limited to the 
mucous and subcrepitant ronchi, dependent upon the increased secretion of mucus in the 
bronchi. The subcrepitant ronchi are frequently continued throughout the attack, being often 
the only stethoscopic signs present. They are rarely replaced by the fine crepitant ronchi. as 
in the pneumonia of adults. Bronchial respiration becomes developed when induration has 
extended to a considerable portion of the texture of the lungs. It is chiefly heard at the 
upper and middle portions of their posterior parts — it is rarely heard in the lower lobe, from 
the comparative smallness of the bronchi, and their early obliteration by the progress of the 
inflammation. The respiratory sounds are very peculiar — the inspiratory murmur, in place 
of being full and expansive, as in a healthy child, is short, obscure, and almost without the 
vesicular murmur, and may or may not be accompanied with the mucous or subcrepitant 
ronchus; the expiration is rarely distinct, unless the bronchial respiration is fully developed, 
when it is usually louder than the inspiration. The sounds indicative of inflammation of 
the texture of the lung are often entirely obscured by the mucous ronchi of bronchitis. 

The anatomical lesions in the pneumonia of children differ very materially, according as 
the inflammation is lobular or lobar, and according to the period of the disease when death 
takes place. 

In lobular pneumonia the lung is usually soft and flaccid, of a mottled appearance exter- 
nally; patches of a deep red or violet colour, generally distinctly circmnscribed, of a circular or 
oval form, hard to the touch, and slightly projecting, being interspersed in the midst of the 
natural grayish red tint. They are commonly situated at the inferior edge of the lung, but 
may occupy other portions of its surface. The part occupied by these patches does not col- 
lapse upon the chest being opened. 

In some cases this marbled appearance of the lung is absent; but spots of induration, more 
or less deeply seated, may be detected by the fingers, giving to the lung an uneven or knotted 
feel. 



PNEUMONIA. 



577 



The same marbled appearance is presented by a section of the lung. The dark patches 
are more or less accurately circumscribed in the first stage of the disease ; they are firmer 
than the surrounding tissue, swim when thrown into water, crepitate beneath the finger, and, 
however carefully separated from the sound portion of the lung, yield upon pressure a red- 
dish fluid intimately mixed with air. In the second stage the dark patches form nodules of 
a firmer and more compact consistence. Their cut surface is smooth, and when carefully 
detached from the surrounding parts, they crepitate none or but slightly, and sink rapidly 
when thrown into water. When the central portion alone of the nodule is subjected to 
pressure, a red sanious fluid escapes without any admixture of air. It is seldom that single 
lobules are found affected, the induration usually comprising four or five, forming a mass of 
the size of an almond. If the patient lives for some time, the intervening substance usually 
becomes affected, and the lobular is converted into lobar pneumonia, and the inflammation 
runs its course, as in the ordinary cases of this latter form of the disease. 

In the third stage of the disease, the section of the lung presents a grayish colour, inclining 
more or less to yellow in different cases. The pulmonary tissue is friable, and when pressed 
gives discharge to a purulent fluid, its texture being infiltrated with pus. Upon minute 
examination, some of the lobules will be found more projecting than others, their vesicles 
not being compressed, as in the less projecting parts. 

According to Barthez and Rilliet, there are two forms of lobular pneumonia. In the first, 
which they denominate the mammelonated^ is marked by nodules of hepatization, comprising 
one or more lobules, differing but little in colour and appearance from the surrounding tissue. 
Their limits are well defined, even when the neighbouring tissue is engorged. They are 
frequently surrounded by a layer, of about half a line in thickness, white, firm, and of a 
fibrous appearance. The hepatized portions slightly project above the surface of the incised 
lung, from the collapse of the surrounding air-cells. They vary in size from that of a hemp- 
seed to that of a pigeon's egg. They are of a spheroidal form, and have usually a regular 
surface. But a single nodule may exist in one lung, or there may be from twenty to thirty 
or more. They are almost invariably surrounded by a circle of pulmonary tissue in a state 
of engorgement. The diseased portions generally attain the third stage of pneumonic hepa- 
tization, which terminates in the formation of an abscess. 

In the saine lung there may exist nodules of hepatization in the first and second stages, 
and also rounded masses of a straw colour, very humid when cut into. At a more advanced 
stage, the pus, which is at first deposited in the interstices of the pulmonary tissue, becomes 
collected in the centre of the nodules. This minute collection of pus is surrounded by two 
concentric zones, the internal one yellow — hepatization of the third degree; — the external 
one red — hepatization of the second degree. At a later period, the size of the abscess is 
increased at the expense of the inner zone, the outer zone at the same time passing into sup- 
puration. At a still later period, an incision through the diseased portion of the lung reveals 
cavities varying in size from a few lines to four or five. These cavities are in general round, 
more rarely oval, and contain usually a thick tenacious yellow or greenish pus, perfectly free 
from any admixture of air. Sometimes small coagula of blood are mixed with the pus 
These cavities are at first formed by a layer of hepatization, lined with a layer of concrete 
pus, or with a false membrane, yellow, soft, and easily detached. Subsequently, this mem- 
brane becomes changed into a thin, smooth, polished tissue, analogous to a serous membrane. 
The abscesses sometimes communicate freely with each other, and at the point where the 
bronchi penetrate their cavity, its mucous membrane presents a true solution of continuity. 
When the inflammation invades separately several neighbouring lobules, the cavity of the 
abscess is multilocular, each cell being isolated by a lamina of the hepatized tissue, upon 
the rupture of which the different abscesses communicate with each other. These abscesses 
have usually a tendency to approach the surface of the lung. An adhesion often takes place 
between the opposing surfaces of the pleura, or the pleura of the lungs becomes gradually 
thinned and finally perforated, giving rise to a true pneumo-thorax. It has happened, that 
an adhesion has formed between the lung and diaphragm, and the abscess of the lung has 
thus communicated v/ith the peritoneal cavity. These abscesses are often completely iso- 
lated, and, with the exception of the thin layer of hepatization in their immediate vicinity, 
are surrounded with a perfectly healthy pulmonary tissue. Occasionally, however, they per- 
vade the great portion of the whole of one of the lobes. Their size is ordinarily in inverse 
proportion to their numbers. In the greater number of cases, they are confined to one lung, 
and are more frequent in the left than the right. They are met with most frequently in chil- 
dren under six years of age. 

Partial, which is the second form of lobular pneumonia, is much less circumscribed than 
the preceding. Indistinct limits exist between the healthy and diseased portions, and the 
disease occupies a larger portion of the lungs. The diseased portions may throughout have 
reached the second stage, or at the centre alone, the circumference being still in the first 
stage, and this being in contact with several other portions of the lung, in a similarly dis- 
eased condition: nearly the whole of an entire lobe may present an admixture of the charaa" 

37 2y 



578 



PNEUMONIA. 



teristics of pneumonia in the first and second stages, and when the disease has reached the 
third degree, it is strictly lobar. 

In the major part of the cases, lobular pneumonia is double — the disease, however, being 
frequently much more extensive on one side than the other. A union of the three forms of 
pneumonia — mammelonated, partial, and general — is often met with in the same patient. 
The first is equally frequent in every portion of both lungs, while general pneumonia is far 
more frequent in the inferior lobes. Partial pneumonia is often disseminated throughout the 
three lobes — it is more frequent, however, in the inferior. Mammelonated pneumonia is of 
much more rare occurrence beyond the sixth year than partial pneumonia, while general 
pneumonia is still more rare than the former between the sixth and fifteenth years. (See 
Barthez and Rilliet — Maladies des Enfants, t. i., p. 61.) 

Some doubts have been suggested as to all the changes in the texture of the lungs, de- 
scribed as characteristic of lobular pneumonia, being actually the result of inflammation. 
For the investigation of this subject, the reader is referred to the Editor's Treatise on the Dis- 
eases of Children, 2d edit., p. 282. 

The anatomical characters of lobular pneumonia in children are the same with those met 
with in the pneumonia of adults. 

Inflammation of the bronchi, particularly of the smaller bronchial ramifications, pleurisy, 
and emphysema of the lungs, are common complications of pneumonia in children. 

The lobular form of pneumonia is the most frequent dm-ing childhood — it is also the most 
serious at that age. 

Lobar pneumonia occupying only one lung, when it occurs in children between six and 
fifteen years of age, whose health has not been impaired by previous disease, unless compli- 
cated by some secondary affection is not a very fatal disease, if judiciously treated from its 
commencenient. Its serious character is however greatly enhanced by its being complicated 
with other diseases. The most common of these are measles, hooping-cough, chronic ente- 
ritis, and small-pox. 

Pneumonia in children is produced by the same general causes, as give rise to it in adults. 
It is common to both sexes, but more frequent in boys. It is particularly liable to occur in 
the same child after a shorter or longer interval. 

In the treatment of the pneumonia of children, bleeding will very generally be demanded 
in the commencement of the attack. In young children leeches or cups should be applied 
to the anterior parietes of the chest, beneath the clavicles, or between the shoulders. Their 
number should be proportioned to the violence of the symptoms, and to the age and strength 
of the patient. In older children, however, bleeding from the arm should be preferred. The 
amount of blood drawn must be proportioned to the extent of the disease. The propriety 
of repeating the bleeding will depend upon circumstances. When the first bleeding has 
been well timed and carried to a sufficient extent, a second will seldom be required ; when- 
ever, however, the leading symptoms, particularly the dyspncea, continue with little abate- 
ment, we should never hesitate to repeat the bleeding, either from the arm, or by leeches or 
cups, according to the violence of the remaining symptoms, the age of the patient, and the 
amount of strength remaining. It is, however, in the early period of the attack alone, that 
any very decided advantage is to be expected from blood-letting; in the more advanced 
stages of the disease, it will seldotn be beneficial or admissible; though cases may occasion- 
ally occur, when the cautious application of leeches or cups to the chest or between the shoul- 
ders will be attended with marked relief, even after the disease has existed for several 
days. 

In the commencement of the attack, if the bowels are active or torpid it will be proper to 
administer a full dose of calomel, to be followed in a few hours, by a dose of castor oil, or 
in robust children, over three years of age, a mixture of equal parts of magnesia and epsom 
salts. Subsequently the bowels should be kept regularly open by enemata, or occasional 
doses of some mild purgative ; a grain of calomel, with half a grain each, of ipecacuanha 
and extract of hyosciaraus, administered twice or thrice a day, will usually effect this object. 
Costiveness is not, however, very common in the pneumonia of infants; an opposite state of 
the bowels is a more frequent and troublesome symptom. 

Subsequent to blood-letting, in robust children over three years of age, tartarized antimony, 
given in small doses during the day, will be found highly beneficial. But in younger chil- 
dren antimony in any form is a dangerous remedy, more particularly when there is any 
tendency to disease of the alimentary canal. Small doses of ipecacuanha and calomel will 
be found very generally to act beneficially in allaying the cough, dyspncea, and general 
restlessness, and may be given to the youngest patient without any inconvenience resulting ; 
adding to each dose a minute portion of powdered digitalis will in most cases be found ad- 
vantageous. Occasionally the calomel will purge ; should this be. the case it will be neces- 
sary to add to it a grain or two of Dover's powder. After the violence of the disease has 
been considerably abated, we have found advantage from the administration, every three 
liours, of small doses of calomel, ipecacuanha and hyosciamus. Under the same circum- 
stances, the compound honey of squill may be given. To children over three years of age it 



PLEURISY.' 



579 



is well adapted to allay tlie cough and dyspn(Ea: to the dose given in the evening a few drops 
of paregoric maybe added. 

Blisters to the chest are certainly very important remedies in the pneumonia of children. 
In violent cases occurring in patients over five years of age, particularly when attended with 
much febrile excitement, they should not be applied until the violence of the symptoms have 
been abated by direct depletion ; they should be kept on no longer than is necessary to pro- 
duce a decided redness of the skin; they should be then removed and the reddened surface 
covered with a soft emollient poultice. In infants, as well as in slight cases, and in those 
occurring in cliildren of a delicate frame or who are much debilitated, in place of a blister a 
thick slice of bread, dipped in vinegar and lightly sprinkled with powdered mustard, should 
be applied to the chest, and removed as soon as it has reddened the skin. 

Warm sinapired pediluvia, or a sinapired hip-bath, will often produce a favourable revul- 
sion from the lungs, and may be frequently repeated. 

In stubborn cases Dr. West speaks highly of mercurial inunction ; under its employment, 
he has seen recovery to take place even where the circumstances had seemed to warrant 
a more unfavourable prognosis. The full value of mercurial inunction is seen in cases which 
have been neglected until the time for depletion has gone by, the patient having become 
exhausted, and the employment of calomel is forbid by the presence of diarrhoea. Dr. West 
employs it in the proportion of one drachm, rubbed into the thighs and axilla every four 
hours, in children of four years of age. He has never seen salivation to be induced by it, 
but he has observed the disease gradually to diminish in severity during its employment, 
and the solid lung, to become once more permeable to air. 

When in the advanced stage of the disease there is great exhaustion, with symptoms of 
impending suffocation, the use of carbonate of ammonia has been strongly recommended — 
but under such circumstances, there can be but little hope of the patient's recovery. 

In chronic cases, our chief dependence is upon revulsives, applied either upon the chest, 
or upon the surface generally, and perhaps upon a judicious mercurial course, particularly 
by inunction. 

In all cases of pneumonia, the exhibition of some mucilaginous drink, in small portions, 
and at short intervals, will be found to abate, very sensibly, the cough, and relieve the dry- 
ness of the fauces, which, in the early stage of the disease, is often a harassing symptom. 
A solution of gum acacia, or the mucilage of the elm bark, or pith of sassafras, sweetened, 
will be the best we can employ. 

The diet of the patient, in the earlier period of the more acute cases, should be confined, 
almost exclusively, to these mucilaginous fluids — after the violence of the disease has been 
subdued, plain water gruel, arrow-root, or tapioca, may be allowed. When the disease oc- 
curs in young infants, they should be taken from the breast — the mother's milk being given 
to them in moderate quantities by means of a spoon, as well to prevent their stomach from 
being overloaded, as to guard against the mischievous effects of the violent exertion of the 
respiratory organs in sucking. 

The patient should be kept in a clean, well ventilated, and moderately warm apartment. 
It is all-important to guard him from cold and dampness, and from sudden transitions of 
temperature. He should be placed upon his bed or couch in a half-recumbent position, in 
order to render the respiration more easy, and to prevent the injurious consequences resulting 
from the stasis of fluids in the posterior jDortion of the lungs. 

When the disease has arrived at an advanced stage, or involves a considerable extent of 
the lungs, the patient should be moved with the greatest care and gentleness, lest convulsions 
be induced. 

After convalescence is fully established, gentle exercise in the open air, in mild, dry wea- 
ther, may be taken; but, for a long period, the utmost care should be observed to guard against 
exposure to cold and dampness; and while a gradual improvement is made in the diet — if 
the child be weaned — all rich, stimulative, and indigestible food must be avoided, as well as 
the slightest excess in the use of those articles that are allowed. See Condie on Diseases of 
Children, 2d ed., page 274, et seq. — C] 

In the next lecture I shall speak of pleurisy. 



LECTURE LII. 

Pleurisy. Its anatomical characters ; false membranes ; liquid effusion ; effects 
of these upon the shape and contents of the chest, and upon its healthy sounds. 
Symptoms of Pleurisy. 

I PROCEED this afternoon to the subject of pleurisy, having in the last lecture con- 
cluded what I had to say on that of pneumonia ; that is, I pass from inflammation 



580 



PLEURISY. 



of the substance of the lung, to inflammation of its invesfing tnembrane. The two 
frequently exist together ; but, when that is the case, the one predominates greatly 
over the other. Pleurisy, however, without pneumonia, is much more common than 
pneumonia without pleurisy. When both are present, and the pneumonia predomi- 
nates, the term pleuro-pneumojna is applied to the compound disease. The whole 
interest of such a case merges in the pneumonic inflammation. Again, when both 
are present, and the pleurisy predominates, the compound affection is sometimes 
called pneumO'pleuritis. 

The pleura, as you know, is one of the serous membranes. Its inflammation is 
attended, therefore, with those events which I formerly took some pains to describe 
as belonging especially to that particular tissue. The inflammation is of the adhe- 
sive kind : it is accompanied by pain, by the pouring out of serum, of coagulable 
lymph, of pus, or of blood. I think it will be best, in this instance, also, to lay- 
before you some account of the morbid anatomy of the disease, before I consider it's 
symptoms. 

The alterations that take place in the inflamed membrane itself are not very 
striking or important. Experiments upon living animals, made by introducing some 
foreign substance, or injecting some slightly irritating hquid, into the cavity of the 
pleura, have proved that, as in other cases, inflammation is attended with redness of 
the part aflected. But it is scarcely ever that we observe this effect alone of inflam- 
mation, in the pleura of a dead person ; unless, indeed, he has died of some other 
complaint while he happened to have incipient pleurisy. The pleura has been said 
to be thickened by inflammation ; but that I apprehend to be a mistake. It often 
appears to be thickened, in consequence of the superposition of a false membrane — 
a layer, or several layers, of plastic lymph. But actual thickening of the pleura 
itself seldom or never happens. Neither does the pleura easily soften, or readily 
ulcerate, under inflammation. It peels off", in some cases, from the lung, or from the 
ribs, with more facility than in the sound state. 

The most remarkable eflects of pleurisy result from the efl'usion of coagulable 
lymph, or of serous fluid, or of both, into a shut sac, having peculiar anatomical 
relations. One part of the membrane lines the firm walls of the chest; the other 
part envelops the soft and compressible lung. The opposed surfaces of this closed 
and empty bag being o/jposed also, but freely movable one upon the other, very dif- 
ferent, and even contrary, effects may be produced by its inflammation. The pul- 
monary pleura ma}^ be glued to the costal pleura, so as to prevent all lateral move- 
ment between them, and to obliterate the pleural cavity ; or the two surfaces of the 
membrane which are naturally in contact, may be forced unnaturally apart by a 
pouring forth of serum between them ; or the opposite surfaces of the pleurse may 
be united by coagulable lymph in some places, and separated by effused fluid in 
others. And great differences will arise in the symptoms, and in the gravity and 
tendency of the complaint, according as one or another of these different conditions 
of the contents of the thorax is established. 

Let us first consider the effect of the throwing out of coagulable lymph only ; or, 
of Avhat comes to the same thing, the effusion of coagulable l^^mph with a small 
quantity of serum, which last is soon reabsorbed. 

One consequence of this is the formation of false membranes. These, indeed, 
are formed whether there be much or little serum poured out. We continually meet 
with them, sometimes when we least expect to do so, in the dead body. They vary 
greatly, in different cases, in respect to their thickness, situation, extent, organization 
and effects. 

When the lymph is first deposited upon the free surface of the inflamed pleura, 
it is soft, and of a grayish-white colour, like paste somewhat. It soon, however, 
acquires an increase of consistence, and shows marks of vitality ; becomes, in short, 
organized. Red points begin to appear in it, few in number and widely separated 
at first ; but they presently multiply, and lengthen into reddish streaks, which run 
along the surface of the eflxised matter. Soon these red streaks may be perceived 
to be slender vascular canals; and at length they inosculate with the vessels of the 
pleura, and the lymph, converted into a false membrane, becomes a constituent part 
of the living frame. 



PLEURISY. 



581 



It is curious, and useful too, to know how rapidly this work of organization may- 
go on. 

Andral made experiments upon the pleurae of rabbits, by injecting acetic acid into 
them. He sometimes found, at the end of nineteen hours, soft and thin false mem- 
brane, traversed by numerous anastomosing red lines. In other rabbits, placed 
under circumstances which appeared to be exactly similar, no such result had taken 
place at the end of a much longer period ; but the pleura contained only a serous or 
puriform liquid, mixed with unorganized flakes of lymph. Now similar differences 
have been remarked in the human subject, under disease. False membranes, 
already vascular, have been found in the bodies of persons who died of pleurisy 
after a very few days' illness : while in other patients, who had lived for many 
months after the invasion of the disease, there has been no trace of such vascular 
membranes. It is clear, therefore, that the organization of the lymph does not de- 
pend solely upon the length of time that has,elapsed from the period at which it was 
poured forth. It has much more to do with the previous state and habit of the 
patient. Caeteris paribus, plastic lymph and early adhesion are more to be expected 
in young, strong and healthy persons ; curdy unorganized lymph, granular deposits, 
with copious and abiding serous effusion tending to become puriform, in such as are 
old, feeble, cachectic, and scrofulous. 

The extent of these false membranes varies according to the extent of the inflam- 
mation which has produced them. When that has been general, they cover the 
whole lung, and line the whole costal surface, and spread themselves over the. 
diaphragm and mediastinum of the same side. Supposing that,there is no serous 
liquid effused, or that it is absorbed, the lung then becomes everywhere adherent 
to the sides of the cavity which contains it. The medium of adhesion, which is soft 
and tender while it is recent, grows firm, and assumes the characters of areolar tissue, 
when the union is of old standing. 

The thickness of the false membranes is also extremely variable. Sometimes it is 
not more than that of the pleura itself, and the lymph might then, in the absence of 
adhesion, be almost overlooked. But in the majority of cases their thickness is much 
greater than this. Frequently several distinct layers or strata are seen, superposed 
one upon another, to a considerable depth. 

Are there any auscultatory signs of this process of adhesion when it occurs ? Yes. 
There is a morbid sound not hitherto mentioned by me, whereby it is sometimes dis- 
closed : the sound, namely, of friction ; the sound produced by the rubbing together 
of the dry, or inflamed and roughened surfaces. You doubtless are aware that every 
time a tolerably deep inspiration takes place, the relation between the ribs and the 
lung undergoes a change. While the ribs are elevated, the lung descends a little : 
and consequently any given point of the surface of the lung is no longer in contact 
with the same point as before of the thoracic parietes. You may convince yourselves 
of this fact by carefully making a small incision through an intercostal space, in a 
jiving animal. Now the pulmonary pleura, when that membrane is inflamed, does 
not slip and glide over the costal in its usual smooth and noiseless manner ; but it 
makes a creaking or rubbing sound, which the ear, applied to the corresponding sur- 
face of the chest, readily catches. I have many times heard this ; yet it is not 
at all a common sound : indeed I had heard it, in one instance, some time before I 
knew what the noise meant. The sound has, mostly, an interrupted character, 
occurring in a series of three or four jerks. The patient is often made aware of the 
harsh movement, by some internal sensation ; and a bystander, who places his hand 
flat upon the corresponding surface of the thorax, may sometimes feel this grating of 
the membrane upon itself. You may wonder, as adhesions are so common, that this 
sound, and these sensations are not oftener heard, and felt. In truth, they are tran- 
sitory phenomena, and cease, of necessity, as soon as adhesion prevents any further 
motion of the opposed pleurse upon each other. If we do not happen to hsten during 
that period, usually a short one, in which the pleurse, roughened by infidinmation 
and effused lymph, but not separated by liquid, stiU chafe against each other, we 
lose the opportunity of hearing the sound at all. This rubbing sound, this noise of 
friction, we shall find to be of greater importance in relation to certain diseases of 

2y2 



/ 

582 PLEURISY. 

the heart, than in cases of acute pleurisy. In pleurisy the liquid matters poured 
into the membranous sac have far more interesting consequences : and to these I now 
beg your attention. 

In some instances we find, after death, a clear serous, or watery fluid, without 
colour, or of a pale lemon colour, and perfectly limpid and transparent. This may 
occur independently of inflammation of the pleura; from some mechanical obstacle 
to the circulation. It then constitutes a species of dropsy; a true hydrothorax : 
and this, though less common than ascites, is by no means an ?/ncotnmon conse- 
quence of disease of the heart. When the effusion does not proceed from a cause 
of that kind, it is always, probably, the result of inflammation of the pleura itself, 
although we may find only a slight degree of redness upon its surface, or a few 
patches of coaguiable lymph. More frequently, besides this clear liquid, with flakes 
of albuminous matter floating in it, there is also a coating of lymph on the inflamed 
membrane. Very often the thinner fluid is tuibid, or whitish, like whey ; sometimes 
it is distinctly puriform ; sometimes it is tinged more or less deeply with blood ; 
sometimes it consists of nothing else but blood, which has separated into the serum 
and crassamentum. There being no wound, nor visible rupture, of large or of small 
vessels, we conclude, in such cases, that the blood has exuded, or been exhaled, from 
the membrane. 

The different kinds of fluid effused into the pleurie are always, or almost always, 
without smell ; — provided that it has remained a closed bag : I mean when no com- 
munication has been estabhshed between the cavity of the pleura and the external 
air, either through an opening in the walls of the chest, or through a pulmonary 
fistula leading to the trachea, or through some breach of the oesophagus. I have 
met with but one exception, and that a doubtful one, to this rule. A patient died in 
the hospital, who, some years before, had nearly killed himself by swallowing, in 
mistake for beer, a solution of caustic potass. The result of this had been ulceration, 
and subsequently stricture, of the gullet. His left pleura was perfectly full of most 
stinking pus ; and we were unable to detect any channel of communication with the 
outward air, although the circumstances of the case rendered it not improbable that 
such a channel might have existed. 

Sometimes air, or gas, is found in the cavity of the inflamed pleura ; either alone, 
or (what is much more common) together with a liquid. We ascertain this fact, in 
the dead body, by the hissing sound that takes place as soon as a penetrating inci- 
sion is made between the ribs ; or by opening the thorax under water, and noticing 
the escape of air in the form of bubbles. It is probable that these gases are some- 
times secreted or exhaled from the diseased membrane ; sometimes they are the pro- 
duct of decomposition within the cavity ; but, for the most part, they are met with 
only when the sac of the pleura communicates somehow with the external air. 

Such being the fluid matters that frequently occupy the cavity of the pleura when 
that membrane has undergone inflammation, let us next examine the necessary effects 
of their being collected in that part. These effects wfll obviously vary considerably 
according to the quantity of the fluid that accumulates. 

Now the quantity of fluid may vary from less than an ounce to several pints. At 
first it is lodged in "the cavity of the pleura solely at the expense of the yielding lung, 
which is compressed to make room for it. But if the quantity continues to augment, 
other parts at length displaced by the increasing pressure, the boundaries of the chest 
on that side are stretched, and even the abdominal viscera are thrust out of their 
natural position. The lung is pushed back towards the mediastinum and vertebral 
column, and flattened, and brought to lie in the smallest possible compass; the 
diaphragm is forced downwards, which sometimes gives rise to a considerable promi- 
nence of one or the other hypochondrium, the spleen and stomach being displaced 
on the left side, or the fiver on the right. The ribs are separated too; the intercostal 
spaces become wider, and are pushed out to the level of the bones, and the vdiole of 
the affected side is smooth and obviously larger than the other. The mediastinum 
also undergoes some change of position, being driven more or less towards the side 
opposite to that on which the effusion exists. If the liquid happens to fill and distend 
the left side of the thorax, the heart may be moved out of its natural place, and be 



PLEURISY. 



583 



heard, and felt, and seen to beat on the right of the sternum. Andral mentions 
havino; met with only one instance of that kind. I suppose that I cannot have wit- 
nessed less than a dozen such. So again the heart may be carried beyond its proper 
place, to the left, by a large effusion into the right pleural cavity. 

I say when the liquid is accumulated in very considerable quantity, the lung is 
pressed into the form of a thin cake, which occupies a very small space alongside 
the vertebral column : and if it happens to be covered over and concealed, as it often 
is, by a strong layer of adventitious membrane, we might fancy, at first examination, 
that it had completely disappeared. It was in cases of this kind — especially when 
the effused fluid consisted of pus — that the lung was erroneously represented by the 
older observers as having been destroyed by suppuration. However, you will always 
find the lung there if you take the pains to look for it, and to divide the false mem- 
branes that bind it down : and, in many instances, it is sound also. Its surface may, 
indeed, be wrinkled, but the lung itself is capable of being restored to nearly its 
former volume by insufflation, as it is called; by blowing air into it through the 
principal bronchus of that side. In this compressed state the lung does not crepitate 
under the finger; it is dense, and sinks in water; in fact it is wholly void of air, 
and has been brought, by the pressure of the fluid around and upon it, into nearly 
the condition of the lung of the foetus that has never breathed. But its firmness, its 
resistance to being torn, and its capability of being again inflated, prevent our con- 
founding it with hepatized lung. Sometimes its cellular texture is obliterated; the 
opposite surfaces of the vesicles and smaller air-tubes adhere together ; the lung will 
not admit air; it looks like a piece of muscle, and is then said to be carnified. 

Such is the general account of the anatomical characters of pleurisy, as they are 
disclosed to us by an examination of the body after death. We m^j now inquire 
what effect these changes are capable of producing on the sounds which are heard 
when the healthy chest is percussed, or listened at. We shall then be the better 
prepared to appreciate the several symptoms, general and physical, which are known 
actually to occur in pleurisy. Now it is clear that when the lung is pushed away 
from the walls of the thorax by fluid between the pleura, it wiU be compressed also ; 
its capacity must be reduced ; less air will be able to enter it. There will conse- 
quently be a proportional diminution in the intensity of the respiratory murmur; 
and this murmur wifl, moreover, be less audible in consequence of the distance, from 
the ear, of the structure in which it takes place. The lung is attached by its roots 
(so anatomists speak) to the spinal column. A moderate amount of effusion will, 
therefore, cause it to recede upwards and inwards ; and a certain quantity of the 
liquid will ascend between the lung and the ribs, compressing the spongy pulmonary 
tissue around the larger and more resisting bronchial tubes. We might expect, in 
this condition of things, that the passing breath and the voice, would be audible in 
those tubes, through the partially condensed lung, and through the circumfused layer 
of liquid: and it is so. We do hear bronchial respiration, and bronchial voice and 
cough ; with some modification, indeed, to be noticed presently. In this respect, 
therefore, you will observe that pneumonia, which solidifies the spongy texture of 
lung around the bronchial tubes by filling ii with blood, has the same effect, so far 
as acoustic principles are concerned, as pleurisy, which solidifies a portion of the 
lung by expressing air from it, and pours round the bronchial tubes a fluid which 
readily transmits sound. Hence bronchial respiration and bronchophony are not 
always indicative of the same condition of parts within the chest, but derive their 
true value and meaning from the context, if I may so say ; from the circumstances 
under which they occur, and with which they are associated. 

When the efiusion is so copious as to squeeze afl the air out of the spongy part of 
the lung, to pack the organ up along the vertebral column, to distend the thorax, and 
to compress strongly the bronchial tubes themselves, no respiratory murmur can 
then be heard, nor any tubular breathing; for the ddated chest can neither expand 
nor collapse, and, therefore, no air can pass along even the larger air-tubes ; neither 
can these compressed tubes vibrate with the patient's voice ; wherefore bronchophony 
also ceases, or is but faintly audible. 

Again, if percussion be made over a portion of the chest, where there is incom- 



584 



PLEURISY. 



pressible serous fluid beneath, in the stead of healthy and spongy lung, a dull flat 
sound will be rendered. But a dull sound is rendered also when percussion is made 
over a solidified lung. Hence the mere dullness of the part struck does not inform 
us whether we have pneumonia or pleurisy to deal with, or some other disease that 
has the effect of making the lung solid, without plugging up the larger bronchi. 

But an expedient presents itself, by which we may, in som.e cases, render this 
experiment of percussion conclusive. The dull sound occasioned by hepatization or 
other sohdificalion of the lung occupies the same spot in every position of the patient. 
Not so, necessarily, the dull sound produced by the presence of liquid in the cavity 
of the pleura. The hquid will gravitate to the lowest part of that cavity, and will 
carry with it the dull sound. We place the patient, therefore, in different altitudes ; 
and if we find that the chest, when struck, is always resonant in the higher, and 
always dull in the lower portions of the thorax, whatever the posture may be, then 
we may be sure that the cavity of the pleura contains liquid. In such a case, when 
the patient sits up, the dull sound will be elicited from the lower part of the chest, 
on one side, from the spine round to the sternum. When he hes on his back, the 
anterior of the thorax sounds hollow ; the posterior dull : and when he reverses that 
position, and lies with his face downwards, these sounds change places also ; the 
hollow sound is still uppermost, in the posterior part of the cavity ; the dull sound 
still undermost, in its anterior portion. 

There are just two states which may interfere with the true interpretation of the 
sounds produced by percussion in the manner now described ; and these are, first, 
partial adhesions of the pleurae, which may confine and isolate the effused liquid, 
and prevent its sinking from one part of the chest to another under the influence of 
gravity: and, secondly, so large an amount of effusion as to fill entirely the cavity, 
and fix the compressed and empty lung in one position ; for it is necessary, in order 
to obtain the shifting sounds in different attitudes of the body, that there should be 
light spongy lung to ascend, as well as heavier fluid to sink down, according to 
the posture of the patient. In this last case, that of excessive effusion, the whole 
surface of the affected side will yield a dull sound. It is seldom so in pneumonia ; 
it is seldom that the entire lung on one side is so blocked up, in consequence of in- 
flammation, as to give rj^e to universal dullness on percussion. But the diagnosis 
of these two conditions is an important one, and apt to puzzle a student. I hope to 
elucidate it as we go on. 

We may now consider, with a better chance of understanding some of them, the 
syynptoms which are generally met with in a case of pleurisy under its ordinary 
form and progress. The general signs, then, of that complaint are rigors, pain in 
the chest, dyspncEa, cough, difficuky or impossibility of assuming certain postures, 
and fever. Very much the same, therefore, (as Cullen truly stated) with those of 
pneumonia, and, it may be added, with those of pericarditis : but auscultation dif- 
ferentiates these diseases. The physical signs I will examine presently. The general 
symptoms will bear, each of them, a short comment. 

The pain which the patient feels — or the stitch in the side, as it is expressively 
called — is one of the most striking and characteristic signs c<f the disease. Point de 
cote the French name it. It occupies a point or spot ; and patients feel as if some 
sharp stabbing instrument were driven in at that spot every time that the act of inspi-? 
ration goes beyond a certain limit. The Latin medical writers, attending chiefly to 
this prominent symptom, call pleurisy morbus laieris." 

This pleuritic stitch is subject to considerable variety in regard to its situation, its 
severity, and its duration. Most commonly it is felt on a level with or just beneath 
one or other of the breasts, in the part corresponding to the lateral attachments of 
the diaphragm : and this, even when the inflammation which occasions it is of much 
greater extent. Why is this ? What is the cause of the pain ? Wherefore should 
it be restricted to one small spot, when the inflammation perhaps pervades the whole 
of the pleura? Pathologists have made attempts to explain these matters; but per- 
haps their explanations are not very much to be trusted to. They say that there is 
a larger degree of motion at the lower part of the thorax, of the pulmonary over the 
costal pleura; and that the pain resulting from that friction, when the membranes 



PLEURISY. 



585 



are inflamed, is therefore felt where the friction is the greatest. However the pain 
is not always confined to that spot. It is occasionally felt in other places, as in the 
shoulder ; in the hollow of the axilla ; beneath the clavicle ; along the sternum : and 
sometimes it is complained of as extending over the whole of one side of the thorax. 
Andral states that he has observed the pain to prevail especially along the cartilagin- 
ous border of the false ribs, when the inflammation has attacked that portion of the 
pleura which covers the upper surface of the diaphragm. He says, too, that in such 
cases, the pain often affects the hypochondrium, and even extends as far as the flank, 
so that it might be mistaken for a symptom of abdominal inflammation. This ob- 
servation is worth remembering. Sharp pain, occupying the right hypochondrium, 
belongs oftener to the pleura than to the peritoneum. 1 have known several instances 
in which such pain was erroneously supposed to be a sign of hepatitis, when in truth 
it resulted from inflammation of the pleura. Cruveilhier observes, also, that he has 
known the pain affect the loins, and simulate lumbago. 

Whatever may be the situation of the pleuritic pain, it is generally increased by 
percussion, by intercostal pressure, by lying on the affected side, by a deep inspira- 
tion, by cough, and by different movements of the body. 

In many patients the pain is exceedingly sharp, whether it be continued, or whe- 
ther it occur only at intervals : the more circumscribed it is, generally the more acute 
it is. The patients are then in a state of great anxiety: they make very short and 
imperfect inspirations, through fear of aggravating the pain ; they dread the least 
effort of coughing, or of sneezing, and suppress the desire to cough which the dis- 
ease may occasion. There are other patients in whom the pain is moderate, is felt 
only when a deep inspiration is made, and is scarcely augmented by pressure or per- 
cussion. And there are even some cases of pleurisy which are unattended with pain 
from first to last. 

The pain commonly exists from the very outset of the pleurisy. It is sometimes 
vague and fugitive at first, and becomes fixed and permanent after a day or two. In 
that case it may be mistaken for a simple rheumatic pain ; for pleurodyne ; or for 
what is thought to be merely a nervous pain. When the pain is increased by shght 
pressure made upon the ribs as well as between them ; when it extends over a large 
space ; when it is unattended with fever ; when it is inconstant or fugitive — we may 
suspect that it is situated in the fibrous and muscular tissue ; but these circumstances 
do not afford any certainty that such is the case. In fact, I have long been of opi- 
nion that some at least of the cases which pass under the name of pleurodyne, are 
really instances of what has been called dry pleurisy. You are aware perhaps that 
adhesions are very constantly found to exist between the lungs and the ribs in per- 
sons dead of pulmonary consumption. Such persons are liable to pains in the chest, 
beneath the clavicles, in the axilla, between the shoulders, at the upper part of the 
dorsal region : in short, in those situations where the adhesions are found after death 
most frequently and in the greatest number. The pains indicated, it may be pre- 
sumed, the periods at which the shghter forms of circumscribed pleurisy, ai tended 
with no other effusion than that of coagulable lymph, took place. And it is probable 
that many cases of pleurodyne are really instances of the same kind of pleuritic 
inflammation. How often do we find, even when there are no tubercles in the lungs, 
firm adhesions between the pulmonary and costal pleuree, in the bodies of persons 
who were never known to have had any pectoral disease ! The pain alone marks 
the inflammation in those cases; adhesion presently ensues ; there is no fever per- 
haps, or none that attracts much notice ; the pain soon subsides, and is soon forgoiten ; 
but the adhesion, the consequence of inflammation, remains: and this is a morbid 
condition which is neither revealed to the sense of hearing, nor in any other way. I 
am much disposed therefore to agree with Cruveilhier in thinking that ''pleurodyne 
is nothing else (in many cases at least) than adhesive pleurisy.'^'' 

I need scarcely repeat the fact which has so many times before been mentioned 
in these lectures, viz., that the inflammation of membranous parts, and especially 
of serous membranes, is attended with much more pain than inflammation of paren- 
chymatous parts. We cannot have a better example of it than is afforded in most 
cases of pneumonia. Most cases of pneumonia are accompanied in the beginning 



586 



PLErRISY. 



with a stitch in the side ; some cases are not. In those cases in which the stitch 
happens, the pleura also is inflamed to a certain degree, and the pain depends 
upon the coexistence of the pleuris}^ : they are cases of pleuro-pneumonia. In 
pure pneumonia, on the contrary, the pleurisy being wanting, the sharp pain is 
wanting also. 

The respiration in pleurisy, at its outset especially, and while there is still pain, 
is considerably embarrassed ; the movements of inspiration in particular are short, 
hurried, and often interrupted or jer4iing. And this depends evidently upon the pain, 
which forbids the free contraction of the muscles that dilate the thorax ; and you may 
often observe that the dilatation is sensibly less on the affected side than on the other. 
Cruveilhier indeed denies this ; or rather he states that he has never observed it : 
but it certainly is not an uncommon phenomenon. I have noticed it, and drawn the 
attention of others to it, again and again. 

When effusion has taken place — that, one can easily understand, will be likely 
to aggravate the dyspnoea ; and it will aggravate it in a greater degree, or in a less, 
according to circumstances. Thus, if the other lung happens to be a diseased lung, 
then the compression of that which is on the side of the pleurisy will have a more 
injurious effect upon the breathing. The dyspnoea arising from the effusion and con- 
sequent pres§ure upon the lung will also be in proportion, first to the amount of the 
effiasion ; and, secondly, to the rapidity with which it has taken place. When 
the effusion has been slow — or when it has long existed, and the case has become 
chronic — the circulation through the lung has had time to accommodate itself to the 
altered condition of the parts, the disturbed equilibrium between the quantity of air 
and the quantity of blood in the lung is restored, and the dyspncea is consequently 
shght. 

But there are very singular exceptions met w^ilh to all this. Andral states (an{3 I 
have seen more than one instance confirmatory to his statement) that there are per- 
sons with pleuritic effusion enough not merely to fill but to dilate that side of the 
chest on which it exists, (and you wull observe that we cannot doubt about the pre- 
sence of the effusion in such a case,) w4io appear nevertheless to be quite free from 
dyspnoea; and that, not while they are at rest merely, for they talk, get up, walk 
about, even take long journeys, without their respiration becoming so short as to 
make them complain of it. Now this is conceivable enough in old and chronic cases ; 
but Andral further affirms that this absence of dyspnoea is not restricted to those 
cases in w^hich the collection of fluid has taken place slowly ; but sometimes happens, 
even in patients in w4iom pleurisy has led to abundant effusion in a few days. He 
gives a case of this kind^ in which the patient was not prevented by an enormous 
pleuritic effusion from carrying on, v/ithout fatigue, in the streets of Paris, his busi- 
ness as a carter. I remember having a butcher in the Middlesex Hospital in ex- 
actly the same predicament ; and nothing could persuade him that he w^as otherwise 
than well, and fit to go out ; and out accordingly he went. Remember, therefore, 
that there are great varieties in this respect. In some patients the dyspncea never 
ceases to be urgent from first to last ; and these are apt to prove fatal cases. In others 
the respiration is very much impeded at first ; then the difficulty of breathing di- 
minishes ; and at length it ceases long before the fluid is reabsorbed. In others 
again, by some unaccountable idiosyncrasy, the respiration remains at all times very 
facile, both at the outset and during the progress of the disease. 

Cough is another of the ordinary symptoms of pleurisy. It does not occur in 
paroxysms. It is small, half-suppressed, ineffectual. In some few cases this symp- 
tom also is entirely absent, even though the inflammation is intense, and the effusion 
into the pleura considerable. When cough does exist, it is dry ; or it is accompanied 
by the expectoration of shght catarrh. If much frothy mucus should be expectorated, 
the pleurisy is complicated with bronchitis : if rust-coloured sputa be brought up, it 
is complicated with pneumonia : and in each case other signs, proper respectively to 
those two diseases,, will be present. 

A good deal has been said and written respecting the position which a patient 
assumes who is labouring under pleurisy. The manner of the decubitus has even 
been regarded as one of the pathognomonic signs of the disease. Yet, strange to 



PLEURISY. 



587 



say, observers are much at variance with each other in respect to this so-called 
pathognomonic symptom. Some affirm that the patient lies on the side affected ; 
others that he can lie only on the sound side ; others again that he lies neither on 
the one side nor on the other ; or even that he hes indifferently in any posture. But 
this dispute is an exact counterpart of that celebrated quarrel which took place about 
the colour of the chatneleon: "they all are right, and all are wrong." I believe 
that, if you narrowly inquire into the facts, they wiU be found to be somewhat as 
follows : — In the outset of the disease, while there is yet pain, the patient cannot he 
on the affected side on account of the pain, which that position exasperates ; he hes 
therefore on the sound side, or on his back ; sometimes he is obliged to sit up. At 
a more advanced period of the disease, when the pain has ceased, and considerable 
effusion has taken place, he cannot lie on the sound side, because of dyspnoea: the 
dilatation of the chest on that side would be impeded by such a posture ; and what 
is more, the effusion, lying uppermost, would press upon the mediastinum, and so 
further tend to restram the expansion of the sound lung. But he is no longer pre- 
vented by pain from lying on the diseased side, and consequently he does, in some 
instances, take that position : but more commonly still he lies in what Andral calls a 
diagonal posture ; i. e., the patient is not on his back, nor on his side, but between 
the two ; on his back, we may say, but inclining towards the affected side. Again, 
however the fact maybe explained, it is certain that there are some few persons who 
lie indifferently on the back or on either side without augmentation of the dyspnoea 
in any of these positions, though one side is choke-fuh of Hquid. 

Now of the symptoms that we have hitherto been considering, the pain, the 
dyspnoea, the cough, the accommodation of position, there is not one which, taken 
alone, can be said to be strictly or absolutely pathognomonic ; or which indicates in 
a positive and certain manner the existence of pleurisy, or of pleuritic effusion. Yet 
when all, or several of them, occur together, they afford a degree of probability on 
these points almost equivalent to certainty. There are yet some other, and more 
conclusive signs, which either in themselves, or taken in conjunction with those 
already mentioned, render the diagnosis of pleurisy easy and sure. These signs are 
furnished by the size of the thorax on the affected side ; by its form and motions ; 
and above all, as you will have anticipated, by percussion and auscultation. 

I have already stated that in some cases, that side of the chest which contains the 
effused fluid becomes evidently larger than the opposite side. The ribs and their 
cartilages present that position which they assume during a deep inspiration : the 
intercosral spaces are pushed outwards and brought up lo the level of the ribs ; and 
occasionally fluctuation may be perceived in those spaces, through the muscles. 
V/hen these appearances are observable, no doubt (or scarcely a doubt) can remain 
concerning the nature of the disease. This dilatation of the thorax on the diseased 
side is more common in old chronic cases than in the earlier periods of acute pleu- 
risy ; yet it may take place in a very short time. Andral declares that he has known 
it sometimes reach a great degree by the fourth or fifth day of the acute disease. 
You may satisfy yourselves that the side is dilated, by measuring it with a string. 
Carry a string round the chest, upon a level with the extremity of the xyphoid 
cartilage, then fold it upon itself, and you will find that the half of it will more than 
encompass the sound moiety of the chest, and will not reach round the disease. The 
diseased side may measure an inch, or an inch and a half, or even sometimes two 
inches, more than the other. But this measurement by a string is seldom necessary. 
The eye takes a very accurate estimate of the comparative volume of the two sides ; 
and the obliteration of the intercostal spaces can only be ascertained by seeing or 
feeling them. It is necessary to remember that, in most persons, the right side is 
naturally somewhat the larger of the two. 

I say when this dilatation is noticed, scarcely a doubt can exist of the true nature 
of the case. Some time ago I should have said no doubt: but having myself mis- 
taken such a case, and seen others mistake it, I introduce this shght quahfication, 
although it is a thousand to one against another such instance occurring to puzzle or 
mislead the observer. My colleague Dr. Hawkins had a patient in the hospital, in 
whom this dilatation of one side of the chest was exceedingly well marked. It was 



588 



PLEURISY. 



the left side that was enlarged ; the heart was evidently pushed over to the right of 
the sternum. This is another circumstance strongly corroborating our conclusion in 
such cases. The intercostal spaces were effaced, and the whole of that side was 
perfectly dull on percussion. The poor fellow had a very unhealthy aspect ; — and 
he had, some time before, suffered amputation of a leg, for what was understood to 
have been scrofulous disease of the knee-joint. It was not unnatural, therefore, that 
every one who saw him should have come to the conclusioh that this was a case of 
empyema ; of fluid, and most likely of pus, collected in the pleura, and very proba- 
bly the result of the extension of scrofulous disease from the lungs. Under these 
circumstances, and inasmuch as his dyspnoea was not urgent, it was not thought 
right to take an}^ steps for evacuating the presumed fluid. The case was pointed 
out to the pupils as a capital example of empyema. At length the patient died ; and 
when his body was examined we discovered — what think you ? not pus, nor serum, 
but a large red solid mass, in the centre of which, when it was divided, was still a 
red, but softer, pultaceous, half-fluid substance. At first it was thought to be can- 
cerous degeneration of the lung ; but it was soon noticed that the solider part was 
arranged in concentric laj^ers, like those which are often seen in aneurismal tumours ; 
and further research showed that the effusion had indeed once been hquid, for it 
consisted entirely of blood, which had coagulated in the manner I have just described. 
And the source of the blood was detected. A portion of two of the ribs had been 
destroyed by ulceration, and one of the intercostal arteries had thus been laid open. 
The lung was found uninjured, but totally empty of air, and pressed flat up against 
the mediastinum. 

No precaution could guard against such a source of fallacy; and you are not 
likely ever to meet with just such another case : yet I have thought it sufficiently 
interesting to relate, in illustration of the subject immediately before us. 

It is urffortunate, as far as the diagnosis is concerned (but not in any other sense), 
that dilatation of the thorax is far from being a constant symptom, even in cases in 
which the effusion is very considerable. 

There is still a cohdition of the thorax to be described, which is the very opposite 
to this. When the effused fluid begins to be reabsorbed — and when some cause or 
other, generally the formation of adventitious membranes, prevents the lung from 
re-expanding, and approaching the ribs in proportion as the fluid is removed — then 
of course the ribs must sink in, and approach the lung, to prevent that void which 
would otherwise exist between the ribs and the lung. Consequently that side of the 
chest on which the fluid has existed becomes narrower than the sound side. And 
the actual difference between the two will be augmented by the circumstance that, 
in such cases, an amphfication of the sound lung, and of the cavity in which it is 
lodged, a true compensatory hypertrophy, commonly takes place. 

This partial or general retraction of one side of the chest is not so much a sign of 
disease actually in progress, as of disease gone by ; and it may exist without evident 
disturbance of the health of any kind. 

Persons who are thus affected have the appearance of being inclined towards the 
diseased side, even when they endeavour to hold themselves upright : and the de- 
formity, for such it is, becomes manifest to the eye when the chest is uncovered. 
You see that the side is narrowed and shrunken. All its dimensions are contracted. 
It measures less, in circumference, by an inch or more, than the other side. The 
shoulder is depressed ; the hypochondrium is tucked up ; and the ribs are drawn 
close together. A patient of mine, whose chest had been punctured (a remedial 
procedure to be spoken of presently), and who drew off' daily, with a syphon, pus 
which did not otherwise find vent, had such difficulty at last in introducing the tube 
between his ribs, that excision of a piece of the bone was contemplated by the emi- 
nent surgeon who had performed the operation. The effect of the atmospheric 
pressure is sometimes so great as to crook the vertebral column, and produce lateral 
curvature of the spine.- This I have myself witnessed. And as one of the unseen 
walls of the cavity, viz., a part of the diaphragm, is carried permanently up under 
♦he ribs, so another of the unseen walls, the mediastinum, is liable to be influenced 
by the tendency to contraction. The heart Avhich, when the left pleura is distended. 



PLEURISY. 



589 



is apt to be thrust over, beyond the sternum on the right, may thus, when the right 
pleura is contracted, be dragged into the same position. In the former case, the 
dull sound given out by the diseased side when struck, will transgress the mesial 
line, and encroach a hitle upon the healthy side : in the latter, the resonance yielded 
by the healthy will transgress the mesial line, and encroach a little upon the diseased 
side. 

The difference of the two sides is so striking, that, at first sight, an observer sup- 
poses it to be even greater than it is actually found to be by admeasurement. Yet 
Laennec tells us that he had met with this deformity in persons who were not them- 
selves aware of its existence. But all such persons had suffered some long disease, 
which appeared to be situated chiefly in the thorax. 

The conditions I have just been describing are physical conditions ; and the signs 
they furnish are physical signs. I have still to speak of the remaining physical 
signs, which are al-so auscultatory signs. What I have already said upon this sub- 
ject in the present lecture will, I trust, enable you almost to foresee the kind of 
information which these signs afford in actual practice. 

As soon as even a shght amount of effusion commences in the pleura, it is an- 
nounced by a diminution of the hollow sound which percussion ehcits in the healthy 
state. In proportion as the effusion becomes more considerable, the chest, when 
struck, gives a sound more and more dull. At first, this flat sound is rendered oppo- 
site the lowermost, depending part only of the cavity ; and this, as I showed you 
before, forms one ground of distinction between the dullness on percussion in pleu- 
risy, and in pneumonia. However, at length, the effusion augmenting, the dead flat 
sound may proceed from the whole of the affected side ; and this forms another 
ground of distinction ; for it is very seldom that the whole lung becomes so solid in 
pneumonia as to yield a uniform dead sound over the whole of one side of the chest. 
Either the dull sound is universal on one side, or it is not. If universal, it is not 
likely to be the result of soHdification by pneumonia; or, I may add, by tubercles : 
if not universal, the dull sound will (except in some rare cases), shift its place as the 
patient akers his posture. 

I may mention another ground of diagnosis, which may be of great assistance 
when the case is seen from the beginning. The dullness comes on much more 
quickly in pleurisy than in pneumonia. It has been noticed within twelve hours 
from the invasion of the disease. In living animals, a considerable quantity of serous 
effusion has often been very rapidly produced by injecting some slightly irritant 
matter into the cavity of the pleura. In pneumonia, the dullness is commonly later 
in its appearance. The induration of the lung is gradual ; and so is the pneumonic 
dullness on percussion : the effusion of serous fluid is early and rapid ; and so also 
is the coming on of the pleuritic dullness. Moreover, as I have just shown you, 
pleurisy may displace the mediastinum, and cause the whole sternum to give a dull 
sound. A hepatized lung will render one-half on\y of it dull. 

The intensity, or completeness too of the dull sound is generally greater in pleurisy 
than in pneumonia. In two days, or even in. twenty-four hours the whole cavity of 
the pleura on one side may be filled quite full ; and the whole of the corresponding 
surface of the chest, from its base to its summit, will yield a sound (to use one of 
Avenbrugger's strong expressions) tanquam percussi femoris. It is very uncommon 
for such total and universal matite, as the French call it, to result from inflammation 
of the lung. 

Again, in the outset of the disease, while there is yet little or no effusion, but 
when the pain is acute, the vesicular breathing is heard more faintly and feebly on 
the painful side than on the other. On that side also the walls of the chest are less 
forcibly expanded. But percussion, when the pain will permit of its being practised, 
gives the same sound on each side. It is clear that the sharpness of the pain causes 
the patient instinctively to expand the chest on that side as little as possible ; and 
consequently the quantity of air that penetrates the lung in a given time is diminished, 
and the respiratory murmur is feeble. 

As soon as elfusion commences, the vesicular rustle is heard still less plainly on 
the affected side ; and in proportion as the fluid increases, that rustle or murmur be- 

2z 



590 



PLEURISY.' 



comes more faint ; and at the same time it becomes more distinct and noisy than 
natural — puerile, in fact — on the sound side. And while the respiratory murmur is 
disappearing on the diseased side, and the spongy lung is becoming empty of air 
from the pressure of the augmenting fluid, and the larger bronchi are surrounded by 
compressed lung and by incompressible liquid, the bronchial sounds begin to be 
heard, which I formerly described — the bronchial voice, the bronchial respiration. 
But the sounds are not exactly the same as those which are heard in pneumonia. 
They are modified by the nature of the substances through which they pass. The 
voice, for example, is still bronchial, still the voice of a person talking into a tube : 
but it has a superadded character; it is trembling, quivering, thrilling, cracked, dis- 
cordant. I strive in vain to convey to you by these epithets a notion of this remark- 
able modification of the voice. Laennec's happy similitudes may enable you to 
form a more exact conception of it. It is hke (he says) the bleating of a goat ; or, 
happier still, it resembles the voice of Punch. But when once you have heard the 
sound, you will never forget it again. I presume that this modification of broncho- 
phony (for such it is, and such I would have you consider it), is caused by the rapid 
undulations communicated to the effused liquid by the vibrations of the bronchi and 
condensed pulmonary tissue. This sound is usually most distinctly heard near the 
inferior angle of the scapula, the patient being in a sitting position. It disappears, 
or merges into pure and distant bronchophony, when the liquid exceeds a certain 
amount, so as to compress the bronchial tubes themselves, and to damp their 
vibration. 

I would have you recollect, therefore, that 3sgo phony, which is the technical ap- 
pellation of the sound I have just been describing (goat-voice), — tegophony is nothing 
more than a species or variety of bronchophony ; and the two run each into the other 
by such fine gradations, that it is sometimes difficult to say Vv'hich it is we are hsten- 
ing to. When the quivering is strongly marked, we may be certain that it denotes 
effusion into the pleura ; when bronchophony only is heard, we cannot be sure, from 
that sound alone, whether there be indurated lung between the ear and the bronchi; 
or a liquid, and a portion of compressed and Condensed lung: but other phenomena 
complete the diagnosis. 

Do not forget that when any modification of the voice is heard, or thought to be 
heard, on the suspected side, the sound of the voice in the corresponding part of the 
other side of the chest must be ascertained also. It is only by a comparison of the 
two sides that we can come to any safe conclusion ; and that comparison becomes 
often a striking and most instructive contrast. 



LECTURE LIIl. 

Pleurisy continued. Recapitulation of Symptoms ; of Diagnostic Signs. Causes 
of Pleurisy. Pneumothorax; its Conditions and Signs. Treatment of Pleu- 
risy. Empyema. Paracentesis Thoracis. 

In the last lecture I enumerated the symptoms, general and physical, which are 
met with, more of them or fewer, in cases of acute pleurisy. I then considered them 
singly : it may be well to take a rapid recapitulatory view of them as they exist 
together or in succession, and compose the actual disease. 

The outset, then, of pleurisy is marked by sharp stabbing pain, most commonly 
situated beneath one of the breasts, and preceded or accompanied by rigors. These 
two signs, the stitch and the shivering, are sufficient of themselves to awaken a 
strong suspicion that pleuritis has set in. At the same time there are usually a dry 
cough ; a dread of breathing ; a check or catch in the inspiration, which is curbed, 
so to speak, by the pain ; fever ; often a comparatively feeble respiratory murmur 
on that side on which the pain is felt ; and the patient cannot lie on. that side. If no 



PLEURISY. 



591 



liquid effusion takes place, these symptoms ordinarily disappear at the end of a few 
days, and the patient recovers. The case has been a case of dry pleurisy ; and the 
chances are much in favour of the lung having become permanently adherent to the 
ribs. 

I should have said, with respect to the fever, that at the outset of the pleurisy it 
is often high. And it was matter of observation long before the method of ausculta- 
tion was thought of, as well as since, that in the acute period of the disease ihe pulse 
is remarkable for its hardness, and forms a contrast with the soft pulse of pneumonia, 
and with the small and contracted pulse of inflammation of the serous membranes 
of the abdomen. Indeed, the older physicians laid great stress upon the quality of 
the pulse, in their endeavours to distinguish pleurisy from pneumonia. 

But to resume the description of the symptoms of pleuritis. Where effusion 
takes place (and it does so very early, so as to form a part of the complaint, just in 
the same sense in which expectoration forms a part of catarrh), the sound ehcited by 
percussion becomes dull on the side on which the effusion exists. While the effu- 
sion is moderate, the dullness shifts its place according to the posture of the patient, 
and is heard only when the lowermost part of the chest is struck. But the fluid 
may soon increase so much as completely to fill the pleura; and then the whole of 
that side is dull. Meanwhile the murmur of respiration becomes feeble and faint, 
and at length, as the effusion augments, ceases altogether; while on the sound side 
it grows noisy and puerile. Tubular breathing, and that modification of the bron- 
chial voice which medical men have agreed to call segophony, become audible during 
the early periods of the efliision. ^Egophony is heard, however, only so long as the 
quantity of liquid poured out observes a specific limit. There must be a certain 
amount of effusion — and there must not be more than a certain amount. T have 
sometimes thought that the peculiar sound depended on the undulations produced in 
the surface of the liquid by the bronchial vibrations. It certainly is somehow con- 
nected with the presence of a stratum of liquid between the lung and the ear. When 
the lung is strongly compressed, and especially when the cavity is stretched and dis- 
tended by the enclosed fluid, the side is necessarily motionless ; no tubular or other 
breathing can any longer be heard, or even occur : nor is the voice conducted, except 
perhaps very faintly, to the listening ear of the physician. 

When the efflision is great, that side of the thorax on which it has taken place 
becomes, often, more or less dilated; and I should add, that the integuments on the 
same side are frequently osdematous. The patient now cannot lie on the sound 
side ; and the most common posture is that which is intermediate between the 
supine position and the lateral ; he fies towards, but not, in general, on, the affected 
side. 

I observed, in the last lecture, that this inabihty, after the effusion has reached a 
certain point, to he on the sound side, might be accounted for in two ways. Partly 
it may be owing to the impediment which lying on the sound side offers to that side's 
expansion. The muscles which dilate the healthy side have then to lift, as it were, 
the weight of the body, and are, some of them, pressed ' upon and encumbered in 
their action by that posture. But the inability in question is chiefly attributable to 
another circumstance, viz., the pressure exercised by the effused fluid downwards, 
through the mediastinum, upon the only lung that is left to perform the function of 
breathing. Now, disputes or differences of opinion have arisen as to which of these 
two circumstances is the most efficient cause in this matter ; and therefore it may not 
'be amiss to provide you with the facts which prove that the last-mentioned cause is, 
in reality, the most operative — I mean the weight of the superincumbent liquid, in 
the supposed position, upon the mediastinum and upon the heakhy lung below it. 
This is shown by the fact that patients, to whom the decubitus on the sound side 
had previously been impossible, on account of dyspnosa, have been able to rest in 
that position immediately after the artificial evacuation of the fluid. Now, in such 
a case, the obstruction to the dilatation of the healthy side, produced by placing it 
under the weight of the body, would remain the same as before, or nearly so. A 
hospital patient of mine, named Coggs, could not breathe if he attempted to he on 
his right side. His left pleura was distended by liquid effusion. I thought fit to 



592 PLEURISY. I 

have paracentesis performed ; and the poor man was greatly delighted to find him- 
self at once enabled by it to assume the posture which his weariness had long made 
him wish for, but which he had not been capable of enduring. We found by per- 
cussion that the diseased side was now filled with air ; the compressed lung had not 
risen at all; so that the necessity for the free expansion of the sound side was just 
as great as before the operation. You may find a precisely similar consequence of 
the same operation related in the fifth volume of the Dublin Transactions. 

The cede ma that is sometimes observed on the diseased side is more or less con- 
nected, probably, with the habitual position of the patient. 

There is yet another sign of pleuritic effusion, which, as it is very simple, and 
readily perceived by even the least instructed observer, is too valuable to be neglect- 
ed. In most persons, one's open hand, laid flat upon the surface of the chest, feels 
the vibration or thrill which the voice occasions when the person speaks. Now, in 
a case of pleurisy with eff'usion, you will generally find a remarkable contrast be- 
tween the two sides in this respect ; i. e., the thrill is strong and evident on the sound 
side, and not perceptible at all on the other. Whereas, when the whole side is dull 
in consequence of solidity of the lung, the thrill is much augmented on that side. 
But this thrill is not always present in the healthy state, and then we can infer 
nothing from its absence on the diseased side. 

After a while, when the fever has ceased, the liquid begins to be reabsorbed : but 
as, in many cases, the lung is more or less bound down by adhesions, or overlaid by 
a membranous stratum of lymph, it cannot expand in proportion as the hquid is re- 
moved : and the necessary consequence is, that shrinking of the affected side in all 
its dimensions, which I fully described yesterday. 

Let me now briefly re-state the points of distinction between pleuritic effusion and 
pneumonic consohdation, when the one or the other of these two morbid conditions 
is proved to exist by dullness on percussion, extending over the whole of one side 
of the chest. The question is one which frequently arises ; and it is one of much 
interest and importance. 

First, then, we distinguish these different conditions, having some physical signs 
in common, by their history. In pleurisy, sharp pain, and a dry cough, or perhaps 
no cough, precede the dullness : and we have not the crepitation, nor the rust- 
coloured sputa, which are antecedent to the dullness of pneumonia. 

We cannot, however, always learn the previous history of a given case. 

Secondly, a lung rendered sohd by inflammation does not distend the cavity. 
Copious pleuritic effusion most frequently does. In the first case, therefore, we 
have not that separation of the ribs, that obliteration of the intercostal depressions, 
that protrusion of the corresponding hypochondrium, that mensurable enlargement 
of the side, that extension of the dull sound beyond the middle of the sternum, or 
that displacement of the heart, which are, some or all of them, apt to result from a 
collection of liquid in the pleura. 

Thirdly, the solid lung transmits the voice from the pervious bronchi to the sur- 
face of the thorax ; and if any motion of the affected side Temains, it transmits also 
the sound made by the passage of the air through them. These phenomena are 
wanting when the pleura is so stretched by its Hquid contents as to make the side 
everywhere dull to percussion. 

Fourthly, the vibration of the thoracic parietes, caused by the patient's voice, is | 
augmented by consolidation of the lung ; prevented when it is strongly compressed ' 
by imprisoned liquid. The increase of this thrill can be fek therefore in the one 
case ; its diminution in the other. 

The simple test fails to be apphcable when, from the feebleness, or the high pitch, 
of the person's voice, no thrill is perceptible on either side in the healthy state. 

Fifthly, a patient having one lung sohd, is generally indifferent as to posture. A 
patient having one pleura quite full of liquid, lies (usually) on or towards that side ; 
and is distressed and suffers dyspnoea if he attempts to lie on the other. 



It is of more importance that we should inquire into the exciting causes of pleu ;, 
risy than into those which give rise to pneumonia. They are more numerous and I 



PLEURISY. 



593 



I complicated, and have a more direct bearing upon the prognosis and treatment in the 
i one case than in the other. I do not desire to refine too much ; and therefore I shall 
I restrict myself to those causes which are obvious, and which you are likely to meet 
with in practice. 

1 merely say of exposure to cold, as an exciting cause of pleurisy, that it is a very 

I common — the most common — cause. You know already all that I can tell you of 
the circumstances that are likely to render that cause elfectual in producing internal 

II inflammations, and, among the rest, pleuritic inflammation. 

But pleurisy is often occasioned by mechanical violence ; or by the accidental 
extension of disease from other parts; and the course, and the event of the disease, 
|. are liable to be considerably modified by the nature of its cause in such cases. 
! Pleurisy may be excited by the splintered ends of a broken rib ; and if the pul- 
' monary pleura be wounded in that manner, air may get into the pleural cavity, as 
I well as into the areolar tissue beneath the skin ; constituting the true and genuine 
! emphysema of our forefathers. Pleurisy may be determined also by a penetrating 
I wound of the thorax ; or by a perforating ulcer of the pulmonary pleura, the exten-, 
I sion of a tubercular excavation. In the one case air will enter from w^ithout, if the 
aperture be sufficiently large ; in the other, air will pass from the lung into the cavity 
of the pleura. In all of these cases of air finding its way into this serous sac while 
in a state of inflammation, the event of that inflammation is much more likely to be 
I the efl'usion of pus, than when no communication exists between the inflamed mem- 
; brane and the atmosphere. This I have mentioned, and offered some explanation 
I of, before. But another very curious consequence results from the admission of the 
air, and its coexistence with puriform or other liquids in the sac of the pleura. New 
auscultatory signs arise, very easily appreciated, very instructive, and therefore very 
necessary for you to be acquainted with. 

You must know that when the pleura contains air alone, the patient *is s^d to 
have pneumothorax ; and when (what is infinitely more common) the air is there in 
company with liquid, he is said to have pneumothorax with effusion. This is the 
name given to that condition of the chest by Laennec ; and it serves its purpose 
sufficiently well. I shall take leave to employ the simple term pneumothorax, in 
speaking of either condition ; whether there be liquid also in the pleural cavity or 
not. Pneumothorax, then, often proceeds from one or other of those causes of pleu- 
risy just mentioned. It is sometimes produced by the operation of paracentesis tho- 
racis ; by the opening made into the thorax by the trocar of the surgeon, in order to 
let out its fluid contents; in plain English, by tapping the chest. The modifications 
of sound that result are particularly curious. Of course the air occupies the higher 
portion of the cavity and the Hquid the lower, in whatever position the patient may 
be placed. And this being the case, percussion will give a remarkably hollow 
sound when made upon the uppermost part, and a totally dull and flat sound when 
made upon the lowermost part : and the change from the hollow to the dull sound 
will often take place quite abruptly, so that you may trace out the exact level at 
which the surface of the effused liquid stands. And if you reverse the posture of 
the patient, the resonant and the dull sounds will interchange their respective places : 
the uppermost part always yielding the clear, and the undermost the flat sound. 
This is just what you would expect. The result of the experiment is the same 
whether you make it upon the human thorax, or upon a beer-barrel. The resonant 
part, you are to observe, wiU be much more resonant than it would be in health — 
more resonant (you have always the other lung to test it by) than the corresponding 
portion of the opposite side of the chest — tympanitic, drum-like : for the air is not 
involved in spongy lung, but contained in a free space ; and the sound is not damped, 
as in a healthy chest it is damped somewhat, by the presence of the lung. More- 
over no respiratory murmur can be heard where this tympanitic resonance occurs : 
nor can any thrill be felt. Now I say all this is no more than you must have fore- 
seen. But the sounds detected in this new condition of things by the^ear applied to 
the chest, as the patient breathes, or speaks, or coughs, you would not, I think, have 
anticipated. You hear then a sound which I must endeavour to describe in words, 
but which you will scarcely form a right conception of till you have heard it, and 
38 2z3 



594 



PLEURISY. 



then all further verbal description will be needless. T can describe it by similitudes 
only. The patient's breathing is hke the noise produced by blowing obliquely into 
an empty flask ; and so the French have given the sound the somewhat magnificent 
title of " amphoric resonance." I have heard, fifty times over, exactly the sound in 
question -when I have been out shooting in a rough day, and the wind has blown 
sideways into the gun-barrel. It is a ringing metaUic sound. When this is present 
during the breathing, the voice also has, even more strongly in general, this metalHc 
character ; and so has the cough ; and each of them is apt to be succeeded by a 
tinkhng echo. The voice and cough resemble those of a person who speaks or 
coughs into a deep well : or with his head bent over an empty copper boiler. The 
same ringing quality is often heard when one speaks in a large vaulted room ; or 
beneath the arch of a stone bridge. You may perhaps now have some idea of what 
these metaUic sounds are. They are very singular : and they are perfectly decisive 
(as far as my experience has gone) of the presence of air in a considerable cavity, 
within the thorax ; which cavity mostly contains liquid also : and of the presence 
of air and liquid in the cavity of the pleura in particular. I do not know that the 
liquid is essential : I do not believe it is ; but commonly there is some hquid, and a 
good deal of air. Almost always too — but that is not indispensable — the cavity 
communicates with the external air, either through the walls of the chest, or through 
the bronchi. Neither is it necessary that the cavity should be in the pleura, for it 
may be in the lung: and when we come to speak of phthisis I shall point out the 
circumstances which will enable you to determine whether the sounds proceed from 
a tubercular cavity, or from the sac of the pleura. What you wiU please to remem- 
ber is, that in actual practice, in ninety-nine cases out of a hundred, these sounds 
will be found to denote the presence of both air and hquid in the cavity of the pleura ; 
and the probable existence of some passage of communication between that cavity 
and the external air : in a single word, they will reveal the existence of pneumo- 
thorax. The voice reverberates in the httle cavern just as it does in a large empty 
room with a stone roof ; and this is the best explanation I can give you of the phe- 
nomenon. Sometimes, as you are listening, especially if the patient has recently 
changed his posture, you will hear a sound just like that occasioned by dropping a 
pin's head into a glass vase, or into a metal basin ; and to this sound the name of 
metallic tinkling has been given. Tt really often closely resembles the distant 
tinkhng of a sheep-beJl. This is supposed to result from the dropping of the liquid 
from the upper part of the cavity ; or sometimes from the bursting of a bubble on 
the surface of the liquid during respiration. You may succeed now and then in 
hearing a species of the same metal he tinkling by applying the stethoscope over the 
stomach, when percussion has already taught you that it is distended with gas, and 
by getting the patient to swallow some drink in successive teaspoonfuls. 

Another auscultatory sound, arising out of the same condition, viz., the presence 
of both air and liquid in the cavity of the pleura, and known even as early as the 
time of Hippocrates, is rendered audible by succussion of the patient's body. You 
lay your ear upon his side, and get him to give his body a sudden jerk or jog; or 
you get some one else to take him by the shoulders and shake him ; and you hear 
the liquid splashing within : just as you hear it w^hen you shake a cask that is 
neither full nor empty of water. This is an unequivocal indication of pneumo- 
thorax ; and demonstrates beyond a doubt that there are both air and hquid in the 
pleural sac ; for no sound would arise if there was hquid only. A moderate quan- 
tity of liquid will make a greater squash than a large quantity. Unequivocal I say 
it is, because one could scarcely be misled by the splashing which may sometimes 
arise from wind and water mingling in the stomach. I wish that a patient, who 
was under my observation for some months last 5'ear in the Middlesex Hospital, and 
could produce this splashing noise at will, were there now; for he was not a little 
proud of his fatal gift, and I should have brought him down here to-day, and given 
you an opportunity of hearing this sound for yourselves, worth a dozen descriptions 
of it. 

It is surprising how long this state of things within the thorax may last, without 
any great declension of the patient's general health and strength, even when the 



PLEURISY. 



595 



I disease is (as it mostly is) incurable. Two men, patients of mine, both of whom had 
I well-marked pneumothorax in connection with tubercular phthisis, remained in the 
I hospital for several months ; til], in fact, I could conscientiously keep them there no 
I longer: and each of them went away in very tolerable plight. 1 was unable to 
i'; trace them afterwards, for they returned to their homes, the one in Ireland, and the 
other in the north of Scotland. 

You see, then, that the conditions of pleurisy, and the symptoms of those condi- 
; tions, may be modified by its causes. All those causes that imply the introduction 
of air into the cavity of the pleura, imply also a more serious state of disease than 
resuks from most other causes. The perforation of the pleura, by the extension of 
I a vomica, I have mentioned as one of those causes. But tubercles in the lungs are 
! frequently, very frequently, the cause of pleurisy, when no such perforation has 
I taken place. A tubercle, or a group of tubercles, approaches the surface of the 
j lung, but does not break through. Generally the pleurisy so produced is slight and 
! partial, and ends in the formation of adhesions : it ,is dry pleurisy. - And this ver}^ 
common occurrence of adhesions between the costal and pulmonary pleuras, in the 
• course of tubercular disease of the luugs, is, in truth, one reason why perforation of 
the pleura, and pneumothorax from that cause, is comparatively so rare. The part 
where the perforation is likely to take place has generally, though not always, been 
secured and clouted, as it were, by previous adhesion. So that even here we find 
j that inflammation has a conservative tendency, and helps to postpone the fatal ending 
: of the specific disease. 

I Pleurisy may terminate in resolution and complete recovery; or in adhesion, 
which is its next best termination, and which obtains for the patient, at the expense 
' of some trifling embarrassment of his breathing, complete security for the future 
against the dangers of pleuritic effusion. Again, acute pleurisy may end in chronic 
disease of the pleural cavity : i. e., in a shrinking inwards of the w^alls of the chest, 
attended with total uselessness, or a very imperfect and hmited use, of the corres- 
ponding lung. Lastly, pleurisy may terminate in death. It may cause effusion so 
copious, that the patient will die of actual suffocation, unless the fluid be removed by 
I art. On the other hand, he may die worn out and exhausted by the disease, espe- 
cially if it be attended with suppuration. In that case he will suffer hectic fever, 
and all its wasting and mournful accompaniments ; and death ultimately by asthenia. 
It is seldom that simple idiopathic pleurisy proves fatal. 

As the matter from a tubercular cavity may break in upon the pleural sac, and 
lead to the admission of air, and the establishment of pneumothorax ; so the puriform 
fluid which has resulted from inflammation of the pleura, and was for some time 
imprisoned in its sac, may also break out, and the result will still be the admission 
of air, and pneumothorax. This is not a very frequent resuk of pleurisy, however. 
When it occurs, an abscess forms externally, generally in front of the chest ; and 
either the abscess bursts, or it is opened by the surgeon, and then it is found to com- 
municate with the cavity of the pleura. 

Sometimes air is effused into the sac of the pleura, in consequence of the rupture 
of dilated air-cells on the surface of the lung: sometimes gas is generated there from 
the decomposition of effused liquids ; and in such cases the gas has a strong odour, 
like that of sulphuretted hydrogen : sometimes, again, gas appears to be secreted 
from the membrane itself. All these events are, however, uncommon. When air, 
from whatever source, is shut up in the cavity of the pleura, and goes on accumu- 
lating there, it w^ill compress the lung, just as certainly and effectually as if there 
were a liquid extravasated. And such compression, if suddenly brought about, may 
cause speedy death by apncea : and this is more apt to occur from a puncture of the 
pulmonary pleura by the extremity of a fractured rib, than from any other cause. 

As to the treatment of pleurisy, you will have anticipated that in the outset of the 
disease we must have recourse to the lancet. I have stated, more than once, that 
blood-letting tells more, and is better borne, in inflammation of serous m_embranes, 
than in any other case. If you see the patient while the stitch in the side, and the 
restrained and cautious respiration are present, you will bleed him, in the upright 



596 PLEURISY. 

posture, from a large orifice, until the pain is relieved, and lie can draw a full breath 
again with ease and satisfaction ; or until he is about to faint. And if the pain and 
catch in the breathing should return, and the pulse continue firm and hard, you will 
bleed again in the same way ; or cover the painful side with leeches ; or abstract 
blood by the cupping-glass and scarificator. It is best to bleed fearlessly at first ; 
and in proportion as you do so, the chance will be diminished of a repetition of the 
blood-letting being needed. The blood, in pleuritis, is always deeply buffed and 
cupped. 

Tartar emetic, which is sq useful when the mucous membrane of the air-passages 
is inflamed, is not adapted to inflammation of the pleura. On the other hand, mer- 
cury, from its well-known power to check the effusion of coagulable lymph, is espe- 
cially indicated. Of course it is to be giv€n with a view to its specific effect on the 
system; i: e., in equal doses, repeated at frequent and equal intervals, and guarded 
by a small quantity of opium. And in very severe cases, or when the internal 
employment of mercury is in any way contra-indicated, recourse must be had to 
inunction of the linimentum hydrargyri, or of the strong mercurial ointment. 

By the early and vigorous adoption of these measures, the inflammation may 
generally be subdued in no long time. If, though the fever diminish, there still be 
pain in any part of the chest, leeches may be again applied, or the part may be 
covered with a blister. I do not think a blister does any good, — on the contrar}'', it 
is likely, by the additional irritation it causes, to do harm — while the inflammation is 
yet recent and active. 

But though pain may have ceased, and no fe\'er remains, and the patient is not 
conscious of much dyspnoea, there may be, and there often will be evidence, not to 
be mistaken, of effusion into the cavity of the pleura. Dullness, I mean, on percus- 
sion, bronchial respiration, eegophony ; and the object of our treatment is now to get 
rid of the fluid. We seek to do so by keeping the patient on low diet. The more 
(says Broussais, with some quaintness), the more the patient eats, the sooner he will 
die. We pursue the same object by keeping his gums tender with mercury ; by 
applying blisters one after another to the afiectecl side ; and by purgatives, and 
diuretics. By keeping the vessels empty we facilitate as much as in us Hes, the 
absorption of the liquid contents of the pleura. A very good form of diuretic for 
this state of matters is a combination of squills, digitalis, and me rcury. Flaif a grain 
of digitalis, one grain of squills, and three or five grains of blue piil, repeated and 
continued according to the state of the mouth. 

Under this kind of treatment the effused fluid will often be completely removed ; 
and the chest restored to its former state. I last week dismissed a lad from the 
hospital in whom all this was accomplished. 

But in other cases, though the fever and the inflammation are at an end, and ab- 
sorption of the liquid takes place, the parts within the thorax do not revert to their 
original condition. This we know by that shrinking of its dimensions on the side 
affected, which was described in the last lecture. This shrinking and narrowing are 
the necessary consequence of the absorption of the liquid, unless the compressed 
lung dilates again in proportion as the fluid is taken up. In most cases of this kind 
the lung cannot rise; being bound down by thick and firm false membranes: and 
then the deformity is irremediable, and lasts for life. If the lung is completely 
emptied of air, and enveloped by strong bands of lymph, so that it is permanently 
unable to admit air again — in that case, as the bony framework of the thorax can 
yield to a certain extent only, there will always remain, I presume, some fiquid in 
the pleural cavity. If, again, the lung recovers a part of its lost volume, and meets 
the contracting parietes of the chest, adhesion may take place : and the cavity of the 
pleura be obliterated by thick layers of false membrane. And other changes are 
apt to arise in the lymph which is adherent to the pleura in these cases of im.perfect 
repair. Sometimes tubercles form in it. Sometimes ossific matter is deposited. I 
shov/ you a fine specimen of this kind of ossification of the pleura. There is yet ' 
another supposable case : the investing adventitious membrane may be thin and 
weak, and yielding; and though the lung may not expand to its full dimensions at \ 
first, it may gradually force its way against the binding power of the coagulable 



PLEURISY. 



597 



lymph, and then the external configuration of the chest may be restored, and the 
symmetry between the two sides return. That this sometimes takes place I cannot 
doubt: but I have only once met with a case in which the dwindling of the side 
was entirely recovered from. In May, 1834, I was asked to see a child four years 
old, who had had cough, and had wasted to mere skin and bone, after scarlet fever. 
I found the whole of the right side of the chest perfectly dull on percussion, and no 
respiration could be heard on that side. He was taken by his parents into the 
country, and I did not see him again for some weeks. He then had ceased to cough, 
and, in a great measure, had regained his strength ; but he presented, on the side 
which had been dull, the most marked and complete example I ever saw of the 
sinking in of the ribs, flattening and contraction of the chest, and depression of the 
shoulder, which denote bygone pleurisy and diminished size of the lung. About a 
year from the occurrence of the original disease his father brought him to my house, 
that I might see the change which had again taken place. The boy was plump and 
rosy, and in perfect health; the right side of the chest was as full and round as the 
other ; the symmetry of the two sides was completely restored ; the breathing natural 
and perfect ; and the sound on percussion hollow. His father, to whom the former 
shrunk state of the side had been pointed out, told me that he had watched, with 
deep interest, the process of recovery, and that it had been very gradual. Whether 
after once having sunk in, the ribs ever quite return to their natural position in the 
adult subject, I do not know. I have never seen that happen. 

There are yet other cases in which the effusion continues and increases, and the 
side, instead of shrinking, enlarges ; the functions of the lung on that side are en- 
tirely abolished; nay, the use of the remaining lung is greatly interfered with, by 
the pushing over of the mediastinum ; and the patient is in imminent danger of 
sulTocation. In such cases, whether the effusion has taken place rapidly or slowly 
—whether the disease has been acute or chronic pleurisy — we must reheve the op- 
pressed lung by letting the fluid out — by tapping the thorax ; and the sooner that 
is done, when such a state of things exists, the better. 

The operation is not difficult, nor formidable ; but a mistake in the diagnosis may 
be very formidable. I have heard of two instances, one in Scotland, and one in this 
town, in which the operation of paracentesis thoracis was determined on, to reheve 
the oppression caused by empyema : but the opening was made on the wrong side ; 
and the patient in three minutes was, in each case, a corpse. There was effusion, 
which had already put a stop to the play of one lung ; and upon air being admitted 
to the surface of the other, it collapsed also, and immediate suffocation took place. 
I do not mention these mishaps to deter you from performing the operation. They 
both took place some years ago. Such a mistake would be unpardonable now. But 
I mention them to show the necessity of our being sure of our ground before we 
proceed to open the thorax of a Uving person. A surgeon told me very recently 
that with the sanction, and at the suggestion, of a physician, who understands aus- 
cultation exceedingly well I believe, he passed a trocar into the chest of a patient ; 
but no fluid followed, to the no small mortification of the physician. This proved to 
be a case of malignant disease of the lung; and fluid was let out afterwards by 
puncturing the ihorax in another place, and much relief afforded ; although of course 
the disease proved ukimately fatal. The surgeon informed me that he had suspected 
the true nature of the case, from observing a livid protrusion in front; which was in 
fact, the specific disease making its way through. 

You will take care, then, to survey the chest narrowly before you plunge a trocar 
into it. If you see by your eye, and ascertain by measurement, that one side is 
larger than the other ; if the intercostal depressions be effaced on that side ; if the 
whole surface affords a dull sound when percussed ; if the side does not move at all, 
or scarcely moves during respiration ; if no vibration can be felt on that side when 
the patient speaks ; if no breathing can be heard in the corresponding lung ; if the 
heart be found beating in an unnatural place, down towards the left hypochondrium, 
or in the other direction on the right of the sternum ; and if, at the same time, the 
other side of the chest moves freely, sounds resonantlj^, communicates a thrill to the 



598 



PLEURISY. 



hand while the patient converses, and is full of puerile respiration ; then you may ' 
be sure that the larger side is distended with fluid. 

But it does not follow that you should, therefore, open that side. The propriety 
of doing so will depend upon circumstances. 

In my judgment, that operation ought never to be performed unless the life of the | 

patient is, or seems to be, in jeopardy, from the continued presence of the liquid | 

within the thorax. ' 

Now, life is plainly in jeopardy when the vital functions of the lungs, or of the | 

heart, are greatly hindered ; when symptoms present themselves of approaching ' 

death by apncea, or by syncope. If we discover no cause for those symptoms, | 
except the increasing pressure of liquid pent up in the pleura, we are warranted in 

ascribing them to such pressure, and bound to act upon that persuasion. When- ' 

ever, with the physical signs of abundant effusion, we have great labour and dis- ; 

tress of breathing; an anxious and hvid aspect; a tendency to delirium — or extreme | 

faintness, and a vanishing pulse — there is no time to be lost : it is our duty to pro | 

pose and to urge the mechanical removal of the pressure, which must else be fatal. I 

Again, when the patient, without suffering much dyspnoea while he hes quiet, is I 

yet evidently losing ground from day to day, and early death by asthenia appears to | 

be inevitable, without the operation ; and when all other means for getting rid of the i 

imprisoned hquid have failed ; and when no other condition of disease, or of advanced | 

age, exists to account for the progressive sinking; then also, in my opinion, the | 

patient should not be denied the chance which the operation may afford. j 

Thirdly, whenever (no matter how we ascertain the fact) the effused liquid con- j 

sists of pus, it should be let out. , 

In either of these three predicaments, and in no other, should we be justified (as 
I think) in making an opening into the living thorax. 

But I wish to be understood as giving you simply the impression which my own 

experience has made upon my own mind. I know that some practitioners recom- ' 
mend the early employment of the trocar ; while (they say) the false membranes, 
which are apt to prevent the comipressed lung from expanding again, are yet tender 
and unorganized. But surely we should risk much, and gain nothing, by admitting 

air into the pleura while the inflammation is still in progress. Most cases of mere | 

pleurisy with effusion do well. The mortality from uncomphcated pleurisy is ex- | 

ceedingly small. It would, I fear, be vastly augmented if every patient having mani- | 

fest effusion were to be tapped. The danger of the operation is this ; — that it may, | 

and probably will, induce suppuration, or cause the effused liquid to become putrid. j 

Generally the effusion consists of serous fluid, which is at length spontaneously re- j 

absorbed ; the lung expands again, or the walls of the chest shrink inwards : and [ 

the ultimate state of such a patient is as good as it probably would have been after j 

a successful tapping. j 

To make assurance doubly sure, it is always right, before proceeding to the ope- | 

ration of paracentesis, to adopt the expedient first suggested and used, I believe, by | 

Dr. Thomas Davies, of trying the chest by means of a grooved needle ; making a I 

tentative exploration of the nature of its contents in that manner. The passage of ' 

this little instrument — like the dismissal of a pilot balloon — affords information ; 

which is useful in guiding the particulars of the subsequent process. It not only | 

ascertains that there really is liquid within the pleura, but it discovers the kind and j 
quality, and exact place, of the liquid. If it be serous, it will flxow readily along the 

groove, and trickle down the patient's side. If it be puriforra and thick, it will not ' 

exude so freely, but a drop or two will probably be visible at the external orifice ; j 

and when the needle is withdrawn, its groove will be found to contain pus. In the j 

former case, it is possible that there may be no false membranes ; in the latter, they i 
are likely to be thick. You would use a larger trocar to evacuate the thicker fluid. 

The puncture thus made is quite harmless, and inflicts very trifling pain. Dr. ' 
Davies gives this useful piece of advice in respect to the trocar, that its point should 
be sharp; for otherwise, after the serous membrane has been penetrated, if there 

happen to be thick tough layers of coagulable lymph, not very closely attached to | 



PLEURISY. 



599 



the costal pleura, they may be driven before the instrument, and so the liquid will 
not be reached, but the operator wiil be perplexed and baffled. 

Connected with the operation itse]f there are some questions concerning which 
medical opinions and medical practice are not yet settled. I do not pretend to decide 
these questions; yet I cannot pass them by — I must point them out to you; and I 
shall, at the same time, state what my own observation has suggested in regard to 
them. 

1. Should all the liquid be let out at once ? 

Some say yes : some say no. If we appeal to experience on this point, we obtain 
no satisfactory answer. I have known patients get rapidly and perfectly well, after 
as complete an evacuation of the liquid as was possible. On the other hand, I have 
heard of speedy recovery when, by a sort of accident, very little had been with- 
drawn ; enough to relieve the pressing distress ; but much less than the operator 
intended. 

We must try the matter, therefore, by our reason. 

I think it very probable that when the serous membrane is stretched by the pres- 
sure of its contents, its natural absorbing power may be lessened. But we have no 
reason to suppose that the mere rehef of this tension will often suffice to renew the 
process of absorption, and to enable the flattened lung to re-expand. 

The theoretic objection to the thorough emptying of the thorax in such cases is (I 
conceive), that the introduction of air is likely to be hurtful, by converting the adhe- 
sive into the suppurative form of inflammation, and by promoting decomposition of 
the extravasated fluids. No doubt there is this risk ; but, in general, it cannot be 
avoided. Unless the lung freely rises at once, the liquid cannot all, nor even much, 
of it, come out, without air getting in. Some attempts have indeed been made, of 
late, to draw the water into an exhausted bag, by the help of a pipe and stop-cocks. 
But it is obvious that, in most cases, very little can be so abstracted. The mere 
admission of air to the pleura does not necessarily create inflammation of the mem- 
brane. This we know from what happens sometimes in emphysema produced by 
a fractured rib. In the only instance of pure pneumothorax which I ever saw, the 
sac of the pleura had become half-filled with air, through a very minute opening in 
the pulmonary membrane, communicating with the air-passages. There was no 
inflammation of the pleura in that case. Except that it was preternaturally dry^ it 
seemed perfectly healthy. Neither does the access of air necessarily superinduce 
suppuration in the membrane already inflamed. Certainly, if pus follows the passage 
of the instrument, as much should be removed as we can get. And, for my own 
part, I should take away as much as would come, if the inclosed hquid proved to 
be serous. 

2dly. Is the orifice to be healed up, or to be kept open ? 

Here, also, practical men differ. I should say, if pus comes out, by all means 
keep the aperture open ; and inasmuch as detention of the pus would be injurious, 
and the depending point is difficult to hit, and the orifice is apt to clog, I would do 
more than leave it open : I would draw the puriform fluid off" twice a day by a 
syphon. 

If serum is let out, by all means close and heal the wound. Then, if all goes on 
well, our object is achieved. But should the condition of the patient fail to improve ; 
should hectic fever, after a day or two, set in or even continue ; should much consti- 
tutional distress or disturbance arise ; — under such circumstances, I would re-open 
the wound. There was mere serum, or liquor sanguinis : there now is, in all pro- 
babihty, puriform matter pent up in the pleura, and even stinking and poisonous 
gases. 

On six occasions I have myself witnessed the evacuation, by puncture, from the 
human pleura, of a clear transparent liquid. Some of the patients were under my 
own charge, some under the charge of others. Of these six patients, one died the 
day after the operation ; I can scarcely say why. She was an extremely timid and 
susceptible young woman ; and I am inclined to attribute her death to the shock pro- 
duced, by apprehension of the operation, upon her sensitive nervous system. Two 
others recovered forthwith, and perfectly. The wound presently healed in the three 



600 



PLEURISY. 



remaining cases also ; but in one of the three it soon broke out again, and a quantity 
of healthy pus was discharged daily. After some time, the expedient of keeping 
the cavity free from accumuJated pus by the use of a syphon was resorted to. Under 
this plan the discharge became gradually less and less, and at the end of many 
months it finally ceased. The patient has a contracted chest, but his general health 
is quite re-established. He was on the brink of sufTocation when the operation was 
performtnj. I have been told of a man who, for the last fifteen years, has had a 
similar thoracic fistula, and who has nevertheless, during nearly the whole of that 
period, being actively engaged in the various labours of a farm-servant. 

I have stiJl two of the six patients to account for. They were both much reheved 
by the operation for a while ; but after a few days they again fell off; and after 
many more days of gradual sinking and distress, they died. The cavity of the 
pleura contained, in both cases, much puriform liquid, and a quantity of most offensive 
gas, consisting in great part, as I judged from its odour, of sulphuretted hydrogen. I 
have since thought that both these patients would have had a much better chance for 
life, if this corrupt and corrupting miass had been duly removed. 

Again, I have twice seen pus let out, by the primary puncture of the chest. One 
of these two patients sunk, exhausted, some months after the opening, which never 
healed, was made. The empyema of the other had been occasioned by fracture of 
a rib. The discharge continued for a short time, then ceased, the orifice closed, and 
the lad got well. 

This constitutes the amount, or nearly so, of my personal experience of the ope- 
ration of paracentesis thoracis. You will see, in the statement I have been making, 
the grounds of those opinions which I have formed and expressed respecting it. A 
full and final solution of the grave and difficult questions that it involves would re- 
quire a much wider field of observation than any one individual is likely to command. 
Dr. Thomas Davies has published a tabular account of the several cases of operation 
which he had then superintended. In sixteen cases of empyema, so treated, there 
were twelve recoveries ; that is, the operation was successful in three-fourths of the 
whole number of cases : a very encouraging result. In three of the less fortunate 
cases, the lung could not expand after the evacuation of the fluid, in consequence of 
the thickness of the false membranes covering it. 

The value of Dr. Davies' table would have been greater, if it had shown in each 
case the time, after the commencement of the disease, at which the operation was 
performed ; the symptoms that called for its performance ; the nature of the liquid 
evacuated ; and whether the orifice made by the trocar was closed or not. 

The quantity of liquid which the distended pleura is capable of holding is enor- 
mous. I have seen upwards of a gallon let out at once. Dr. Townsend mentions 
the case of a patient of Dr. Croker's, in Dublin, from whose left pleura Mr. Cramp- 
ton drew off the almost incredible quantity of fourteen imperial pints of pus. Of 
course this could not have accumulated there without making injurious pressure in 
all directions: upon the ribs, upon the heart and mediastinum, upon the diapl^ragm, 
and the abdominal viscera beneath it. It is interesting to know with what raj^idity 
the capacity of the diseased side of the thorax will, in favourable cases, diminish. 
The same writer gives the history of a boy, 12 years old, in whom the circumference 
of the diseased side was sixteen inches and six lines, while that of the sound side 
was fourteen inches and one line. IN'ine days after the operation the circumference 
of the diseased side had decreased nearly three inches : it measured thirteen inches 
and nine lines ; that is, rather less than the circumference of the healthy side. The 
side had shrunk somewhat within its natural size. This is common in such cases. 

There is yet a third question of some importance. Whereabouts should the 
opening be made ? 

If any soft inelastic tumour has appeared, marking a tendency in the effused liquid 
to make its own way outwards, that tumour should be punctured without loss of 
time ; for there will be no chance of the reabsorption of the pus ; and if the swelling 
be left to itself, troublesome, burrowing sinuses will be apt to form in the thoracic 
and abdominal parietes. As we have no choice in such a case about the place 
where the aperture is to be made, authors have termed the operation the operation 



PLEURISY. 



601 



of necessity ; and they distinguish the case in which the surgeon is at hberty to in- 
troduce his trocar whenever he pleases ; they say that then the operation of election 
takes place. Now the question is, what spot is the best for this operation of election ? 

If there be any part of the surface which is resonant on percussion, or which 
affords any sound of respiration, that part must be avoided. It is probable that the 
lung, in that place, is fastened by adhesions to the costal pleura. Of course you 
would not thrust in a trocar where you saw or felt that the heart was beating. 

The object to be kept in view is that of making the opening in the situation which 
will allow the most free and perfect vent for the hquid. The intercostal space 
between the sixth and seventh true ribs, where the digitations of the serratus major 
meet those of 'the obliquus externus muscle, is the place usually recommended. 
Laennec prefers the space between the fifth and sixth ribs. He observes that, on 
the right side, an enlarged liver frequently reaches as high as the sixth, or even as 
the fifth rib. When the diaphragm is pushed as high as this (and t believe that 
Dr. Edwin Harrison, who has paid much attention to this point, will tell you that 
it is often pushed up even higher) there is an obvious risk of penetrating it with 
the trocar. In fact, Laennec committed that error himself. After making an in- 
cision between the fifth and sixth ribs, he thrust the instrument, as he supposed, 
into the thorax; and was a good deal surprised to find that no gush of liquid fol- 
lowed its introduction. The patient died; and dissection showed that the trocar had 
entered the cavity of the abdomen after transfixing the diaphragm, which, having 
been forced upwards by a large fiver, had contracted firm adhesions to the seventh 
rib. I have myself witnessed a similar mischance, on the other side of the chest. 
The integuments of the side were osdematous ; and it was thought that a little serum 
issued upon the passage of the grooved needle. The serum must have come from 
the infiltrated areolar tissue. No liquid was evacuated by the trocar. The patient 
died a day or two afterwards of peritonitis. The instrument had perforated the 
diaphragm, and entered the spleen, which was unusuaJIy large. 

I am tempted to relate the particulars of one of the prosperous cases that I 
hefore briefly adverted to. It occurred in a lad of nineteen; a patient of my col- 
league, Dr. Wilson. On his admission into the hospital he bore ail the marks of 
copious effusion into the left pleura ; the side enlarged and motionless, and dull on 
percussion ; ihe intercostal s{)aces tense, and even wiih the ribs ; the heart beating 
to the right of the sternum; respiration puerile on the right side, inaudible on the 
left; urgent dyspncea; a tendency to coma, marked by drowsiness and blueness 
of the cheeks and lips. In short, the boy was on the very verge of suffocation. 
He had been ill about a month : and had been bled, and cupped, and brought under 
the specific influence of mercury. Dr. Wilson judiciously directed that the liquid 
should be let out. 

A grooved needle was first passed between the fifth and sixth ribs ; and some 
scrum following the {juncture, a trocar was then introduced by Mr. Tuson, and 
nine pints of a clear fluid were drawn off. During the operation the patient became 
faintish at times, and ihen the orifice in the canula was stopped fer a moment by 
the finger. The irnmediate effect of the lapping was most interesting and grati- 
fying. Even while the liquid was flowing, the heart was observed gradually to 
move over from beneath the right mam.ma towards its natural situation ; and his 
difficulty of breathing was signally relieved. At the beginning of the operation he 
respired fifty times in a minute ; at its conclusion thirty-eight times only. A good 
deal of air entered while the hquid was escaping : and for some days after the 
operation a splashing sound was audible on succussion of the chest: and one part 
of that side was unnaturally resonant, when struck, and another part unnaturally 
dull ; and whatever was the posture of the patient, the hollow sound was uppermost, 
and the dull sound was uncFermost ; and when he sat up and spoke, or coughed, a 
brazen resonance was heard by the ear applied to the scapular region. This lad 
got quite well, without the recurrence of a single bad symptom. He afterwards 
presented himself at the hospital ; and I understand that the left side was found to be 
in a very slight degree smaller than the right. 

The liquid evacuated in this case was clear and transparent. It separated, on 

3a 



602 



PLEURISY. 



cooling, into three parts : one of quite watery consistence, one more viscid, and a 
third which constituted a soft, transparent, jelly-Hke mass of fibrin. 

In this instance no injurious consequences resulted from the free admission of air 

It may sometimes be necessary to puncture the cavity for mere pneumothorax : 
when, for instance, the pulmonary pleura has been pricked by a fractured rib, and 
air passes from* the lung into the pleural sac faster than it can be absorbed; fast 
enough to compress the lung, and to threaten death by apnoea. The diagnosis of 
such a state cannot be difficult. The existence of the fracture, the tympanitic sound 
yielded by the chest on the injured side, the absence of respiratory murmur in the 
tymi.panitic part, and the increasing dyspnosa, all point to the same conclusion. Now 
a trocar of the smallest size — or even an acupuncture needle — may suffice to give 
vent to the imprisoned air, which will escape with an audible hissing noise. In 
some cases it must have existed in a very large quantity, for the stream of issuing 
air has been strong enough to blow out a candle several times in succession ; the 
flame being each tim.e immediately re-Hghted. 

The same necessity for puncturing the cavity of the pleura from without may 
arise in cases of pneumothorax depending on specific disease in the lungs : but we 
cannot regard the operation as curative in such xases. Its value is very different 
from that which experience has shown to belong to it in empyema from acute or 
chronic (but simple) pleurisy. Yet if it saves life for the time, if it prevents im- 
pending suffocation, and reheves existing distress, and postpones the fatal event, it is 
not without its value ; and it has many times been done, and been followed by very 
gratifying results ; but it has never, that I know of, been followed by entire recovery. 
Dr. Da vies had superintended the operation in nine instances of pneumothorax with 
effusion : and all the patients died from tubercular complications. 

There are, indeed, on record examples of recovery after the operation, when 
pneumothorax had existed, and under very unpromising circumstances. I should 
have stated before, that as the pus, in empyema, sometimes finds its waj^ outwardly, 
penetrating between the ribs, and forming an external swelling, which, if not opened 
by the scalpel, will at length burst ; so it also, sometimes, escapes by making a road 
into some part of the air-passages, and being expectorated. Is^ow the operation of 
paracentesis, in such a case, there being no tubercular disease, has been successful. 
Le Dran relates an instance in which he operated for empyema, where " the injec- 
tion of a small quantity of mel rosarum and barley-water through the wound excited 
coughing, and part of it was coughed up through the mouth, mixed with pus ;" thus 
clearly proving the existence of a fistulous passage through the lung; notwithstand- 
ing which the patient recovered completely. The effiision was probably circum- 
scribed. But you will find other cases of a similar kind referred to by Dr. Townsend, 
in the Cyclopssclia of Practical Medicine. 

This concludes what I have to say, not only of pleurisy, but also of pneumothorax, 
and of empyema, which are often treated of as separate and independent disorders. 
They are more frequently connected with pleurisy than with any other form of dis- 
ease, and they are almost always consequences of disease or of injury. But I beheve 
I have omitted nothing of importance in respect to either of them. 

[TxPHOiD PifETTMOJiriA. — A State of congestion, or of inflammation, more or less intense, 
of the lungs, accompanied by that impairment of the sensorial powers, and morbid condi- 
tion of the circulation and of the organism generally, which characterize the more grave 
forms of typhus fever, has repeatedly prevailed in different portions of the United States, as 
an epidemic, often of wide extent, and, in its earlier ^ visitations, producing an amount of 
mortality truly appalling. 

The first notice we have of the appearance of this form of disease, remarks Dr. Dickson, 
(^Essays on Pathology and Therapeutics, vol. i. 435), "was in the year 1806, in Medfield, a 
town of the State of Massachusetts, whence it spread gradijally — extending itself, winter 
after winter, throughout New England, into Canada, and the Middle States, progressing 
from village to village, and from one portion of the country to another, until, in 1813, it had 
reached Philadelphia. In the winter of 1815 it first prevailed in South Carolina, and was 
then, and more widely in 1816, epidemic; since which time its ravages in this state have 
been slight. It continues to show itself, sporadically, everywhere, I believe, where it has 
once found footing. In South Carolina we scarcely pass a winter without meeting with 
instances of it, especially among the blacks." 



PLEURISY. 



603 



The disease is of frequent occurrence in other portions of the United States, and may be 
considered, to a certain extent, as endemic in several localities. 

We are informed by Dr. Gibbes, (^American Journal of the Medical Sciences^ Oct., 1842,) that 
it prevails extensively during the winter months, on the rivers, swampy plantations, in the 
neighbourhood of Columbia, South Carolina, and destroys more negroes than all the other 
maladies combined to which they are ordinarily liable. 

According to Dr. Dickson, it has not been observed farther south than the State of Georgia, 
nor is it of very frequent occurrence beyond the latitude of Charleston. 

Typhus pneumonia, as it prevails in the United States, is very similar in character to, and 
is probably the same affection as that described by Sydenham, Huxham, and others of the 
older writers, as peripneumonia notha. Sauvages has very accurately portrayed the disease 
under the denomination of peripneumonia typhoides. An account is given by the late Dr. 
John Bard, of New York, of an epidemic that prevailed on Long Island, in the winter of 
1749, which he terms a malignant pleurisy, that in all its essential features corresponds ex- 
actly with the disease under consideration; a similar affection is also noticed by Dr. Hugh 
Williamson, as prevailing in North Carolina in 1792. 

Typhoid pneumonia is described by Dr. Stokes as not uncommon in Ireland, while Dr. 
Burne, of the Westminster Hospital, mentions that a great number of cases of what he calls 
"the spotted fever,'' were brought into that institution in the year 1838. He describes the 
affection as '• an adynamic or typhus fever, combined with a latent and dangerous pneumonia, 
and exhibiting on the surface a very regular and uniform spotted eruption — not petechise." 
This is evidently the same disease as the typhus pneumonia of this country, which, when it 
first attracted attention, was so frequently attended with an eruption upon the skin, that it 
was very generally designated by the popular name of spotted fever. The eruption, how- 
ever, soon ceased to attract attention ; it was seldom observed as a phenomenon of the dis- 
ease south of the Potomac, and even in the northern and middle portions of the United States, 
the eruption ceased early to present itself 

Dr. Mackintosh, of Edinburgh, describes a form of pneumonic inflammation, attended by 
symptoms that are generally denominated typhoid, and which, in consequence, has obtained 
the name of pneumonia typhoides, as very prevalent among the British troops stationed in 
exposed situations along the coast, and in large garrisons where the duty is severe. Dr. 
Mackintosh, however, objects to the adjunct typhoides, as expressing erroneous ideas of the 
pathological condition of the body;- — and the objection is not without foundation — for although 
that peculiar form of pulmonary engorgement quickly followed by inflammation and hepa- 
tization, to which the term typhoid pneumonia has been applied, does very frequently occur 
in connection with genuine typhus, it is likewise a very common complication in certain 
seasons and localities of the bilious remittent fever, while it is also met with in cases of 
gastro-enteritis, of ambulent and erratic erysipelas, of diffuse cellular inflammation, and of 
other diseases by which the thoracic afl'ection is more or less modified, and often completely 
masked : hence to denominate the pneumonic disease as essentially and invariably typhoid 
in its character is evidently a misnomer, and very liable to lead tO- serious errors in practice. 

In the United States the disease is known by various names, according to the predomi- 
nance of particular symptoms. In the more violent cases, the patient being suddenly seized 
with a very severe chill, accompanied with marked coldness of the surface, it is, according 
to Dr. Gibbes, frequently denominated the cold plague. The head being almost invariably 
affected, before the pneumonic symptoms are developed, it is often called head pleurisy. In 
the autumn or spring, when, in particular districts of country, it is frequently attended by the 
symptoms of ordinary bilious fevers, it is called bilious pleurisy. From the symptoms of pros- 
tration by which the disease is so generally attended throughout its whole course, and the 
rapidity with which the patient sinks in the more violent cases, the term typJioid pnewmania 
has become, however, the one by which it is most frequently designated. 

In its mode of attack, and the general symptoms by v/hich typhoid pneumonia is ordinarily 
attended, there is no uniformity. Usually, however, the disease is ushered in by a chill, 
which is often of great severity and long continuance — the heat of the whole surface being 
to the touch much below the standard of health. The cold stage is not unfrequently so in- 
tense as to destroy the patient before the slightest reaction occurs. Where the disease is vio- 
lent in its attack, Dr. Gibbes states, that the patient may suddenly become cold and pulseless, 
lethargic, and often insensible without previous complaint ; he has known instances in which 
the patient was found dead, or died within three or four hours after being apparently well. 

During the cold stage, the respiration is short and oppressed, and a pain on one or other 
side of the chest is generally complained of; pain of the head is also present in most cases,- 
and not unfrequently the patients experience severe pains in the back, limbs, and other parts 
of the body — similar occasionally to those of rheumatism. The muscular strength is greatly 
prostrated, and there is a sense of general uneasiness and great restlessness. After a period, 
longer or shorter in different cases, but usually protracted, reaction ensues, and the heat of 
the surface is restored — it is seldom, however, increased much above the ordinary standard 
of health. The heat is often unequally difiused over the surface — portions being decidedly 



604 



PLEURISY. 



liot while others are comparatively cool. Occasionally, the skin becomes -hot, dry and harsh, 
while, at other times, it is relaxed, cool, and clammy. The pulse, when reaction ensues, 
becomes somewhat faller, and more quick and frequent, but in very few cases does it acquire 
any degree of tension, excepting, perhaps, when the disease attacks young subjects and those 
who retain some degree of vigour. Most commonly the pulse is soft, or it yields to the 
slightest pressure. During the febrile stage, the pain, oppression of the chest, and difficulty 
of respiration are increased, and, very generally, a cough comes on within the first twenty- 
four hours, by which the pain in the thorax is greatly aggravated. When the cough is at- 
tended with expectoration, the pain in the side is considerably relieved, and the oppression 
of respiration diminished. When, however, the cough continues dry, or the expectoration is 
slight, ali the more serious symptoms become aggravated. The matter expectorated is a 
thick, tenacious mucus, often tinged with blood, but at other times of an ash or dark-brown 
colour. The respiration besides being oppressed is usually hurried, and irregular — the pa- 
tient's spirits are greatly depressed — he often utters deep and heavy sighs, and complains 
of a sense of weight, or of constriction at the praecordia ; he is often affected with nausea, 
and occasionally with vomiting. 

Dr. Mann (^Med. Sketches, page 308), notices, as a common symptom of the disease, a re- 
markable pink-coloured suffusion over the whole face, distinct from the usual febrile redness 
of the cheeks — the face becoming, at the same time, puffed or bloated. This appearance is 
most conspicuous in individuals of a light complexion ; it is present, also, upon the body, but 
to a less extent. In many cases it is not observed even on the face, or in a very slight 
degree, and for a short period. 

The tongue, in the first period of the disease, is often clean but red, particularly at its 
edges ; in other cases, and perhaps most commonly, it is thickly coated with a yellowish 
mucus, which, in the progress of the disease, changes to a dark-brown — the tongue becoming, 
at the same time, dry, hard, and rough — often chapped. Upon the separation of the crust, 
the tongue presents, not unfrequently, a bright-red colour, which colour occasionally pervades 
also the fauces. 

In many cases, the patient exhibits from the very commencement of the attack, particularly 
where there is much pain of the head, more or less delirium, and great restlessness. 

As the disease advances, the teeth and the whole interior of the mouth become coated 
with a dark-coloured sordes ; the breathing becomes shorter and more oppressed — the 
strength more prostrated, the pulse smaller and weaker — the patient sinks into a state of low 
muttering delirium or of coma, more or less complete, and the fatal event takes place as in 
the ordinary cases of typhus fever. 

The duration of the disease is very variable. Death, as we have seen, may occur within 
a very few hours from the commencement of the attack. Dr. Mackintosh has seen the dis- 
ease, in the strongest subjects, run its course to a fatal termination in from forty-eight to sixty 
hours ; while Dr. Gibbes has known patients to be destroyed by it in from" three to twenty 
hours. In other cases, the disease may continue for several days before a fatal event occurs. 

In cases where, under an appropriate treatment early commenced with, the nervous power 
is quickly aroused, the activity of the circulation is excited and a free action of the peripheral 
capillaries restored, according to Dr. Gibbes, the attack may be cut short, without the occur- 
rence of any symptoms of pneumonic disease. 

When symptoms of pneumonia become developed, these will often yield to a proper treat- 
ment, within the first thirty-six or forty-eight hours, though they will occasionally continue 
for six or seven days, or even longer. The pulse increasing in volume and in firmness, the 
surface becoming, throughout, warm, soft, and moist, the tongue cleaner and less red. the 
delirium diminishing, the expectoration becoming more free and copious, the cough less fre- 
quent and annoying, the pain of the thorax less intense, the respiration more full and easy, 
and the occurrence of a quiet sleep, from which the patient awakes refreshed and with 
greater cheerfulness, are the certain indications of amendment — recovery, however, is in 
general very slow — the period of convalescence being protracted, while relapses readily 
occur from slight exposure or the least imprudence of any kind. 

Dr. Gibbes states, that he has frequently known patients who were convalescent and able 
to walk about, complaining, in fact, of nothing but debility, to " yield suddenly to a cold 
change of weather, and die in a few hours, or linger several days with pneumonic symp- 
toms," Symptoms that were before mild and favourable, will often become aggravated 
upon a change in the atmosphere to cold and damp. If a patient has been much enfeebled 
by a first attack, a second is very likely to prove fatal. 

In many cases of pneumonia typhoides, instead of a gradual decline of the symptoms of 
thoracic disease taking place, these cease suddenly, and a severe pain is immediately expe- 
rienced in some other and perhaps remote part of the body, as in the region of the liver, in 
the bowels, or in the head, attended with the other symptoms of inflammation in these 
parts. According to Dr. Gibbes, when upon the cessation of the thoracic symptoms, a he- 
morrhage from the bowels ensues, it is generally critical — when inflammation of the brain 
ov peritoneum takes place, the case usually terminates fatally. 



PLEURISY. 



605 



The foregoing is the description of pneumonia typhoiJes as it most frequently presents 
itself. In the different epidemical visitations of the disease, at diiferent seasons, and in dif- 
ferent localities, or even during the same periods and in the same places, it not unfrequently, 
however, assumes a very different form. Thus, in some cases, the only symptoms which 
the patient exhibits are extreme prostration and wandering pains of the back, loins, shoul- 
ders or legs. In other cases, after a severe and protracted chill, the patient is seized with 
severe pain of the head and back, and great gastric distress — delirium soon sets in, which 
quickly gives place to coma, and death ensues within a few hours. 

"Occasionally," remarks Dr. Gibbes, "an acute pain in the back part of the eye, in the 
ears, or side of the neck, with stiffness of the muscles, is present. In severe cases the ton- 
sils, the submaxillary and sublingual glands are swollen, with acute pain in swallowing ; 
these are usually the worst cases." In a few instances the symptoms of genuine erysipelas 
present themselves on some portion of the skin, and invade successively almost every part 
of it. 

In these irregular forms of the disease, the symptoms of the thoracic affection are often 
very slight, or they may be entirely absent. There is usiially, however, some sense of 
tightness about the chest, some difficulty of respiration, and a slight occasional cough — with 
or without expectoration ; and it is remarked by Dr. Stokes, that the physical signs of pneu- 
monia may frequently be detected in cases unattended with dyspnosa, pain, cough, or 
expectoration. 

A very common form of the disease under consideration — and which at certain seasons, 
and in particular districts, is even more prevalent than that to which the appellation typhoid 
is ordinarily applied — is the one usually known as bilious pleurisy or bilious pneumonia. 

In this, the attack commences with symptoms differing but little from those which usually 
usher in an ordinary case of bilious remittent fever — there is, perhaps, in general, a more 
severe and protracted chill, and a sense of distress and oppression about the chest, which is 
not usually observed in the latter disease. Occasionally, the attack is preceded, for a day or 
two, by a sense of fulness and weight in the right hypochondrium, and, in a few cases, by 
symptoms of a dysenteric character. Very generally there is severe pa'm of the back and 
extremities, and often of the head also. Almost invariably, the attack is accompanied by 
an acute pain of the forehead — well-marked febrile symptoms, with, usually, decided exa- 
cerbations in the morning and remissions towards evening. — During the exacerbations the 
face is flushed, and as the skin, from the commencement of the disease is more or less tinged 
with bile, the mixture of red and yellow gives to the countenance a very peculiar, sickly 
aspect. The eyes are red and watery, the conjunctiva having often a deep yellow hue. In 
many instances, it is only after the fevei* has continued for several days that pain in the 
chest is complained of : this is sometimes very severe and acute, more commonly, however, 
it is obtuse — of an aching rather than of a lancinating character — there is, at the same time, 
a sense of weight and oppression of the chest, with more or less difhculty of respiration and 
cough. The cough is at first dry, and its repeated paroxysms cause an increase of the pain 
in the thorax and head. The expectorated matter is frothy and of a yellowish colour, often 
streaked with blood, and of variable consistence. The tongue is, at first, coated on its sides 
with a whitish mucus, while at the centre it is covered by a dark-yellow or brownish crust 
— the edges of the tongue are ordinarily of a decided red. As the disease advances, the 
tongue becomes dark-brown, dry, and hard. The pulse is usually small, frequent, and quick, 
with a slight degree of tension. 

There is always more or less gastric distress, and very commonly vomiting, the matter 
discharged from the stomach being often bile or a thick ropy mucus mixed with bile. In 
many cases the epigastrium is hot, and painful upon the slightest pressure. The urine is 
always of a deep yellow colour from the presence in it of the colouring matter of the bile. 

The stage of excitement in bilious pneumonia is ordinarily of short duration, and, unless 
the disease is arrested by an appropriate treatment, great muscular prostration speedily 
supervenes, and the same train of symptoms ensue as in the typhoid form of the disease. 

In the affection we have described, under whatever form it may present itself, the period 
of convalescence is always slow, irregular, and for a long while imperfect. " Chronic hepa- 
tization, with or without hectic fever, or a lurking congestion, may continue for weeks ; and 
although, under appropriate management, the disease may be ultimately removed, atrophy 
of the lungs, with or without ulcerative disease, is often established. In certain cases, months 
may elapse before the respiratory murmur is heard, and, in many instances, it is never re- 
established. On the other hand, it has been known to cease in a single day, on the super- 
vention of an attack of gastritis or enteritis." (^Dunglison' s Practice of Medicine^ vol. i. 313.) 

The principal exciting cause of pneumonia typhoides is unquestionably protracted expo- 
sure to a damp and cold atmosphere, while die predisposition to its attacks is promoted by 
all those causes which tend to reduce the vital energies of the system — as bodily or mental 
fatigue, intemperance, improper or deficient diet, insufficient clothing, mental distress or 
anxiety, long watching, previous disease, &c. Nothing, remarks Dr. Mann, predisposes to its 
attack in so high a degree as an intemperate use of intoxicating drinks. The soldiers, says 

3 a2 



606 



PLEURISY. 



Dr. Mackintosh, were often seized with the disease who were exposed at night as sentinels — 
" instead of walking about they frequently stand shivering in their sentry-boxes, the surface 
continues long chilled, and with a view to fortify themselves, and to produce warmth, they 
are in the habit of drinking ardent spirits in considerable quantity." 

It is a common complaint among the poor and labouring classes in many parts of this 
country, during the prevalence of long-continued cold and damp weather, such as frequently 
occurs during the spring and autumn, in the more northern states, as well as during the open 
winter of the middle states. In the south, according to Dr. Gibbes, it is rarely met with on 
highland plantations, and if at all, is confined to such negroes as are more or less exposed 
to work on low or wet ground. On the swamp plantations the disease is endemic. 

As we have already stated, the disease occasionally occurs as an epidemic, but generally, 
during seasons when the temperature of those districts in which it prevails is marked by 
sudden and considerable vicissitudes from heat to cold, and by extreme and long-continued 
moisture. 

Typhus pneumonia more frequently attacks males than females, and adults than children — 
this is a statement in which nearly all who have written upon the disease concur. The pre- 
disposition of adult males to its attacks, is very readily explained by the amount of exposure 
and fatigue to which they are usually subjected being much greater than that of females and 
children — and probably, also, from the fact that their habits, generally speaking, are much 
less temperate. The disease is not, however, confined to any age, nor are females and chil- 
dren entirely exempt from it, particularly when it prevails as an epidemic. It is usually, 
however, most severe in individuals over fifty years of age, and is very seldom seen in chil- 
dren under ten years. The negro race is particularly liable to its attacks. 

In the treatment of pneumonia typhoides much must necessarily be left to the judgment 
of the practitioner. In the selection of his remedies, more perhaps than in any other disease, 
must he be guided by the particular character of the symptoms present in each case. It is 
all important that the true nature of the disease be carefully investigated in its earliest 
stages — ^it being then, in its ordinary form, readily controlled by an appropriate treatment, 
and, even when marked at its onset by symptoms of very considerable severity, it may often 
be arrested by prompt and judicious management. 

In this disease, Dr. Gibbes remarks, and a similar observation is made by others," if the 
cases are immediately attended to, it is found quite manageable, as much so as an ordinary 
catarrh; but when neglected for twelve or twenty-four hours, and the symptoms are at all 
aggravated, the patients are very apt to die." 

We shall often succeed, when the patient is seen during the first period of the attack, or 
during the cold stage, as it is not improperly teriied, in rousing the nervous energy — pro- 
ducing a free and equable circulation, and a due degree of heat and moisture upon the sur- 
face, by resorting at once to moderate doses of opium, camphor, calomel, and ipecacuanha, 
in conjunction with the milder class of difi'usible stimulants internally, and the application 
of heat and rubefacients externally. By this treatment, early and judiciously pursued, and 
carefully watched so as to prevent a state of over-excitement being produced by it, the en- 
gorgement of the lungs may often be prevented or removed, and a speedy restoration of 
health secured to the patient. 

In the more open form of the disease, known as bilious pneumonia, the early administra- 
tion of an emetic will often be found beneficial. Richter states, that in the bilious form of 
the disease, emetics will often remove the pain and aflection of the chest as by a charm, and 
StoU makes the same observation (Ratio Meden., i.). In the few cases Dr. Eberle had seen 
of bilious pneumonia, he states that the utility of emetics in its treatment was strikingly 
evinced. They, in general, bring on an uniform diaphoresis, promote expectoration, and 
allay the pain in the thorax, often almost immediately. Dr. Dickson also remarks, that he 
has been much pleased with the effects of the early administration of an emetic, or an 
emetico-cathartic. A combination of ipecacuanha and calomel maybe given, or the sulphate 
of magnesia dissolved in a strong infusion of seneka or serpentaria, with the addition of 
twenty grains of ipecacuanha. Dr. Mann, likewise, speaks favourably of the eifects of an 
emetic of ipecacuanha. In the more decidedly inflammatory cases, the emetic was not ad- 
ministered by him until after bleeding and cathartics had been employed ; especially where 
the head or chest was affected with severe pain: — when after the occurrence of expectora- 
tion, this had become arrested from any cause, small emetics, he states, were found benefi- 
cial, and in many cases had to be frequently repeated. The emetico-cathartic or even the 
emetic alone, is, however, a remedy of very doubtful propriety in cases attended with early 
symptoms of prostration and extreme muscular debility. 

The propriety of blood-lettiiig in any of the forms of typhus pneumonia, has excited not a 
little controversy. By some practitioners, the use of the lancet is condemned in every case, 
as a remedy fraught with danger, from its liability to induce speedily a state of prostration 
from which the patient is with difficulty roused ; while others of equal celebrity insist upon 
the necessity of full and even repeated venesection — considering it to be an important, "if not 
an indispensable remedy in the treatment of the form of pneumonia under consideration- 



PLEURISY. 



607 



This discrepancy of opinion is satisfactorily accounted for by the very different characters 
under which the disease presents itself in different localities, and at different periods — often, 
indeed, during the same epidemic visitation ; south of the Potomac, we are informed by Pro- 
fessor Potter, that the disease is seldom so inflammatory as along the shores of New Jersey, 
Delaware, and Maryland ; and the farther south, the more it is said to assume a middle ty- 
phoid complexion. In the winter epidemic of 1815-16, along the northern frontier of the 
United States, we are assured by Dr. Mann, that in many districts " the disease was highly 
inflammatory from its commencement to its final resolution," and that, " it was as idle to 
administer stimulants for its cure, as it would have been to have poured oil on fire to extin- 
guish the flame." " Its cure," he adds, " depended upon the assiduous administration of the 
antiphlogistic regimen: evacuants, expectorants, and diaphoretics, with the aid of blisters," 
It is very certain that in the ordinary cases of typhoid pneumonia, the use of the lancet 
will seldom be demanded, and in many, would be altogether inadmissible. Cases, it is 
true, will not unfrequently occur, in which the detraction of a moderate quantity of blood 
from the arm, during the early period of the febrile stage, will be productive of the best 
effects. General blood-letting, however, should always be resorted to with the utmost cau- 
tion — perhaps- it would be better, in every instance where symptoms of a typhoid character 
early set in, and the loss of blood is considered advisable, to apply cups to the chest in pre- 
ference to resorting to the lancet. In cases of bilious pneumonia, blood-letting will be much 
more frequently demanded than in the typhoid form of the disease but even in these it 
should be resorted to only in the early period of the attack, and it is more safe to take away 
a sufficient amount at the first bleeding, than to trust to small and repeated bleedings. In 
the bilious form of the disease, when much pain or tenderness of the epigastrium is present, 
leeches or cups to this part are always proper, and will often be found to afford very decided 
relief 

The bowels should be early evacuated by some mild but effective laxative — the best is 
unquestionably calomel in moderate doses, followed by castor oil or magnesia — active or 
watery purging should always be cautiously avoided. 

In the cases marked by early prostration, and extreme muscular debility, we should resort 
at once to moderately stimulating diaphoretics ; of these, according to Dr. Dickson, camphor, 
nitrous ether, the carbonate and acetate of ammonia are the best ; and they are rendered 
more beneficial by combining them with Dover's powder, " The efficacy of all these," he 
adds, " will be much aided by the pediluvium, and by the application of warm fomentations, 
poultices, and heat in various forms to the surface of the patient. Cataplasms with mustard 
must be laid over the chest, if pain or dyspnoea is present, and applied also to the wrists and 
insteps. Epispastics are also of use, by their double power of stimulants and revulsives: 
the back of the neck, if the head be affected, the sternum and the epigastric region, if the 
lungs or heart or stomach suffer, should be selected for their application. There has been 
some dispute as to the preference due to the dry or moist form of heat, as the best to be re- 
sorted to in this disease. It is, I think, easy to decide. If the skin be dry, I prefer fomen- 
tations, or even the vapour-bath ; if moist, I prefer bottles of hot water, heated bricks, bags 
of hot salt, chaff, &c. Sweating will in the greater number of cases, come on readily, but 
must be regulated. If too profuse, and kept up for too long a time, it may prove injurious 
and debilitating. You restrain it by substituting dry for moist applications, and removing 
some of the bed-clothes, and changing cautiously the body linen of the patient; dry garments 
carefully and well aired, being put on in the place of those moistened by the cutaneous 
discharge." 

In cases where a tendency to sinking is early evinced. Dr. Gibbes recommends small doses 
of calomel as a general excitant of the secretions, with camphor, opium, carbonate of am- 
monia, and free vesication. 

In nearly every form of the disease, whether typhoid, bilious, or more openly inflam- 
matory, the effects of small doses of calomel, combined with ipecacuanha and opium are 
spoken of as particularly beneficial. Large blisters over the chest will also, in most cases, 
be found of the highest importance, from the very commencement of the attack. In obstinate 
cases. Dr. Mann directs them to be renewed daily until the pain of the chest is removed. 

Where the patient's strength rapidly fails, and he is sinking into that low typhoid condi- 
tion which marks the second period of the disease, stimulants must be freely resorted to : of 
these Dr. Dickson prefers " the volatile alkali in large doses, from five to ten grains every 
half hour or hour, with wine whey or brandy toddy; spts. nit. dulc, spts. of turpentine, the 
tincture of cantharides." "I can set," he remarks, "no limit to the administration of this 
class of remedies, but the excitement of a notable degree of reaction, which being observed, 
will guide you in the future quantities to be exhibited ; taking care, however, that the patient 
shall not suffer by their timid or inefficient amount, nor be allowed to retrograde by any sud- 
den subtraction of dose." 

" It is well to be reminded," observes the same writer, " that in this strange disease it is 
never permitted to despair of your patients, recoveries being in considerable number recorded, 



608 



PULMONARY HEMORRHAGE. 



from circnmstances the most deplorable, and, indeed, to all reasonable anticipations, abso- 
lutely hopeless." 

During the whole period of convalescence the patient will require to be watched with 
care. — " You must abstract gradually from the amount of stimulants which have been given, 
him, and substitute in their stead the more permanent tonics. Of these each practitioner has 
his favourite. Arsenic is preferred by many of the New England physicians, and is, accord- 
ing to Dr. Dickson, without doubt, highly serviceable." The muriate of iron is also spoken 
of as well adapted to this period of the disease — and is certainly preferable in all respects 
to the arsenic. Dr. Mann states, that the only stimulant employed by him in the convales- 
cent state, was a mixture of spts. nit. dulc, and aqua ammonise ; a teaspoonful of this proved 
a cordial and expectorant, at the termination of the disease, when repeated every two or 
three hours ; as did, also, a mixture of equal parts of the camphorated tincture of opium and 
antimonial wine, where the cough was troublesome. Other practitioners prefer, as a tonic, 
at the close of the disease and during the period of convalescence, the cinchona or the sul- 
phate or muriate of quinia. Dr. Dickson gives the bark in infusion, combining it with ser- 
pentaria, adding to each dose a small proportion of carbonate of potass, and camphorated 
tincture of opium. The patient should be supplied Vv^ith a light diet of nourishing and easily 
digested food — and should be guarded sedulously from the slightest amount of exposure to 
cold or damp, and should be guarded from sudden alternations of temperature for a con- 
siderable time after recovery — he should to that end wear flannel next his skin, and adapt 
his clothing not only to the season, but to the temperature of each day and each portion of 
the day. — C] 



LECTUEE LIY. 

Pulmonary Hemorrhage ^ its varieties ; its connection with pulmonary consump' 
tion, and with disease of the heart. Pulmonary apoplexy. Prognosis in 
Hxmoptysis. Symptoms. Tvealmint. 

Having gone over the inflammatory affections of the organ of respiration ; having 
brought before you inflammation of the membrane vi^hich lines the air-passages, or 
bronchitis; inflammation of the membrane vv^hich invests the l\ir\gs, or pleurisy ; 
and inflammation of the ivhole substance of those organs, or pneumonia ; I proceed 
next to the subject of pulmonary hemorrhage. 

You may remember that, in an early part of the course, I drew your attention to 
some general facts respecting internal hemorrhages. I showed you that the blood 
does sometimes proceed from visibly ruptured vessels, but that it is much oftener 
- poured forth from unbroken surfaces, in the way of exhalation ; and that hemorrhage 
of this kind takes place from the mucous membranes far more frequently than from 
any other natural surface of the body. I observed also that such hemorrhage is 
almost always preceded by congestion ; either by active congestion, which is less 
common, or by passive and mechanical, which is extremely common : and we speak, 
accordingly, of active and passive hemorrhage. Hemorrhage is also sometimes 
primary, or idiopathic, and then constitutes the whole disease ; while at other times 
it is merely a symptom, direct or indirect, of some other disorder, in which case we 
call it secondary. 

Now in the lungs we find examples of all these varieties of internal bleeding; but 
pulmonary hemorrhage is secondary much more often than it is primary. 

In speaking, therefore, of some forms of pulmonary haBmorrhage, I must touch 
upon certain diseases of which the bleeding is a symptom : but I shall not go further 
into the consideration of those diseases at present, than may be necessary to elucidate 
the hemorrhage. Bleeding from the lungs is a thing of most fearful interest; and 
it will be useful to take a general view of that phenomenon, whether it be a substan- 
tial disease in itself, or merely a sign of other pre-existing diseases. 

The blood, then, in pulmonary, as in all other hemorrhages, may issue through a 
breach in the walls of some considerable blood-vessel ; or it may proceed from innu- 
merable points in the mucous membrane of the lungs, by the process of exhalation; 
and the iat1;er mode of hemorrhage is much the more common of the two, although 



PULMONARY HEMORRHAGE. 



609 



it is the popular belief that the " breaking a blood-vessel in the lungs" is of very- 
frequent occurrence. 

The particular vessels injured in the first class of cases, and the nature and origin 
of the breach made in their sides, are matters of infinite variety. Sometimes the 
blood is extravasated through apertures, the results of a disorganizing process which 
has commenced in the coats of the vessels themselves; as when, for example, aneu- 
risms of the thoracic aorta, or of its primary divisions, burst, and pour their contents 
into the air-tubes. Having pointed out this accidental and hopeless form- of pulmo- 
nary hemorrhage, I shall postpone any further account of the disease that gives rise 
to it, to a future lecture. 

Sometimes, again, a large blood-vessel is laid open by the encroachment and ex- 
tension of disease from contiguous structures. Here is represented (Carswell, fasc. 
vi. plate iii. fig. 5) the perforation of a large branch of the pulmonary artery, and of 
a neighbouring bronchial tube, by the extension of tubercular idceration. The blood 
escaped so abundantly in this case, that the patient was dead in less than a quarter 
of an hour. And here I show you a preserved specimen of a similar opening made 
in the pulmonary vein. 

It will be necessary that I should anticipate somewhat ; and in order to include in 
one view all that relates to pnlmonary hemorrhage, that I should speak cursorily of 
Its connection with tubercular phthisis. No one here can be ignorant that in that 
terrible disease portions of the lung are liable to be hollowed out by the softening 
and expulsion of tubercular matter, into what are called vomicse. Now seeing that 
haemoptysis occurs very frequently in persons labouring under consumption, and 
that the expectoration of blood is often copious, and takes place when it is evident 
that there are tubercular excavations in the lung, it would be very natural for you 
to suppose that the bleeding in such cases proceeded from large vessels which had 
been laid open during the softening of the tubercles, or by the subsequent extension 
of the ulcerating cavities. But in point of fact, this is very rarely the case. I shall 
explain to you hereafter how it happens that this hemorrhage from the larger vessels 
is generally prevented ; still it does sometimes happen. 

But in a far greater number of instances the blood in haemoptysis is exhaled from 
the mucous membrane that Hnes the air-passages. For when this surface is examined 
in the dead body, and immediately after the occurrence of pulmonary hemorrhage, 
it is very often found to be perfectly entire, from the commencement of the trachea 
to the remotest divisions of the bronchial tubes ; as far, at least, as minute dissection 
can follow them. The membrane in these cases is usually red, as in simple bron- 
chitis ; but it is sometimes pale, or with scarcely any traces of vascularity. The 
former of these appearances results from the continued turgescence of the capillary 
vessels ; the latter is the consequence of their having been completely emptied of 
blood by the last hemorrhage. We shall meet with analogous conditions when we 
come to examine the hemorrhages that proceed from other mucous surfaces ; and 
especially from that of the alimentary canal. 

When blood is thus exhaled from the mucous membrane of the air-passages, the 
hemorrhage may be strictly primary or idiopathic ; i. e., it may be independent of 
any discoverable alteration of texture, either in the mucous surface itself, or in any 
other part which, by reason of some intelligible connection of structure or relation, 
seems capable of influencing the capillary circulation of the membrane. But the 
occurrence of pulmonary hemorrhage strictly idiopathic has been more frequently 
affirmed than proved. Active hemorrhage from the lungs is stated by systematic 
writers to be the hemorrhage of adolescence, as epistaxis is that of childhood. I 
believe, however, that idiopathic active hemorrhage from these organs is very rare 
indeed ; unless we may consider as such, certain forms of vicarious bleeding, which 
I shall presently advert to. Andral tells us that in one instance only, in which 
hemorrhage from the surface of the air-passages had been the immediate and appa- 
rently the sole cause of death, had he ever found the substance of the lungs free 
from tubercles, and perfectly healthy. He does not, however, state whether in this 
one instance the heart also was in its natural condition : an important omission, as 
we shall hereafter perceive. He relates, indeed, as an example, of idiopathic 
39 



610 



PULMONARY HEMORRHAGE. 



haBmoptj'-sis, the case of a young man who suffered profuse hemorrhage from the 
lungs on four several occasions, between the ages of twelve and eighteen, without 
any apparent detriment to his health, which remained excellent. It is consistent, 
however, with much experience to suppose that crude tubercles might have been 
scattered in the lungs of this person, and have sufficed, on the application of some 
exciting cause, to determine the hemorrhage, although as yet their presence was not 
indicated by any other sign. Almost every systematic writer quotes, as an example 
of idiopathic hemorrhage from tlie lungs, the story of the Roman governor, men- 
tioned by Pliny, who lived to the age of ninety, though he was afflicted with habitual 
hEemoptysi's. Now the frequent citation of this supposed instance is of itself a suffi- 
cient proof that spontaneous pulmonary hemorrhage is far from being common. 

Cscteris paribus, disposition to pulmonary hemorrhage is increased by what- 
ever tends to diminish the capacity of the thorax, and to compress the lungs, or the 
heart and great blood-vessels. The mechanical congestion thus produced may be- 
come a very intelligible cause of the exhalation of blood from the mucous membrane. 
And it is partly on this principle that we may account for the frequency of hae- 
moptysis in persons with crooked spines ; in tailors, who sit continually in a stooping 
posture : in young women who lace their stays too tightly ; and even in those who 
labour under dropsy, or other cause of distension of the belly. Haemoptysis accom- 
panying ascites has been known to cease at once upon the performance of the 
operation of tapping, and to recur upon the reaccumulation of the dropsical fluid ; 
and this is not on one occasion only, but so often and regularly as to preclude all 
notion of accidental coincidence. There can be little doubt, however, that in this 
class of cases, or at least in a vast majority of them, the hasmoptysis is mainly to be 
ascribed to organic disease of the heart or of the lungs ; and that the pressure which 
precedes and determines the bleeding is simply a concurrent cause. 

If we cannot properly rank that pulmonary hemorrhage as idiopathic, which is 
constitutional and vicarious of some other natural or morbid discharge, — and most 
frequently of all of the menstrual discharge in females, — it may be considered as 
forming a link of connection ; as lying midway between secondary and primary 
hemorrhages. There are a great number of very curious and well-authenticated 
facts upon record concerning this singular form of hemorrhage by deviation. I will 
give you one history of the kind by way of sample ; it is related by Pinel, who held 
that there was no supplemental hemorrhage more common than the haemoptysis that 
is vicarious menstruation. 

A female, 5S years old, born of healthy and robust parents, of strong constitution, 
of a sanguine and plethoric temperament, and of great sensibility, lived in the Sal- 
petriere, and was therefore, under constant observation from the age of 14. She 
enjoyed excellent health till she was 16 3^ears old. In her 16th year the menstrual 
discharge commenced without mishap or difficulty ; but this, hex first menstruation, 
was suddenly suppressed, in consequence of the fright and agitation produced by the 
sight of an epileptic patient in strong convulsions. From that time the catamenia 
never reappeared, nor did any kind of discharge take place from the genital organs; 
but at the next period, when regular menstruation ought again to have come on, the 
girl was attacked with violent haemoptysis. The hemorrhage was preceded by vague 
pains in the uterus and loins, and by other symptoms which frequently announce the 
catamenia. It lasted two days, during which lime the girl expectorated nearly a 
quart of blood. With one interval of exception only, this female continued to men- 
struate throiip^h her lungs at each monthly period, from her 16th to her 5feth year, 
i. c, during 42 years of her life. The coming on of the hemorrhage was sometimes 
a httle accelerated by strong mental excitement ; sometimes a little retarded by 
causes of a contrary nature. It was suspended during one whole year, without any 
serious impairment of the general health, or the occurrence of any other hemor- 
rhage : during this interval, however, the patient suffered most severe headaches. 
Occasionally the haemoptysis was complicated with hcematemesis. The symptoms 
by which the pulmonary hemorrhage in this instance was gens^rally preceded or 
accompanied were the following: — a sensation of weight and uneasiness in the loins 
and in the L-ituaticri of the uterus, soon followed by chilliness of the surface, general 



PULMOxNARY HEMORRHAGE. 



611 



lassitude, and a feeling of oppression and heat in the chest, with some dyspnoea. 
The face became red, and she had intense iieadache. Then she began to have a 
distinct sensation of pricking, and of a sort of babbhng, in the trachea and about the 
commencement of the bronchi ; then followed sharp cough, and the expectoration 
of blood, often bright-coloured and frothy, sometimes of a darker hue. The dura- 
lion of the hieinoptysis was generally confined to a single day, and it never exceeded 
three days. It recurred with tolerable exactness at monthly periods ; sometimes the 
interval was longer, and then the hemorrhage continued longer, but was less abun- 
dant ; and upon the whole, about the same quantity of blood was lost on each occa- 
sion. This woman continued plump, and otherwise healthy, though liable to some 
thickness of the breath upon unusual exertion. 

Cases of this kind are not at all uncommon ; although the vicarious hemorrhage 
seldom persists so long and so steadily. They are not usually attended with any 
peril to life. 

It is, however, a melancholy truth, that the hemorrhage, which takes place by 
exhalation from the mucous membrane of the air-passages, is dependent, in a very 
large proportion of instances, upon incurable disease. The hemorrhage is secondar}^ 
and the disease of which it is symptomatic is usually a fatal disease. And the com- 
plaint of which hsemoptysis is by far the most frequently symptomatic, is tubercular 
phthisis. When the tubercles are found upon dissection to be yet crude and entire, 
and no breach can be detected in the membrane, then no doubt can be entertained 
about the source and manner of the bleeding ; and even when cavities exist, espe- 
cially if they are found to contain no blood, it is probable that, in most cases, the 
hemorrhage has had a similar origin. 

When haemoptysis is thus actually symptomatic of tubercular disease of the lungs, 
it is Hable to considerable variety in regard to the period of its first occurrence, and 
the symptoms by which it is succeeded. There are many persons in whom the first 
attack of hcemoptysis precedes, even for years, the primary symptoms of unequivo- 
cal phthisis. There are others in whom the first attack of haemoptysis is immedi- 
ately followed by all the signs which announce the presence of tubercles in the lungs. 
Many, again, do not spit blood until the tubercles have acquired a considerable 
degree of development, andthe phthisical symptoms have been for some time clearly 
marked ; and occasionally, in these cases, the first hemorrhage proves fatal. Lastly, 
it is far from being an uncommon thing to see pulmonary consumption run its 
whole course, and terminate in death, without having been attended with any spitting 
of blood. 

Andral gives the following statement as the result of his own observation, in re- 
gard to the relative frequency of these several modes of connection between haemo- 
ptysis and consumption. 

Of the persons whom he had known to die of that disease, one in six never spat 
blood at ah. Three in six (or one half of the whole number) did not spit blood 
until the existence of tubercles in the lungs was already made certain by unequi- 
vocal symptoms. In the remaining two-sixths the haemoptysis preceded the 
other symptoms of tubercular disease, and seemed to mark the period of its com- 
mencement. 

By this comparative statement you will see how very frequently hcemoptysis 
occurs as one of the symptonis connected with tubercular phthisis. Under this 
physician's observation it happened in five cases out of six. In the experience, 
however, of M. Louis, the proportion, though very large, is not quite so great as 
Andral found it. Among eighty-seven instances of consumption, there were fifty- 
seven, or four in every six, in which hcemoptysis had been present. 

It has, however, been made a question, whether the spitting of blood which thus 
occurs hi connection with tubercular phthisis, is always to be considered as indica- 
tive of the existence already of tubercles in the lungs ; or whether it may not some- 
times precede, and give occasion to, their formation in those organs. Ttiis question 
has evidently been suggested by those cases (constituting, according to Andral, one 
third of all that happen) in which the ordinary signs of phthisis begin to manifest 
themselves immediately upon the occurrence of the first heemoptysis, or within a 



612 



PULMOxNARY HEMORRHAGE. 



short time afterwards. Morton, who has noticed this kind of pulmonary hemorrhage, 
includes among his species o[ phthisis, the " phthisis ab hsemoptoe ;" and Cullen 
held that spitting of blood was often the cause of pulmonary consumption. It is a 
very important question, and I shall revert to it again hereafter. 

Next to tubercular disorganization of the lungs, the most frequent source of pul- 
monary hemorrhage is to be found in the organic disease of the heart. It has been 
stated by Chomel, Bouiilaud, and others, both in this country and abroad, that the 
disease in these cases is most commonly situated in the right chambers of the heart. 
But certainly this is a mistake. The error has arisen from arguing upon erroneous 
analogies, instead of attending to matters of fact. However, the statement is just as 
little supported by reason as it is by the result of general experience. The only 
alteration in the right cavities of the heart which we could suppose likely, a priori^ 
to cause pulmonary congestion, and thereby hsemoptysis, would be increased strength 
and thickness of their muscular parietes : hypertrophy ; a morbid condition which 
is compamtively rare on that side of the heart, and which, perhaps, would not suffice 
for the production of haemoptysis, even if it did oftener exist. The direct effect, on 
the other hand, of any obstacle to the free passage of the blood in the right cham- 
bers of the heart, would be to gorge the liver, and the system of the vena portx ; 
and to prevent the lungs from receiving their due proportion of blood. But any 
material obstruction existing in the left auricle or ventricle will impede the return 
of blood from the lungs, lead to its accumulation in those organs, give rise to me- 
chanical congestion, and so dispose strongly to pulmonary hemorrhage. And, in 
point of fact, we find that heemoptysis is very frequently the result of disease in the 
left side of the heart ; and this leads me to speak here of one very remarkable morbid 
condition of the lungs, w^hich is often directly connected both with pulmonary hje- 
morrhage and with cardiac disease ; though it is not always, or necessarily, associated 
with either. 

The morbid state to which I allude is far from being infrequent ; yet it had been 
scarcely noticed by or known to pathologists, until Laennec described it under the 
title of pulmonary apoplexy. It appears under two forms. In the one form we 
find an uncertain number of hard knobs, or compact masses, situated here and there 
in the substance of the lungs, chiefly in their lower lobes,, and towards their posterior 
surface. Their size varies from that of a marble to that of a hen's egg. When 
cut through ihey are seen to be very exactly circumscribed, the cut surface being 
more or less circular, of a uniform- and very dark colour throughout, and exhibiting 
a strong contrast with the surrounding tissue. Careful examination shows that these 
masses are composed of blood that has coagulated in the pulmonary vesicles. Occa- 
sionally the pulmonary substance seem.s broken down, or torn, by the exlravasated 
blood ; and in these cases, perhaps, the resemblance between the injury done to the 
lung, and that which is inflicted on the substance of the brain in cerebral hemorrhage, 
is tolerably close. Generally, however, there is no such laceration of the pulmonary 
tissues ; but one, or more, of the lobules of the lungs are gorged and cramm.ed with 
blood, which has been poured out from the surface of the mucous membrane. These 
lobules, it is known, have no direct communication with each other ; but are 
isolated (except where they severally open into the bronchial tubes from ^yhich they 
spring) by a distinct investment of areolar tissue ; and it is to this peculiarity in 
their structure and disposition, that the exact circumscription of the dark-red indu^ 
rated masses is to be attributed. 

In the other form of pulmonary apoplexy, there are fewer of these solid spots; 
perhaps one only, large, diffused, occupying sometimes nearly the whole of one 
lobe, its hmits obscurely defined, and its colour gradually deepening to the centre, 
which is obviously formed by little else than a black clot of blood. 

Now the principal symptom attending the formation of these masses is haemoptysis; 
and the principal, though not the only cause is disease of the heart. The hemor- 
rhage is often severe and copious in the first, or circumscribed form : sometimes 
slight and scanty, but commonly slow, oozing, and persistent, in the second or uncir- 
cumscribed form. The heart disease is in its left chambers, and very often consists 
m contraction of the mitral orifice. No example of pulmonary apoplexy, or of 



PULMONARY HEMORRHAGE. 



613 



pulmonary hemorrhage, even apparently dependent upon hypertrophy of the right 
side of the heart, has ever fallen under my notice. 

In truth the morbid condition of the lungs which I am now speaking of,* has been 
badly named. The application, by Laennec, of the term apoplexy to ttie lungs v/as 
singularly unfortunate : for it suggests an analogy between two things, which, though 
resembling each other in the appearances which they leave behind them in the organ 
affected, ard* yet, essentially, unlike. I have shown you, in a previous part of the 
course, that cerebral hemorrhage depends almost always upon the giving way of a 
blood-vessel, in consequence of the morbid brittleness of its coats ; while what is 
called pulmonary apoplexy can very seldom indeed be so caused. The notions which 
I have been led to form upon this subject differ materially from those which you 
will find expressed in the works of almost every writer on pulmonary apoplexy. 
The opinions I entertain were stated several years ago, in some lectures which I 
was appointed to deliver before the College of Physicians; and I have constantly 
been in the habit of mentioning them to the pupils of the Middlesex Hospital, and 
to my medical friends. It is a matter of satisfaction to me to find that they are 
esteemed to be correct by so sound a pathologist as Dr. Carswell, who has alluded 
to them in one of his fasciculi on the Elementary Forms of Disease. Laennec 
speaks of the pulmonary apoplexy, as if it were the cause of the hsemoptysis. But 
this is surely a very incorrect view of the matter. The partial engorgement, and 
the haemoptysis, are not mutually connected with each other as cause and effect, but 
they are concurrent effects of the same cause ; of that cause which gives rise to the 
extravasation or exhalation of the blood in the first instance. A part of the blood so 
extra vasated passes outwards by the trachea and mouth ; while a part is forced in 
the contrary direction, into the ultimate divisions of the bronchi, so as to fill and 
block up the whole tissue of a single lobule, or of a bunch of contiguous lobules, 
and thus arises the circumscribed variety. Andral conceives that the sanguine effu- 
sion takes place in the ultimate air-cells ; and he apphes to this form of disease the 
term pneumo-hemorrhage, to distinguish it from ordinary hasmoptysis, which he calls 
broncho-hemorrhsige ; and ihis I believe to be the true pathology of the uncircum- 
scribed variety. But it seems to me vastly more probable, that in the other form of 
the complaint the seat of the effusion is in one or mor the larger branches of the 
air-tubes; and that the blood, a part of it at least, is i. n backwards into certain 
of the pulmonary lobules, by the convulsive efforts to respire which the patient 
makes when threatened with suffocation by the copious explosion of blood, or by a 
paroxysm of cough and extreme dyspnoea : especially if the blood is poured out from 
the membrane while the chest is in the state of expiration. It is easy to understand 
how certain portions of the Jungs, without undergoing any actual change of texture, 
may in this manner be so choked up, and crammed with blood, which afterwards 
coagulates, as to preclude any subsequent admission of air. 

This view of the formation of circumscribed pulmonary apoplexy affords an easy 
explanation of some of the phenomena attending it, which it would be difficult to 
account for on any other supposition : I mean, first, the occurrence of several of the 
clots or masses of blood, in different, and sometimes in distant parts of the lung at the 
same time ; and secondly, the exact manner in which they are commonly bounded 
and limited to certain lobules. And if (as is sometimes, though seldom, the case), 
even the texture of the lung be lacerated, it is easier to conceive that this may happen 
in consequence of the violence of regurgitation during the struggle of impending suf- 
focation, and that the mere impulsion of a thickened muscle at the centre of the cir- 
culation should be capable of driving the blood through the walls of an artery with 
sufficient force to tear anS break down the substance of the lung around it. 

In the diffused or uncircumscribed form of pulmonary apoplexy, the congested 
lung is not relieved by a sudden and copious gush of hemorrhage, but the impeded 
and stagnating blood oozes slowly through the vessels containing it into the neigh- 
bouring interstitial and vesicular tissues, clogs up a larger and larger space, and is 
partly expectorated in separate dark-red sputa, combined with a certain quantity of 
mucus. A similar condition of the lung sometimes occurs in purpura haemorrhagica, 



614 



PULMONARY HEMORRHAGE. 



without any mechanical impediment to the passage of the blood into and through the 
heart. 

The belief that the dark-coloured, circumscribed spots seen in the lungs, and 
spoken of as pulmonary apoplexy, are often, if not always, produced in the manner 
I have just been describing, was suggested to me by the observation of a case, in 
which these appearances existed, and in which they certainly ivere so occasioned. I 
told you, when speaking of cynanche tonsillaris, that I had seen one person, and one 
only, die in consequence of that complaint; and that his death was occasioned by the 
laying open of the Ungual branch of the carotid artery in the progress of ulceration. 
The phenomena attending that patient's dissolution were of deep, though of painful 
interest. 1 described them to you before. He had been taken out of bed, and laid 
upon a table in the ward, in the middle of the night, in order that Mr. Mayo might 
more conveniently place a hgature upon the carotid. Suddenly the bleeding burst 
forth afresh: and he expired, before our eyes, in the course of two minutes: not 
from syncope or exhaustion, but evidently suffocated. The blood entered and cl ^^ked 
up the trachea, and he had not strength enough left to expel it by coughing. ' felt 
his heart and the artery at his wrist pulsate firmly for some httle time after tl;e last 
attempt to dilate the chest had been made. This you know is what always happens 
when death takes place from the sudden denial of air to the lungs. We found the 
upper surface of the glottis covered by a clot of blood. There was blood also in the 
windpipe; and scattered through the substance of the lungs there were numerous 
hard, and dark, but not very large masses, precisely resembling those described by 
Laennec as constituting pulmonary apoplexy. This man had shown no symptoms 
of any pulmonary complaint ; nor was there any morbid appearance in his lungs 
except those which resulted from the presence of the blood that had been poured into 
them through the trachea, and rammed home into some of the air-cells, in his con- 
vulsive attempts to breathe. All that I have observed since this case happened, has 
tended to confirm my belief, that what has been erected into a distinct form of dis- 
ease, under the objectionable name of puhnonary apoplexy, is simply an accident of 
pulmonary hemorrhage. When haemoptysis has occurred, to any amount, in con- 
sumption, it is by no means uncommon to find pulmonary apoplexy after death ; and 
Dr. Latham has mentioned to mic, in conversation, one remarkable instance of that 
disease, strongly corroborative of the doctrine I have been endeavouring to support. 
A young female patient of his, labouring under confirmed phthisis, was attacked, for 
the first time, with haemoptysis. The bleeding was so profuse as to cause almost 
immediate death by suffocation. Her lungs were found riddled with small tubercu- 
lous cavities ; and each of these httle cavities contained a little clot of blood. Surely 
it is more credible that the blood should have reached each cavity by regurgitation 
from the larger air-tubes, than that each should have been the seat of an independent 
hemorrhage at the same moment. It is by a similar reflux of blood that the ap- 
pearances are produced which characterize the circumscribed form of pulmonary 
apoplexy. 

Upon the whole, the occurrence of haemoptysis, considered in reference to the 
probable duration of life in those who are the subjects of it, is of melancholy omen. 

I have long arrived at this conclusion : — that if from any given number of persons 
who have been known to spit blood, we subtract those in whom that symptom was 
connected with irregularity in the uterine functions, there will remain but few in 
w^hom the haemoptysis did not depend upon disease, incurable and progressive in its 
nature, of the lungs, or of the heart ; and that if we still further subtract those per- 
sons in whom the hemorrhage was symptomatic of cardiac disease, there will be. 
very few indeed left, in whose lungs the existence of tubercles may not be confi- 
dently predicated. 

Among these few may be reckoned persons who have suffered haemoptysis de- 
pendent upon the detachment and expulsion of " bronchial polypi;" and who exhibit 
no other indication of cardiac or pulmonary disease. 

You will, of course, understand that 1 do not include in this estimate of hasmo- 
ptysis as a prognostic symptom, those cases in which (as in simple bronchitis) the 
expectoration is merely streaked with blood : — nor those in which small quantities 



PULMONARY HEMORRHAGE. 



615 



of blood are intimately combined and amalgamated with the bronchial mucus, and 
form the rust-coloured sputa so indicative of the presence of pneumonia : — nor those 
in which the hemorrhage is a consequence of mechanical injury to the chpst. 

Of those individuals whom Andral had known to spit blood at some period or other 
of their hves, there was- only one in five whom he did not also know to have tuber- 
cular pthisis. On the other hand, Louis states that for three years he asked all the 
patients who came before him, in the practice of a large hospital, and who were not 
affected with pthisis, whether they had ever spat blood; and the answer was always 
in the negative, excepting only a few instances in which the patients had received 
violent blows upon the thorax; and the (^ses of females in whom the menstrual dis- 
charge had been suddenly suppressed. 

The quantity of blood which is brought up in different cases of pulmonary hemor- 
rhage, is extremely variable. Sometimes it is so copious and overwhelming that the 
patient either dies suffocated, or he dies of syncope, outright : but this i* not very 
common. Sometimes, on the other hand, a small quantity of blood finds its way into 
the mouth, the patient scarcely knows how. And between these two extremes there 
is every gradation in respect to quantity. 

" When blood is thrown out by the mouth (says Cullen), it is not always easy to 
determine from what internal part it proceeds; whether from the internal surface of 
the mouth itself, from the fauces, or adjoining cavities of the nose, from the stomach, 
or from the lungs. It is, however, very necessary to distinguish the different cases." 

Now the diagnosis between hemorrhage from the lungs and hemorrhage from the 
stomach, in other words between hfrmopfysis and hacniafernesis, I shall not enter 
upon, until I have described the latter disease. And the diagnosis between hemor- 
rhage from the fauces or cavity of the mouth, and hemorrhage from the lungs, can 
never be very difficult, if once the doubt suggests itself, and the necessary examina- 
tion of the mouth be made. And 1 would advise you not to omit that inspection. I 
could tell you of cases in which the neglect of this simple precaution has led to 
needless activity of treatment, and to the ultimate discredit and disadvantage of the 
practitioner. Blood may ooze into the mouth from spongy gums, or drip from the 
posterior nasal orifices, and be at length spat out in considerable quantity. Etymo- 
logicaliy speaking, these are cases of hxmopfysis ; but they do not constitute the 
particular disease or symptom to which alone nosologists have agreed to restrict that 
term. The sources of the bleeding are manifest as soon as they are carefully looked 
for. 

Patients who are subject to hajmoptysis generally know by experience when it is 
about to happen. It is frequently preceded by some uneasy feeling within the 
thorax — pain, or a sense of weight, or of heat or of pricking, beneath the sternum, 
with anxiety ; and they tell you that they taste the blood in their mouths before it 
comes up, i. e., they perceive a saltish taste ; and just before the blood appears, a 
tickling sensation is experienced about the top of the larynx. To relieve this sensa- 
tion, the patient coughs or hawks a little, and a certain quantity of frothy and florid 
blood is expectorated. 

In a person disposed to pulmonary hemorrhage, the bleeding may be determined 
by a variety of causes ; which ought to be pointed out to him, in order that he may 
avoid them. Any thing which hurries the circulation will, of course, have a ten- 
dency to excite the hermorrhage. Straining of any kind ; great efforts of the body; 
active exercise ; much talking; and more especially public speaking, or singing, or 
playing on wind instruments. A diminution in the superincumbent weight of the 
atmosphere is supposed to be, in some cases, sufficient to bring on hemoptysis ; and 
blood is said to have been forced even from sound lungs, in persons who have 
ascended very high mountains, where the atmosphere is rare- and where the pres- 
sure upon the surface of the body is sensibly lessened. Perhaps the labour of the 
ascent may have shared in the production of the hemorrhage ; for I am not aware 
that any such effect has ever occurred to persons who have much more rapidly 
reached a very great altitude in balloons. 

Auscultation and percussion do not stand us in much stead in cases of hcEmoptysis, 



616 



PULMONARY HEMORRHAGE. 



so far as that symptom itself is concerned. Indeed, if they were capable of affording 
us information, it would in most cases be superfluous ; for we see the blood, and we 
can generally satisfy ourselves that it comes from the lungs. 

But pulmonary hemorrhage may occur without hemoptysis. In what is called 
pulmonary apoplexy there is extravasation of blood : and it is not always attended 
with the expulsion of a portion of the extravasated fluid through the mouth. Laennec 
and others pretend to say, that when there is blood in the bronchi, they can distin 
guish, by the peculiar character of the crepitation to which it gives rise, that it is 
blood, and not mucus; that the bubbles, passing through a thinner liquid, are 
larger, and break oftener, than those prodaced by the passage of air through viscid 
m.ucus. This distinction is too subtle for me. If, indeed, there has been haemoptysis, 
and especially if the heemoptysis has been sudden and copious, and if, after it, you 
hear a large crepitation in one or more isolated parts of the lung, it will be reasonable 
to conclude that the air-tubes contain blood in those parts. Those lobules that are 
plugged up with blood, to the entire exclusion of air, will not, of course, be the seat 
of any sound during respiration ; but this limited absence of sound will be scarcely 
appreciable unless the infracted portion lies near the surface of the lung. Around 
the spot thus rendered solid the sound of crepitation may be audible. 

Yet, although the method of auscultation furnishes but httle help towards the 
detection of pulmonary hemorrhage, it will often afford us most precise and valuable 
information respecting the disease of which the hemorrhage is a consequence, and 
an index. Thus, it will frequently teach us, with absolute certainty, that the heart 
is diseased, or that the lungs are occupied by tubercles. The precise sounds, or de- 
ficiencies of sound, which supply the key to this knowledge, I shall describe when I 
come to those disorders. 

Whatever may be the source and organic cause of the hasmoptysis, the bleeding 
should be stopped as soon as possible : not, however, merely by suppressing it, but 
by relieving the necessity on which it depends. The longer it is suffered to con- 
tinue, the more likely is it to add to the damage which already, in too many cases, 
exists in the lungs. If it leads to the formation of blocks of pulmonary apoplexy, the 
portions of lung so filled up are rendered useless for a long period, and probably^for 
ever. Now as in most cases the hemorrhage is a hemorrhage by exhalation, and 
depends upon congestion, active or mechanical, we shall stay the hemorrhage if we 
remove the congestion. 

The congestion may be either mechanical or active when it results from the pre- 
sence of tubercles in the lungs ; it is almost always mechanical when it depends 
upon disease of the heart. The tubercles may press upon the blood-vessels, and 
so lead to mechanical engorgement ; or they may provoke by their presence an 
active determination of blood to those organs, just as we know that they often 
provoke inflammation, which is congestion and something more; and just as any 
foreign body lodged in the lung may cause either the one or the other of these 
conditions. 

Frequently there is a distinct febrile movement accompanying the hemorrhage : 
the heart beats with increased force and frequency, the cheeks are flushed, and the 
skin is hot; sometimes the pulse is quite hard, and full, and bounding, and people 
speak of such a pulse as a hemorrhagic pulse. Now I mentioned in a former part 
of the course, that hemorrhage occurring under such circumstances as these, often 
works its own cure ; but it is better, when an organ so vital and important as the lung 
is the seat of the effusion of blood, that we should cure the bleeding than that it 
should cure itself — that we should diminish the congestion with which it is linked, 
through the safer channel afforded by the veins of the arm. The patient is to be 
surrounded with cool fresh air. His head and shoulders should be elevated. He 
should be restricted to the most meagre diet ; and be forbidden to exert himself, or to 
speak more than is absolutely necessary. His bowels should be freely purged, in 
the first instance, and then hept lax and open, both with the view of deriving (as it is 
called) from the thorax, and of preventing Costiveness and straining. And, in con- 
junction with these measures, he should lose blood from the arm. The amount and 
the repetition of the bleeding must be determined by the circum.stances of the case, 



PULMONARY HEMORRHAGE. 



\ i. e., by the cessation or continuance of the hemorrhage, and especially by the con- 
dition of the pulse. It would be idle to attempt to lay down precise rules on this 
matter. We do not bleed, however, so resolutely and perseveringly in hsBmoptysis 
as we are often obliged to do in acute inflammation. 

A prejudice has been taken (such, at least, I think it) against local blood-letting 
in pulmonary hemorrhage. Inasmuch as leeches applied to the groins in amenorrhoBa 
appear sometimes to restore the catamenia, so they have been thought hkely, when 
apphed over the surface of the chest, to attract the blood somehow to that part of 
the body, and even to cause hemorrhage when none before existed. Now I have so 
many times taken blood from some part or other of the exterior of the thorax by 
leeches, or cupping-glasses, without observing any such effect, of causing hasmoptysis, 
or of increasing it while already present, that I cannot help considering the objection 
rather a fanciful one. 

When the fever or congestion are abated ; or when there has been no constitu- 
tional disturbance, and the hemorrhage has shown a passive character from the 
beginning, and when a continuance of it, so far from being curative in its nature, is 
likely to be injurious ; then we are to employ those remedies which have been found 
efficacious in restraining and suppressing hemorrhages. 

Nov^^ of the substances which are held to possess more or less of a specific virtue, 
when taken internally, in arresting the efflux of blood, the sugar of lead, the plumbl 
acetas^ enjoys in this country the highest reputation. And it certainly is a very 
serviceable remedy. Dr. Paris speaks of it as one of the most valuable resources of 
physic: and says that in respect to its power over internal hemorrhage there is 
nothing simile aut secundum. He states also that its use is equally safe and 
manageable. There is, in fact, no doubt of its efficacy: but most other writers use 
very cautious language in recommending its employment. Physicians have been 
deterred from giving it by the fear of its poisonous qualities; by the dread of pro- 
ducing the disease called colica pictonum. Culien observes, that the preparations 
of lead are certainly powerful in controlling hemorrhage, but that they are otherwise 
of a character so pernicious as to forbid their use except in cases of the utmost dan- 
ger. Of late years this drug has usually been administered in small doses, and 
guarded by opium ; and it is to this combination that ]3r. Paris refers when he de- 
clares it to be a safe and manageable remedy. More recently, however, a statement 
has been made by Dr. A. T. Thomson, which must be considered of much impor- 
tance if further experience shall show it to be well founded. He was led, it seems, 
by some accidental circumstance, to suspect that lead acted as a poison upon the 
animal body, only in the shape of its carbonate. And the result of a series of expe- 
riments upon brutes satisfied him of the correctness of this notion. He holds, that 
when the acetate of lead produces the well-known symptoms of the painter's colic, 
it does so in consequence of its being somehow converted, after its reception into the 
body, into the carbonate ; that the conversion may be obviated by a very simple ex- 
pedient ; and that the remedy may then be given with perfect safet}^. in large and 
efficient doses. The expedient is merely that of administering the lead in draughts 
containing some dilute acetic acid, which prevents the decomposition of the acetate 
by any carbonic acid that happens to be present in the intestinal canal. In this way 
he tells me he has given as much as fifteen grains daily for ten days together, with- 
out any inconvenience, and with most excellent effect upon the hemorrhage. I have 
often exhibited lead in this manner; and I have never known it to give rise to any 
unpleasant consequences. At any rate this method of administering it deserves 
further and careful inquiry. 

[We have also administered acetate of lead very extensively in cases of hgemoptysis, and 
in tolerably large doses, continued, at short intervals, for one or two days, and have never 
known any injurious or even unpleasant effects to be produced by it. As a means of con- 
trolling the hemorrhage from the lungs we know of no remedy so ce'rtain in its effects. In 
the disease under consideration, we have very generally combined a small portion of ipeca- 
cuanha with the acetate of lead. — C] 

In shght cases of haemoptysis, the mineral acids, with or without alum, are often 
insufficient ; or, if there be feverishness, the saline draught with nitre and digitalis. 

3b3 



1; 



618 



PULMONARY EMPHYSEMA. 



Of the numberless other drugs which have been vaunted as specific in hemorrhage 
I have very httle personal experience ; at least in pulmonary hemorrhage. In cer- 
tain other forms of internal bleeding there are some of them that are worth trying. 
But in hemoptysis there are none I can venture to recommend bi^ such as 1 have 
now mentioned. You may sometimes be urged to give a celebrated quack medicine 
— RuspinVs styptic, which has obtained a high repute, and sells at a high price. 
This nostrum seems for a long while to have baffled analysis. The late Dr. Wol- 
laston told Dr. Maton that it contained no metallic substance ; Dr. Thomson has 
since announced that it mainly consists of a solution of gallic acid in alcohol diluted 
with rose-water. But I believe that all the remedial agents which contain gallic 
acid are more effectual in another form of internal hemorrhage, to be considered 
hereafter. 

Of mercury, as a remedy for pulmonary hemorrhage, I have already mentioned 
both my own insufficient experience, and the very favourable report of som.e excel- 
lent judges who have much employed it. 



LECTURE LV. 

Pulmonary Emphysema; vesicular and interlobular. Anatomical characters of 
vesicular emphysema ; physical signs ; general symptoms ; causes; treatment. 
Interlobular emphysema : its anatomical characters, symptoms, cause, and cure. 
(Edema of the lungs. Phthisis Puhnonalis. 

T HAVE yet one or two morbid conditions of the lungs to consider and to describe, 
before I go to that which is the most common and most extensively fatal of all its 
morbid conditions — tubercular phthisis. 

There is a state of the lung, or rather there are two or three different states, to 
which Laennec has applied the name emphysema. A very injudicious name it was 
for him so to impose. We are infinitel}'- indebted to Laennec for the entirely new 
hght which his able researches have thrown upon the morbid anatom}^ and the pa- 
thology of the lungs : but we have to regret that he should have employed, in several 
instances, a vicious nomenclature. Emphysema is a term that had long been fa- 
miliar among medical men in a certain sense. It was used to express the inflation 
of the areolar tissue of the body with air ; and surgeons still make much of it as an 
indication, in cases of fractured rib, that the bone has grazed the pleura, and allowed 
air to pass into the areolar tissue, and to diffuse itself over the chest and neck, and 
other parts ; so that these parts, when pressed, convey a curious sense of crackling 
to the finger. But emphysema of the lung, as that term is employed by Laennec, 
includes dilatation of the air-cells of the lungs, and rupture of the partitions which 
separate them from each other ; and also the infiltration of air into the interlobular 
areolar tissue, or into the subpleural areolar tissue. In strictness of language these 
last conditions alone should have been called emphysema of the lung. Laennec has 
distinguished the two species in this way. To the dilatation of the air-cells, with or 
without a breach of their partitions, he gives the name of vesicular emphysema : 
"the vesicular (I quote the words of Dr. Forbes' translation), or pulmonary, properly 
so called." Now in truth this is emph3^sema improperly so called. To the infiltra- 
tion of the areolar tissue in or around the lung with air, i. e., to emphysema of the 
lung in the old sense of that word, he apphes the title of interlobular emphysema. 
We cannot change these denominations nov/. They have fastened themselves upon 
medical language. But it is very fit that you should be aware of their inconsistency 
with the ancient signification of the same word, and have clear notions of ^vhat, in 
Laennec's nomenclature, they are intended to express. 

The change called vesicular emphysema was not unknown, as a mere morbid 
condition, before the time of Laennec ; but it had been noticed by very few writers, 



PULMONARY EMPHYSEMA. 



, 619 



and practically, it was 7vholly unattended to. Yet it is extremely common ; much 
more so than you would suppose : and when rightly studied it is of great interest, 
too, in relation to the general pathology of the chest. But it is still so new, and 
may so readily escape observation, both in the dead and in the living body, if it be 
not looked for, that I shall devote a somewhat more minute attention to it, on those 
accounts. 

Laennec was undoubtedly the first to put emphysema pulmonum upon the list 
of definite and cognizable diseases ; to point out its frequency ; and to collect its 
symptoms. But when he affirms that, before his time, the pulmonary change which 
constitutes the disorder was misunderstood by nearly all those persons who had no- 
ticed it, he scarcely does them justice. "All of them (says he) seem to have thought 
that the derangement in question consisted in the infiltration of the cellular substance 
of the lungs with air." He inconsistently adds, " R'uysch and Valsalva are the only 
authors, as far as I know, who have observed in individual cases, the dilatation of 
the cells ;" and with still greater inconsistency he proceeds to quote, from Morgagni, 
the following passage, in which this dilatation is very clearly described : " Sinistri 
pulmonis lobus superior, qua claviculam spectabat, vesiculas ex quibus constat 
minim in modum auctas habebat ; ut nonnullse avellanas magnitudinem sequarent; 
casterte multo minores erant." You will find the same change noted by Dr. BaiUie, 
in his Morbid Anatomy: and by earher writers than he. 

Vesicular emphysema, then (to adopt Laennec's phraseology), consists in dilata- 
tion of the air-cells. The enlarged cells become misshapen also in many cases. 
They vary in magnitude from that of a millet-seed to that of a swan-shot : nay, the 
cavities may even reach the size of a nutmeg, or of a hen's egg: but when they are 
as big as this — and a fortiori if they are still bigger — the distension and vacuity are, 
no doubt, the result oif the union of several air-cells, broken into one, by the stretch- 
ing or destruction of the partitions that naturally divide and isolate them. You may 
see the dilated vesicles very plainly through the pleura, if you carefully examine the 
surface of the lung. They appear to the naked eye as the healthy vesicles appear 
when seen through a magnify ing-glass. Sometimes all the vesicles belonging to one 
lobule are enlarged, while those of the adjoining lobules are of the natural size. In 
that case^ the emphysematous lobule is conspicuous both by its peculiar colour, and 
by its protrusion. The surface of the lung is often rendered quite irregular and 
uneven by projections of this kind. Sometimes one large globular prominence is 
seen, like a bubble on the water, or Hke a httle bladder springing from a footstalk ; 
but if you examine it closely, you will generally find that the footstalk is merely a 
constriction at the surface, and that there is as large a cavity beyond it, in the lung, 
as there is without. These bullte you cannot slip about by pressure from one part 
of the pleura to another. 

The unevenness produced by vesicular emphysema upon the outside of the lung 
is manifest enough, when looked for; but the same condition of the air-cells exists 
also within, and there it is not so readily perceptible. The fluids which the lung 
contains obscure all distinction of parts when the organ is cut. The best way of 
getting a fair view of the dilated cells as they appear in the substance of the lung, 
is to inflate the emphysematous portion, by blowing air in at the bronchial trunk 
which belongs to it, and then tying that trunk to prevent the escape of the air. The 
inflated lung should be hung up in a current of wind, so that it may quickly dry; 
and, during the drying process, it should, from time to time, he reinflated ; for else 
the included air gets out somehow, and the piece of lung shrinks and shrivels up. 
When it is quite dry, if a section of it be made with a thin sharp knife, the altered 
state of the air-cells, some of which are more and some less dilated, will be very 
conspicuous. 

No part of the lung is exempt from liability to these morbid changes ; but gene- 
rally they are limited to certain portions of the organ ; and they are much more 
common and more pronounced at its loose anterior borders, and near its summit, 
than anywhere else. Both lungs appear to be alike obnoxious to the disease, which 
seldom affects the one without affecting, in a greater or less degree, the other also. 

The parts that are emphysematous are usually paler than the rest, and sometimes • 



620 



PULMONARY EMPHYSEMA. 



they are quite white. Tn extreme cases, the surface of the lung presents a sort of 
piebald appearance ; large patches of it looking as if they had been bleached. This 
pale colour is oftenest seen towards the free edges of the lung. Sometimes those 
edges are rounded and thick ; sometimes thinner, and folded back ; while sometimes 
the margin is blown out, as it were, into an irregular fringe ; some of the inflated 
portions remaining connected with the lung by slender pedicles, and thus forming 
appendices to it of a light yellow colour. I presume that what was thought and 
called a fringe of fat, garnishing the edges of the lung, in the body of King George 
IV^., was of this kind. At least I have never seen nor heard of any other example 
of fat deposited in those organs. If you hold the emphysematous border between 
your eye and the light, you perceive that it is translucent : if you prick it with a 
pin, the puffy part surrounding the puncture collapses ; which shows that the dilated 
vesicles communicate together. 

An emphysematous lung is not only paler, but drier also, than ordinary ; and for 
the same reason. It possesses fewer capillary blood-vessels, less blood, and conse- 
quently less moisture. It is dry and hght, and floats high upon water, like a bladder 
filled with air. 

If you take such a lung out of the body, having its surface embossed with irre- 
gular groups of enlarged air-cells — and if you inflate that lung, by blowing into the 
bronchi — the emphysematous portions will seem to sink in, and flatten, and return 
to the ordinary level as the lung becomes distended. In point of fact, however, these 
portions remain permanently dilated, and the other parts of the surface rise, as the 
air enters them, until the whole is smooth and even. Air is shut up in the emphy- 
sematous portions, which do not subside, as the adjoining portions do, when left to 
the agency of their proper elasticity. Hence you wifl see how it is that, when the 
vesicular emphysema is extensive, so as to occupy nearly the whole of the lung, the 
lung becomes apparently too big for the case in which it is contained. Not only 
does it not collapse when the sternum is raised, and the pressure of the atmosphere 
is admitted to its external surface, but it even protrudes, the moment that the open- 
ing is made. When you handle such a lung, it gives a very different sensation to 
the fingers from that produced by pressing a healthy lung. It feels like a down 
pillow. It crepitates less ; the air is less easily forced out of it, and escapes slowly, 
with a slight hissing noise. 

Such being the slate of the lung, as discovered after death, you will naturally be 
inquisitive to know by what signs the existence of a condition so remarkable is re- 
vealed during life. First, then, when the emphj^sematous distension is considerable 
in amount, and extensive, it produces alterations in the shape and movements of the 
chest. The lung, having lost much of its elasticity, does not subside as a healthy 
lung does. The act of expiration is arrested and incomplete. Consequently, the 
thorax remains nearly in that position which it assumes after inspiring. It is promi- 
nent and rounder on the diseased side, or on both sides, if both lungs be affected ; 
but it is apt to be irregularly prominent, and unsymmetrical ; to bulge here and 
there in correspondence with the bulging of the lung within. The ribs are less 
oblique than they should be, and the chest is, therefore, more cyhndrical. The cla- 
vicles are ill-defined in such persons. ' They are so, as you know, in fat persons ; 
wherefore this aid to the diagnosis is of most value in those who are spare. In them 
it is a valuable sign, for it is simple and obvious. The distended lung presses up- 
wards, as well as in other directions, and tends to efface the depressions which natu- 
rally exist both above and below the collar-bone. This symptom is the more to be 
depended on if it presents itself on one side only. The manner of breathing is 
instructive also. The ribs, never receding within their proper limits after ea?pira- 
tion, can move but little during i/ispiration ; and the breathing is in a great measure 
abdominal. 

Now, all these signs are physical signs. But what, in the second place, are the 
auscultatory physical signs ? Why, in the emphysematous regions, which com- 
monly are also the most bulging, percussion yields an unnaturally clear and resonant 
sound, while auscuhation discovers a very indistinct vesicular murmur. The two 
modes check and explain each the information afforded by the other. Percussion 



PULMONARY EMPHYSEMA. 



621 



ascertains that there is air beneath the part struck : auscultation ascertains that there 
is Utile or no air in motion beneath that part. It follows, therefore, that there is 
stagnant air; air shut up in the enlarged air-cells, or air interposed between the ear 
and the lung in the cavity of the pleura: air at rest, in fact. I say the respiratory 
murmur is very feeble. This partly depends upon the hmited play of the ribs, partly 
and chiefly upon the circumstance that the air is imprisoned in the dilated cells. 
When none entesrs or leaves them during respiration, no vesicular breathing can be 
heard ; and then we must call in the aid of other considerations to determine whe- 
ther the air be contained in the cavity of the pleura, or in the emphysematous lung. 

Pure pneumothorax is extremely rare. Pneumothorax with liquid effusion is 
easily recognised by its proper signs. If these be absent, we conclude that the 
stagnant air occupies the lung, and not the pleura ; and this conclusion is strength- 
ened if the unduly resonant part be prominent also. Almost all writers on this 
subject follow Laennec in stating that dry crepitation may be heard in the emphy- 
sematous parts. It may be so ; but, if so, I cannot distinguish it. I mean that I 
know no crepitation but that which is moist, and which proceeds from the formation 
and rupture of bubbles, as air passes through liquids in the bronchial tubes. But 
other people believe that they can hear a dry crackling, such as may be produced 
by inflating a portion of dry areolar tissue out of the body, or a dry bladder. You 
will try this by your own experience. I do not deny that such a sound exists : I 
only say that if it does exist, I cannot tell when I hear it, and when I hear large 
moist crepitation. But I more than suspect that no such sound is given out by an 
emphysematous lung, and that the sound heard is really large crepitation in the 
neighbourhood of the dilated cells ; for emphysema is very often accompanied by 
catarrh ; and the sounds in question, authors agree, are not permanently audible. 

So much for the physical signs of emphysema pulmonum. The general signs, 
when the change is extensive, are an habitual shortness of breath, with occasional 
paroxysms of extreme dyspncea; cough which, however, is far from being a 
constant symptom : palpitation in most instances as the disease advances, and more 
or less oedema of the ankles. Usually the appetite remains unimpaired, and the 
patient does not lose flesh. The disorder is unattended with fever ; and is essen- 
tially chronic. 

The paroxysms of urgent dyspncea are frequently concurrent with, and apparently 
excited by attacks of smart bronchial catarrh ; but they sometimes arise without any 
obvious cause. They are apt to come on suddenly, in the night, and the patient is 
obUged immediately to sit up, and even to open the doors and windows of his bed- 
room, that he may breathe more freely. In one word, he undergoes a paroxysm of 
asthma. These attacks become more frequent and more severe as the patient and 
the disorder grow older. They are attended with much wheezing ; and in the lower 
posterior part of the lungs crepitation is generally audible. At first the palpitation 
of the heart, and oedema of the feet, abate and cease as the violent dyspnoea goes off : 
but at length these symptoms become permanent. 

We see a reason, in the physical condition of the thorax, why the breathing should 
be more oppressed, and why the paroxysms of orthopncea should occur more fre- 
quently in the night. Whenever the respiration is principally abdominal it is apt to 
be embarrassed by the recumbent posture, which throws a part of the weight of the 
viscera of the belly upon the diaphragm. The horizontal position is always ill borne 
by these patients ; and, for similar reasons, flatulence or fulness of the stomach, how- 
ever caused, distresses them. 

Cough, as I observed before, is an occasional, but by no means an essential accom- 
paniment of vesicular emphysema : the expectoration, where there is any, is thin- 
nish, like gum-water, and full of foam. 

Louis, who has analyzed, with his accustomed care and exactness, a considerable 
number of cases of emphysema, states that the disease is seldom complicated with 
tubercles in the lungs. We may suspect that complication, if haemoptysis, or ema- 
ciation, occur ; which are otherwise rare symptoms. 

To what cause can we ascribe this dilatation of the pulmonary vesicles, whereby 
the proper function of the lung, in the part aflected, is impaired, or annulled? 



622 



PULMONARY EMPHYSEMA. 



Mainly, I think, in the outset at least, to the imprisonment of air within them, under 
circumstances of disease. You may often trace back ihe shortness of breath to the 
period of infancy. Patients will tell you that from their earhest recollection they 
have been easily put out of breath : that they never were able to engage heartily, 
and to the same degree with their companions, in the active sports of childhood, it 
is easily to conceive that under chronic inflammation, or other disease of the mucous 
membrane, air may enter the vesicles more readily than it can escape from them 
again. The act of inspiration is voluntary and strong ; the tubes are made patent 
by it, and air rushes in and finds its way to their extremities. But the act of expi- 
ration is passive, and comparatively feeble. Slight tumefaction of the membrane, 
or a little plug of viscid mucus, may so close up a small bronchial ramification, that 
the air cannot pass through it in expiration : and more and more air may thus be 
accumulated and incarcerated in certain air-cells, which yieJd to its distendmg force, 
and losing their elasticity become permanently large. And this process will be acce- 
lerated if the original disorder which gives vise to it is attended with violent cough ; 
with forcible efforts, that is, of expiration. Emphysema is always (in my opinion) 
a consequence of pre-existing disease or disorder of the chest. There are some who 
believe it to be occasionally a congenital and idiopathic affection. They build this 
notion upon the fact that the complaint is traceable, from one generation to another, 
in certain famihes ; and as it often is present at an early age in children born of 
emphysematous parents, they conclude that the emphysema, in such cases, is a vice 
of the original bodily formation. I am not convinced by this mode of reasoning. 
The facts upon which it rests show simply that the disorder runs much in families, 
and that the tendency to it is sometimes inherited. The lax or weak fabric, which 
favoured the production of the disease in the parent, is repeated in the offspring, and 
imparts the same predisposition. Children are very hable to severe coughs, such as 
are calculated to strain and overstretch the cells of their delicate lungs. What can 
be more hkei^ to do so than the reiterated and violent parox3rsms of coughing which 
occur in pertussis ? After the cough has ceased, however, the shortness of breath 
which it leaves behind is easily overlooked, until with the increase of the emphysema, 
it forces itself into notice. For when once the morbid process has begun it tends, 
slowly often, but surely, to its own augmentation. As the cells dilate, the capillary 
blood-vessels distributed over their parietes are gradually compressed and emptied : 
and many of them are, at length, completely obJiterated. Hence, not only an ex- 
sanguine condition of the pulmonary tissue, but atrophy also of the intervesicular 
partitions, which become first thin, then tattered and imperfect. In dried specimens 
of emphysema you see very plainly the remains of the former walls of separation 
between the vesicles. 

It is this interference with the nutrition of the lung which causes vesicular em- 
physema to be always 2^ progressive disease. We see why it is that, speaking gene- 
rally, the extent of the morbid change is proportioned to the age of the patient : 
why paroxysms of severe dyspnoea at length supervene ; and become more and 
more frequent and trying. The function of the lung becomes year by year more 
limited ; until it can no longer bear, without a struggle of distress, that further en- 
croachment upon its office and capability which a slight catarrh, rapid movements of 
the body, a distended abdomen, or even the recumbent posture, may be sufficient to 
produce. 

Laennec attributes the dilatation of the air-cells, in the first instance, to Vv'hat (with 
a curious infelicity of diction) he terms dry catarrh, which is characterized by its 
tendency to recur, and by the expectoration of small pieces of hard, pearly phlegm. 
But doubtless the disorder may be produced, and aggravated when produced, by any 
cause that impedes the free exit of the air from the lungs during expiration : by 
blowing on wind instruments of music, by pressure made on parts of the lung ; by 
tumours therefore in the thorax, a large heart, aneurism of the thoracic aorta, de- 
formity of the chest from crookedness of the spine, tight lacing, and even the pre- 
sence of tubercles ; although lungs that are fuU of tubercles are not, in general, much 
affected by emphysema. This last fact has led to the absurd project of attempting 
to prevent phthisis by producing emphysema. It is the same disease which exists 



PULMONARY EMPHYSEMA. 



623 



in broken-winded horses ; and Sir John Floyer, in his Treatise of the Asthma, pub- 
lished in 1698, sets forth, in the quaint language of that olden time, both the altera- 
tion which Laennec thought he had been the first to describe, and the mode in which 
it takes place. His observation respecting the lungs of horses are equally applica- 
ble — -and he no doubt intended to apply them — to the human lungs. After speaking 
of "the broken wind, from the rupture or dilatation of the bladders of the lungs, by 
which the air is too much retained in the bladders or their interstices, and thereby 
produces a permanent flatulent tumour" — and stating that " these horses wheeze 
much after filhng their stomach, by water or food, because that keeps up the dia- 
phragm" — he goes on thus. "As it happens in external flatulent tumours, they at 
first go off and return, but at last fix in permanent flatulent tumours ; so it is in the 
flatulent asthma, the frequent nervous inflations induced at last a constant windy 
tumour or inflation ; and it ought to be considered how far holding the breath in 
hysteric fits, or the violent coughing in long catarrhs, or the great distension of the 
lungs by an inflammation in the peripneumonia, may strain the bladders and their 
muscular fibres, and thereby produce the same rupture or dilatation or hernia as hap- 
pens in the broken-winded. This must be observed by the help of the microscope; 
and if the air blown into any lobe will not be expelled thence by the natural tone or 
muscle of the bladders, that the lobe may again subside of itself, 'tis certain some 
injury is done to the ventiducts ; the bladders are either broken, and admit the air 
into the membranous interstices, or else they are over-distended hke a hernia in the 
peritoneum ; and this will produce an inflation of the whole substance of the lungs, 
and that a continual compression of the air and blood-vessels, which will produce 
a constant asthma." Really this is a capital piece of pathology for the seventeenth 
century. 

It is, at first sight, a matter of surprise that vesicular emphysema of the lung, and 
dilatation of the bronchi, do not more often go together. Sometimes, indeed, the 
smaller branches of the air-tubes do partake of the dilatation of the cells : but this is 
not commonly the case. Still the mechanism of both diseases appears to be, in the 
first instance, the same. The detention of mucus in them leads to dilatation of the 
bronchial lubes : the incarceration of air in them to enlargement of the pulmonary 
vesicles. 

Vesicular emphysema may arise then, and receive increase from, various disor- 
dered conditions that precede or accompany it, and of which it is the effect. On 
the other hand, it is often itself the cause of subsequent disease, not merely in the 
lung, but in other parts ; and above all, of disease in the right chambers of the heart. 
The smaller blood-vessels, as I have shown you, are gradualljr effaced as the dilata- 
tion of the air-cells proceeds : the emphysematous lung is evidently in a state of 
comparative anosmia, and incapable of admitting all the blood which is due to it 
from the pulmonary artery. In other words, the right side of the heart does not 
empty itself with its accustomed ease. Hence increased muscular contractions of 
the right ventricle: and a yielding of its walls to the augmenting pressure of the 
contained blood. And this embarrassment of the circulation in the right side of the 
heart is aggravated at those periods when the paroxysms of urgent dyspnoea occur. 
Now nothing is a more sure cause of anasarca than a permanent dilatation of the 
right cavities of the heart: and this influence of the emphysematous lung upon that 
organ is clearly seen in the palpitations to which such patients are hable, and in the 
cedema of the feet and ankles which often becomes manifest at the same time. 

I must beg you to bear in mind that emphysema of the lung is one, and a very 
common, cause of asthma. The asthma so arising is less perilous than that which 
proceeds from certain other organic changes, to be described hereafter. Vesicular 
emphysema, indeed, in its simple uncomplicated form, is seldom attended with much 
danger. When it proves fatal, it is so in consequence of the superaddition of some 
other disease. Laennec states very truly, that of all the varieties of asthma, this is 
the one which affords the patient the best hope of a long life. 

The condition that I have been describing, when once it has fairly been establish- 
ed, can scarcely admit of a cure. We shall do our patients good, not by any treatment 
addressed to the existing emphysema itself, but by guarding them against those cir- 



624 



INTERLOBULAR EMPHYSEMA. 



cumstances which are likely to aggravate it ; and by mitigating or removing those 
other disorders with which the emphysema is apt to be combined. Whatever is 
calcAilated to put the patient out of breath is bad for him. It is observed that they 
who, having emphysema, are obnoxious also to catarrhs, during which the dyspnoea 
is singularly increased, are much more free from such attacks in the warm weather 
of summer, than in the winter. This explains the beneficial influence of a judicious 
change of chmate upon such persons, and it points to the necessity of warm clothing, 
in the colder seasons for those who are obliged to remain in this country. The feet 
especially should be kept dry and warm ; and the liability to catarrh may be some- 
times diminished by the use of the cold shower-bath, in the way I formerly recom- 
mended. During the fits of extreme dyspnoBa, 3'ou may hear the expiratory wheeze 
remarkably loud and protracted ; and if, withal, you hear any small crepitation, in- 
dicative of pneumonic inflammation, you will do well to cup the patient between his 
shoulders. This will always give relief to loaded lungs, whether there be inflam- 
mation present or not. But the great assuager of the dyspncsa in this disorder is 
opium; and especially opium combined with sether. Haifa drachm of Hoffman's 
anodyne, with a third of a grain of the acetate or muriate of morphia, in camphor 
julep, will operate like a charm often, in quieting the whole system, and removing 
the difificulty of breathing. This circumstance would lead us to suppose that the 
access depended, in part at least, upon a spasmodic state of some of the muscles 
concerned in respiration. To this question I shall revert when I speak of asthma 
as a separate disease. At any rate you will find that some such formula as I have 
just mentioned will stand you in good stead when you have to deal with asthma 
engrafted on emphysema. And T may add, that this is a case of exception to a rule 
I formerly laid down. You need not be deterred from giving a full dose of opium 
by the blueness, which is temporary, of the patient's hps and countenance. 

The interlohidar and suh-pleural emphysema of the lungs is a species of true 
emphysema, the air being contained in the meshes of the common areolar tissue. 
When it appears on the surface of the lung, it may be distinguished from the bladder- 
like prominences which sometimes form there by the dilatation of the air-cells, in 
this way : the bullse which are situated in the areolar tissue connecting the pleura 
with the lung, may be made to move hither and thither under pressure ; whereas 
those which result from the protrusion of an enlarged cell or cells cannot be made 
thus to change their place. This sub-pleural effusion of air is sometimes enormous. 
I have seen it as large as a hen's egg. Bouillaud mentions a case in which the 
bladder or pouch was equal to the size of a stomach of ordinary dimensions. It 
proceeds, I presume, from the rupture of a superficial air-vesicle. Sometimes, as I 
mentioned before, the pleura also gives way, and air is poured into the cavity of 
the thorax. More commonly the membrane remains entire, and then these large 
bubbles of air may be seen upon the surface of the lung. 

Of interlobular emphysema I can give you but little account except from the ob- 
servations of others. I have never seen more than one well-marked example of it. 
The lobules of the lungs cohere together by means of areolar tissue, which is dense 
and close in the natural state, but which admits of considerable expansion when it is 
inflated with air. If the emphysema be shght in degree, the lozenge-shaped spaces 
visible on the surface of the lung are defined by little bubbles of air, that look like 
beads strung upon a thread. But in extreme cases the lobules are fairly blown 
asunder by the air ; the partitions between them increase in width, and are said to 
be sometimes as much as an inch broad. They are broadest towards the surface of 
the lung, and narrower towards its roots ; and exhibit somewhat of the arrangement 
seen in the section of an orange, the septa radiating and diverging from a centre. 
If the areolar tissue could be taken out, there would be left cracks and clefts in the 
lung. When the interlobular emphysema penetrates to the roots of the lung, the 
air readily passes into the areolar tissue of the mediastinum, and thence to the sub- 
cutaneous tissue of the neck and chest — and then we have the genuine emphysema 
of authors who vv^rote prior to Laennec. 

There is this material diff^'ence between vesicular and interlobular eraphj^sema; 



INTERLOBULAR EMPHYSEMA. 



625 



that the one is slow and gradual in its formation, the other sudden. The permanent 
dilatation of the air-vesicles is the work of time. They yield, and lose their elasti- 
city, and break into one another, only by degrees. The interlobular effusion of air 
may be effected in a few minutes or seconds. It is caused by violent straining 
efforts ; such as those made by a woman in childbirth, or by any one who exerts 
himself to hft a weight which is too much for him. A deep inspiration is taken ; 
then the glottis is voluntarily closed, and a strong expiratory effort is made. Some 
rupture must take place and form a communication between the air-vesicles and 
the areolar tissue ; but such rupture has never been traced, nor is it likely that it 
should be. * 

They say that this form of emphysema is revealed also by large dry crepitation ; 
why it should, is not evident. 1 can only say of that sound, as I said before : it 
may exist, and it may be distinguishable from large moist crepitation, but my ear is 
not delicate enough to distinguish it : and to speak the truth, I doubt exceedingly 
whether any such sound reeilly occurs at any time. But do not let my doubts infect 
you : try for yourselves ; and till you have had opportunities of investigating this 
point, consider it as adhuc sub judice. 

Again, they say that the noise of friction denotes the existence of interlobular and 
subpleural emphysema. On this point I can give you no information of my own 
knowledge. That you may sometimes hear the costal pleura rub against the pul- 
monary during inspiration and expiration, I know ; I have often heard that sound 
(as I mentioned to you before) when the membrane has been roughened by pleurisy; 
but that a sitft, smooth, moist lung, though embossed by emphysema, will give rise 
to a rubbing sound, I do not know. It may be so, but it has never occurred to me 
to hear it. 

We may be more certain that interlobular emphysema has arisen when, im- 
mediately after some violent straining effort, considerable dyspnoea and oppression 
ensue, and presently the subcutaneous areolar tissue becomes emphysematous. 
You will understand how rapidly the inflation of the areolar tissue may take 
place if you ever saw a butcher blow up that of a calf which he is in the act of 
skinning. 

As interlobular emphysema differs from vesicular emphysema in its seat, and in 
the suddenness of its formation, and in some sort also in its cause, so does it differ in 
its curability. Under favourable circumstances it will soon cure itself — the air will 
be reabsorbed, and the dyspnoea cease. I do not know that we can do much by art 
to accelerate that process. If the dyspnoea be extreme, it will be relieved by blood- 
letting : and if the air makes its appearance, and can be felt, crackling, beneath the 
skin, you may let it out by making a few punctures with a lancet, and the deeper- 
seated emphysema will be lessened as the air escapes. I believe that this inter- 
lobular emphysema is more common in infancy than in any other part of hfe ; 
on account, 1 suppose, of the greater dehcacy and tenderness of all the tissues at 
that age. 

The interstitial areolar tissue of the lungs, as well as the air-cells, is liable to be 
filled not only with air, but with serous fluid ; and this constitutes oedema of the 
lungs ; a condition which is by no means uncommon, and one of which you ought 
therefore to be aware ; but it need not long occupy our attention at present. When 
a lung, or a portion of a lung, is anasarcous (and you will often find that the oedema 
is limited to the most depending part of those organs), it is generally of a pale gray 
or yellowish tint ; is heavier than healthy lung, and less crepitant ; and pits more 
on pressure — is doughy. And if the oedema is extensive, the lung does not collapse 
when the chest is laid open. When incisions are made into the lung in this state, a 
thin watery fluid flows out, more or less spumous ; and if the lung be well squeezed, 
the whole of the hquid may be expressed ; and then it will be obvious that the tex- 
ture of the organ is sound, but that it had previously contained less air than usual, 
in consequence of the presence of the watery fluid. 

This condition of the lung seldom takes place except as a part of general anasarca : 
and we may discover its existence, first by noticing that there is dropsy of the areolar 
40 ' 3c 



626 



PHTHISIS PULMONALIS. 



tissue in other parts ; secondly, that the patient has dyspnoea ; and thirdly, hy hearing 
crepitation, produced by large babbles, at the lowermost portions only of the lungs. 
Into those portions the liquid gravitates ; just as it sinks into the ankles when the 
patient sits up or walks about. There is still air in the (edematous portion ; so that 
percussion still gives a hollow sound : as hollow at least on the one side as on the 
other. With the air there is also liquid, which transudes, I suppose, from the areolar 
tissue, or is exhaled from the surface of the membrane : and the liquid is from time to 
time coughed up and expectorated. Sometimes, however, there is but httle expecto- 
ration. What does come up is chiefly aqueous, with occasionally a piece or two of 
mucus floating upon it ; and it is somewhat foamy also. ' 

This oedema or anasarca of the lung is symptomatic of other disease ; generally 
of disease of the heart or great blood-vessels : and it is capable of no other rational 
treatment than such as is suited to the original disorder : and therefore I have nothing 
further to say about it now. 

I proceed, in the next place, to that most prevalent and lamentable disease of the 
lungs, which is well known to everybody, under the titles of pulmonary consump- 
tion^ and tubercular phthisis. And without pausing to make any general reflec- 
tions, respecting facts which must be familiar to you all — the fatal and almost 
hopeless character of the disease, and the havoc it produces among the young, the 
most gifted, and the most beautiful, of the human race — I shall commence by 
inquiring into the morbid anatomy of tubercular phthisis: which will naturally 
introduce us to the consideration of its symptoms, causes, treatment, and general 
history. 

Phthisis, you know, means a wasting away, or a consuming; but of late years 
the term has been restricted to that species of wasting disease, which consists in the 
occupation of the lungs by tubercular matter, and the changes which that matter 
suffers and works. But it would be an error to suppose that the disease is restricted 
to the lungs in these cases. The lung disease would be sufficient at length to destroy 
life ; but its mortal tendency is aided and accelerated, in most instances, by disease 
of a similar character, situated in other organs. " The pulmonary consumption (as 
Dr. Latham justly observes) is no more than fragment of a great constitutional 
malady." 'But that malady plays its part most conspicuously in the lungs. I shall 
notice its comphcations as [ go on ; but I am desirous of cautioning you in the outset 
against supposing that tubercular phthisis is exclusively a pulmonary disease. 

Before I proceed to a more particular description of the changes that, in the pro- 
gress of consumption, are wrought in the lungs, I must briefly recall to your recol- 
lection certain points, relating to tubercular disease in general, which were brought 
before you in an earlier part of the course. The formation of tubercles is closely 
linked with the existence of the scrofulous diathesis. Tubercles themselves are com- 
posed of unorganized matter, deposited from the blood, of a yellowish colour, opaque, 
friable, and of about the firmness and consistence of cheese. This is v^-'hat all 
pathologists agree in regarding as the true tubercular matter. It is most commonly 
deposited on the free surface of mucous membranes ; and not unfrequently amidst 
areolar tissue. You will remember that tubercles are not necessarily, as some have 
supposed, of a round shape. Their form depends upon the nature of the tissue in 
which the tubercular matter is deposited. Wherever it is laid down, it is liable to 
increase in quantity by the continual accretion of fresh matter of the same kind. 
Hence, when a speck of this peculiar matter is deposited in any soft uniform tissue — 
such as the brain, or the areolar membrane — there being no inequality of pressure 
from any quarter, it preserves a spherical or globular form as it grows larger. But 
taking the lung, with which we are at present chiefly concerned, the round form is 
sometimes real, sometimes apparent only. It is real when the tubercular matter fills 
up, or fines, and therefore takes the shape of, the pulmonary vesicles. So it is when 
a number of these, contiguous to each other, coalesce by the increase of deposit and 
compose one large globular mass. And you may often catch the tubercles, if I may 
so say, in the process of forming these large rounded masses ; i. e., you may see 
them arranged in circular groups or clusters, the interstices between them becoming 



PHTHISIS PULMONALIS. i . 627 



gradually smaller and smaller. But when, as is often the case, the tubercular matter 
is laid down in the smaller ramifications of the bronchi, it assumes a cyHndrical 
shape. This you may ascertain by carefully following the branching of the air- 
tubes : but in the manner in which the lung is usually divided by the scalpel, you 
see merely sections of these cylinders; and then the round form is apparent only. 
If the tubercular matter comes to fill one of these smaller- air-tubes, and also all the 
vesicles to which that tube condncts, then the new substance, when fairly displayed, ' 
represents a branch, with a cauliflower termination ; hke a twig with a bunch of 
leaves at its extremity. You may see these appearances delineated, from nature, in 
Dr. Carswell's admirable lithographic drawings. 

If this account of the formation of tubercles, as explained by Dr. Carswell, be the 
I true one ;— of which [ entertain little doubt ; — it will follow, as a matter of necessity, 
il that no alteration can take place in the tubercular matter, after it has once assumed 
the solid form, except through the agency of the parts around and in contact with it. 
I No change can originate in the organic tubercle itself. 

! Besides this true and undisputed species of tubercle, you will often find the lungs 
more or less thickly studded with a number of small granules, of firmer consistence, 
almost as hard as cartilage, semi-transparent, and of a bluish gray colour. Respect- 
ing the nature of these granules — which are sometimes called miliary tubercles, 
sometimes the granulations of Bayle, who first described them- — miany different • 
j opinions are entertained. Laennec considered them to represent the incipient stage 
ij of the opaque yellow substance ; and he calls them accordingly nascent tubercles, 
jl Andral believes that they are simply some of the pulmonary vesicles rendered solid . 
j and hard by chronic inflammation. Dr. Carswell explains their formation in this 
way. The membrane lining the air-passages secretes from the blood, not only the 
matter of tubercle, but its own proper fluid ; whence it sometimes happens that a 
dull yellowish point of tubercular matter becomes enclosed and set, as it were, in a 
small pallet of gray, tough, semi-transparent mucus. Whatever may be the true 
theory respecting these little bodies, it is certain that they acknowledge some intimate 
cormection with the true cheesy tubercle. They both occur in the same persons, in 
I the same lungs, in the same parts of the lung. One very seldom occurs without the 
other. They both belong essentially to the disease w^e are considering — -pulmonary 
pthisis. Louis, a minute and faithful observer, states that the granules present, at a 
certain period of their development, a central opacity. Upon the whole, it seems 
probable, that Laennec"s doctrine, in regard to the relation subsisting between the 
gray semi-transparent granule and the yellow opaque tubercle, was well founded. 

He was wrong, however, in some other points, especially in his statement that the 
softening of tubercles begins in their centres. Dr. Carswell has shown how the ap- 
pearance of a central sof^tening arises, first, in the smaller tubercles; secondly, in the 
larger agglomerated tubercular masses. The morbid secretion is ' deposited, princi- 
pally, upon the mucous surface — upon the inner fining of the air-ceils, and of the 
bronchial tubes communicating with them. Now it may so accumulate as to fill 
those cavities ; and then, sections of them will represent the crude tubercles of 
Laennec. But it may only line the cavities : it may leave a central vacuity, con- 
taining miucus or other secreted fluids ; and if the lung be cut across under these 
circumstances, the divided air-cells will look like rings of tubercular matter grouped 
together; and so also will the divided bronchial tubes. We then have the appear- 
ance of tubercles, with central depressions, or soft central points ; and Laennec was 
deceived by those appearances. 

But the larger masses begin also, he says, to soften at the centre. True : we do 
find the process of softening going on at several points within them at the same time. 
The masses, you must bear in mind, are formed by the growing together of many 
smaller tubercles; and the areolar tissue, Avith the other tissues which originally 
separated these tubercles, still exists, though it ceases to be visible. At length, under 
the augmenting pressure, or some other influence, it suppurates; and in this way the 
tubercular mass is broken down. Now this is the very process by which the tubercles 
are at length, often, expelled from the body. They increase till the surrounding parts 
take on inflammation, either from the increasing pressure, or from some accidental 



628 



PHTHISIS PULMONALIS. 



cause. The inflammation thus excited, occurring in scrofulous persons, has the 
scrofulous character. The thin pus which it throws out pervades and loosens the 
tubercular deposit ; a process of ulceration goes on in the surrounding textures ; and, 
at last, the softened scrofulous matter is gradually coughed up and expectorated. 

This explanation of the mode in which the tubercles are formed, and increase, and 
soften, and are removed, has been given to the world within the last few years, by 
Dr. Carswell ; and it is much the most simple and probable of any that I have seen. 
It is moreover, perfectly consistent wnih the best ascertained facts concerning the 
progress of tubercular disease. You will find numberless theories broached by dif- 
ferent authors on this subject, if you hke to look for them ; but I do not think you 
will find any so satisfactory as Dr. Carswell's. And having recalled these things to 
your memory (for it is some time now since I mentioned them before) w^e may go 
on to the further consideration of the morbid anatomy and pathology of tubercular 
phthisis. 

It is a remarkable and very important fact, that tubercles, when they affect the 
lungs, are not deposited at random, or indifferently in all parts of those organs. It is 
in the upper lobes, and in the upper and back parts of those lobes, that, in nineteen 
cases out of twenty, and in more than that proportion, we meet with tubercles when 
they are few. It is in the same part that they are largest, and most numerous, when 
they are scattered throughout the whole lung. It is here, also, that they first ripen, 
and grow soft, and become ready for expulsion through the bronchi and trachea : 
consequently, it is here, that we have the most frequent, the most numerous, and the 
largest excavations in the lung — what are technically called vomicfi'.. And the 
num.ber and magnitude of the tubercles and of the vomicae gradually diminish from 
the summit of the lungs downwards. 

Now these are not merely curious facts: they have a most important bearing 
upon the diagnosis, in cases that might otherwise be doubtful. It is a rule which 
has but few exceptions — just enough to estabhsh its claim to be a rule — that the 
favourite habitat of pulmonary tubercles is the upper part of the superior lobes of the 
lungs ; and I may remind you that the converse of this is true (though with more 
numerous exceptions) of common inflammation of the lungs. Pneumonia affects by 
preference the lower lobes; it does sometimes commence in the upper, but that is 
comparatively rare. When it occupies the superior lobes it generally has arrived 
there by travelling upwards from the inferior. You will at once perceive the prac- 
tical advantage of knowing these points of contrast. 

It is a curious fact also — less practically useful, perhaps, than the former, but still 
a valuable fact — that the left lung is much more obnoxious to tubercular disease than 
the right. Modern observers have collected numerical statements showing that this 
really is so. Why it should be so, I know not. Thus Louis, whose volume is the 
result of immense labour in observing, and is full of the most instructive matter, had 
met with seven cases in which tubercles were confined to a single lung: in tvjo of 
the seven cases it was the right lung that was thus exclusively affected, in five it was 
the left. Of 88 instances in which the upper lobe was totally disorganized by the 
disease on one side, 28 were of the left, and only 10 of the right. Eight times he 
had known the pleura perforated by the extension of tubercular disease ; and seven 
times out of the eight the perforation happened on the left side of the chest. So also 
Reynard met with 27 cases of pneumothorax on the left side, to 13 on the right. No 
less curious is it that here also the facts ascertained with respect to pneumonia are 
just the contrary of those which belong to phthisis. I mentioned, in a former lecture, 
Andral's conclusion, derived from the observation and collation of 210 examples, that 
pneumonia is more than twice as common on the right side as on the left. M. Lom- 
bard, of Geneva, found the ratio somewhat less than this, but still great. Of 868 in- 
stances of pneumonia, 413 occurred on the right side alone, 2(50 on the left alone, 
and 195 on both sides at once. That is, there were three on the right side alone, for 
every two on the left alone. 

The tubercular matter, then, being deposited on the mucous surface of the vesi- 
cles, and of the small bronchial tubes that conduct to them — groups of these diseased 
air-cells, lying contiguous to each other, become, more or fewer of them, amalga- 



PHTHISIS. 



629 



mated, or fused, as it were, into one large mass : and generally there are tubercles 
of various sizes, from that of a pin's head, to that of a pigeon's egg, in the same 
lung. And there is yet another disposition which the tubercular matter is apt to 
take : it sometimes is diffused uniformly over a considerable space, occupying all the 
areolar and interstitial portions of the part affected, and having no distinct circum- 
scribing boundary. The part looks as if fluid tubercular matter had been poured 
into it, and there had hardened. This is what the French call tubercular injiltration 
of the lung. 

The tubercular matter, once deposited, may remain for a longer or shorter time in 
what is called the crude state ; surrounded by perfectly healthy lung, undergoing 
no increase in quantity, and no alteration of consistence. But in a vast majority of 
cases, scrofulous inflammation is sooner or later set up around the tubercles — or in 
the areolar tisssue imprisoned within the agglomerated masses — and then the whole 
breaks down in the way I mentioned before ; and the detritus is conveyed through 
one or more tubes into the primary divisions of the bronchi, and thence to the 
mouth, to be expectorated. Of course there is an excavation, cavity, cavern, or 
vomica, left. All these names are given to the void space which the tubercular 
matter previously occupied. Now there are some curious particulars to be men- 
tioned respecting these cavities ; but I must postpone them till our next meeting. 



LECTURE LVI. 

Phthisis, continued. Vomicsc ; adhesions of the pleurae ; ulceration of the larynx 
and trachea — of the intesthies ; fatty liver ; auscultatory signs of a vomica : 
gurgling, cavernous respiration, pectoriloquy : general symptoms of phthisis : 
cough, expectoration, dyspnoea, pain, hectic fever, diarrhoea, wasting, oedema, 
aphthse. 

We were engaged, when we separated yesterday, in investigating the morbid 
anatomy of consumption. Bear in mind how and where the tubercular matter, 
which is the essence of that disease, is deposited in the lungs : that it occupies, by 
preference, their upper lobes, and the upper part of those lobes ; invading gradually 
the lower lobes, from above downwards, as the disease advances. Both lungs are, 
commonly, affected at the same time, though in unequal degrees. Among one 
hundred and twenty-three instances of phthisis, Louis found that the tubercles were 
limited five times to the left lung, and twice to the right. The tubercular matter, 
once deposited, may remain quiet and unchanged for some time ; but in general it 
increases in quantity, until at length inflammation of a low and scrofulous character 
arises in the pulmonary substance in immediate contact with the tubercles — or in the 
areolar tissue involved in the larger agglomerated masses — in consequence of which 
inflammation a sort of suppuration takes place ; the tubercular matter becomes soft, 
and breaks down, and is ukimately expelled through the bronchi, trachea, and 
• mouth. The vacuities left in the lung after this process of expulsion are called cavi- 
ties, excavations, caverns, vomicas. And I go on to consider certain points of prac- 
tical interest connected with these voraicse. 

In the first place, as you may see by the specimens upon the table, they vary 
greatly in size. They may be no bigger than, or not so big as a pea : or they may 
be large enough to contain a pint or more of fluid. Sometimes the whole of the 
upper lobe is converted into a bag of this kind. These large cavities are never met 
with in the lower lobes. They are formed by the union of several that are smaller ; 
so that they are often of very irregular shape, and divided, as it were, into cham- 
bers, by imperfect partitions, or by bands which cross them in various directions. 
Opening into the cavity there is always one, and there are generally several, per- 

3c2 



630 



PHTHISIS. 



vious bronchial tubes, which seem as if they had been cut off just where they enter 
the cavity. Bat you never, or very seldom, indeed, find a blood-vessel thus opening 
into the cavity. And the reason of these differences is plain enough. It is not, as 
some modern authors have fancied, that the arterial or venous tissue possesses a low 
degree of vitality, and therefore resists or avoids the destruction in which the sur- 
rounding tissues are involved. That principle may be applicable to other cases, but 
it is not applicable to this. The opinion I am now referring to proceeds on the sup- 
position that the bands which sometimes cross the cavities are really blood-vessels 
that have escaped the disorganizing process. Such seems to have been the notion 
entertained by Bayle ; and it has been more recently and more expressly advanced 
by Cruveilhier. But the truth is, that these bands rarely co??/'«m blood-vessels : and 
when they do contain them, the blood-vessels are mostly impervious. In one hun- 
dred and tvv^enty-three cases, Louis found pervious blood-vessels in the bands no 
oftener than five times. 

The true reason why bronchial tubes open into these cavities, and blood-vessels 
do not, is to be found in the natural differences between the two sets of vessels, in 
respect to their structure, and in respect to the fluids that pass through them. The 
blood-tubes yield readily to external pressure. Many of them are pushed aside and 
flattened by the progressive increase of the tubercular matter around them ; some, 
probably, are obstructed by its gradual accumulation within. In either case the 
stagnant blood coagulates, and the vessel is obhterated to some distance from the 
place of the original obstacle ; just as you know a clot forms, and seals up an artery, 
which has been tied during life, for some httle way anterior to the ligature. But 
the bronchial tubes are neither so easily compressed, nor do they carry any coagu- 
lable fluid. In the agglomeration of the tubercular masses, by the softening of Avhich 
the cavities are formed, the air-tubes included within the mass are filled up by it ; 
and when the whole breaks down in scrofulous suppuration, they are expectorated 
with the rest of the detritus. Meanwhile, their open mouths, on the hither side 
of the point where the tubercular matter stopped, remain, and afford a channel 
through which the same matter, after it has become soft, finds its way towards the 
trachea. Occasionally, indeed — but that, I repeat, is a rare occurrence — a con- 
siderable blood-vessel does get laid open during the formation of a vomica, and then 
copious and fatal hemorrhage ensues. Occasionally, also, an oozing or exhalation 
of small quantities of blood takes place from the inner surface of the cavity, tinging 
the matter expectorated. 

When the vomica is first formed, by the expulsion of the tubercular matter, its 
inner surface is soft and ragged ; and if other softening tubercles are in the imme- 
diate neighbourhood, the cavity goes on enlarging; that is, two or more vomicae 
coalesce. If, however, there happen to be no more tubercles thereabouts, the cavity 
may remain stationary. Its inner surface then becomes smoother ; and something 
like a membrane forms upon it : and somietimes a puriform fluid is poured out by 
this surface, and sometimes not. Generally the pulmonary tissue around such a 
cavity is condensed and solidified ; partly perhaps by crude tubercular matter which 
it contains, partly in consequence of the inflammatory process of which it has been 
the seat during the softening of the tubercles. It is important to bear in mind this 
fact of the condensed, solid state of the lung immediately surrounding a vomica ; for 
it explains certain peculiarities met with in the symptoms. 

There is another point of much interest connected with these vomicae. When 
they occur singly, without other tubercles or cavities (which, though a very rare 
thing, does sometimes) ; and when occurring thus singly they have been completely 
emptied of the tubercular matter; they may gradually contract, and ultimately be- 
come obliterated. This approach of their sides leads to a puckering of the pleura 
on the surface of the lung ; and, on the other hand, a puckering of the surface indi- 
cates that beneath it there is probably a collapsed vomica. Its inner surface becomes 
converted in that case into a substance resembhng cartilage ; and the appearance it 
presents is called a cicatrix ; and really it deserves that name. The process which 
has gone on is a process of natural recovery ; and the recovery would be complete, 
if no fresh deposit of tubercular matter took place. Too often, however, the tuber- 



PHTHISIS. 



631 



cles multiply, until at length their number, or size, or effects, become incompatible 
with the further continuance of life. 

This, then, is one way in which tubercular disease, limited io one small portion 
of the lung-, may be eliminated, and the part which it occupied undergo a kind of 
repair. But the disease, when so limited, may cease in another way. The more 
watery parts of the morbid secretion may be absorbed, and the earthy salts it con- 
tains may concrete, and the whole be converted into a shrivelled, hard, chalky mass, 
which sometimes is coughed up ; sometimes, in favourable cases, remains for years 
in the lung, an inert and almost harmless body. 

Let me state, while I think of it, that the expectoration of these chalk-like concre- 
tions, denoting, as it usually does, the existence of pulmonary consumption, marks 
at the same time the chronic character of the case. I am acquainted with a gentle- 
man w4io, though delicate, enjoys a very fair share of health, and who has for years 
been coughing up, at intervals, little branching fragments, like bits of white coral, 
consisting principally of carbonate and phosphate of lime, and evidently moulded in 
the smaller bronchial tubes. 

When the tubercles are numerous — or rather when they lie near to the surface 
of the lung, as, of course, they are likely to do when they are numerous — they very 
generally give rise to dry or adhesive pleurisy. So that, in a person dead of con- 
sumption, it is a very rare thing to find the lungs free from adhesions to the ribs. I 
mentioned before that this attachment of the lung to the walls of the chest affords a 
protection against a much more formidable condition; namely, perforation of the pul- 
monary pleura, and the escape of tubercular matter and air into the serous cavity; 
producing that worst kind of pleurisy which constitutes pneumothorax. That the 
pleurisy and adhesion are consequences of the presence and irritation of the tuber- 
cles, appears from this : — that, for the most part, the extent and the situation of the 
adhesions corrospond with the extent and situation of the tubercular disease. Thus, 
a single spot of adhesion has been seen to unite the costal and pulmonary pleurae 
exactly opposite a solitary tubercle which lay near the surface of the lung. As the 
summit and back part of the upper lobes are most thickly set with tubercles, so 
here also is the adhesion the most constant, and the most firm. You will often find 
the upper part of the lung invested with a thick cap of false membrane ; and the 
connection between the pleurae so tough, that the lung breaks down in the attempt to 
separate them. 

To show you that these statements— which have long been farniHar to those much 
conversant with disease and with morbid anatomy — to convince you that they are 
strictly borne out by numerical or tabular facts, I may again have recourse to Louis. 
He tells us that in 112 cases which he himself examined of persons dead of con- 
sumption, and having therefore tubercles in their lungs, there was but one in which, 
both lungs w^ere free from adhesions. In eight cases the right lung was exempt 
from them, and in seven cases the left. Again, in twenty-five other instances, there 
were either no cavities, or very little ones ; and the adhesions were accordingly of 
small extent, and easily broken down. Tn the remainder there were large vomicae, 
and the adhesions were extensive, dense, and firm. 

Such is a sketch of the changes which take place in the lungs, in consequence 
of tin' deposition of tubercular matter in them, and of the changes which that matter 
undergoes. But the air-passages that lead to the lungs are very liable to become 
implicated as the disease proceeds. The mucous membrane of the larynx and tra- 
chea ulcerate ; and when the morbid condition of the larynx gives rise to prominent 
symptoms, and especially (as it is apt to do) to hoarseness and loss of voice, the dis- 
ease is sometimes called laryngeal phiJmis. But there is no such disease, that I 
know of, existing by itself. I mean, that scrofulous ulceration of the larynx and 
trachea occurs only when the lungs are affected with tubercles. It is curious that 
when ulcers are met with in the trachea, they are often found on one side of it only ; 
on the side, viz., which corresponds with the diseased lung, or with that lung which 
is most diseased. In Kke manner, when some of the bronchi are found red inter- 
nally, and even ulcerated, these appearances are confined to those bronchi which 
communicate with cavities ; and do not occur in the bronchial canals leading to 



632 



PHTHISIS. 



crude tubercles. It is towards the back part also of the trachea that the ulcers, espe- 
cially when large, are iriost commonly observed ; the floor of that channel when the 
patient hes supine. And when the epiglottis is involved in the mischief, the ulcers 
are situated, almost always, on its laryngeal surface alone. We have strong reasons, 
therefore, for beheving that their formation is influenced by the contact of the matter 
which is expectorated, in its frequent passage over the macous membrane. More- 
over, the little mucous glands wherewith the membrane is provided, are most nume- 
rous at the posterior part of the trachea and bronchi ; and these glands are especially 
prone to ulcerate. 

In respect to these points, also, Louis has made comparative observations. Among 
180 persons who died of some chronic disorder, not phthisical, he once only met 
with ulceration of the larynx ; whereas, of those who perished with consumption, 
nearly one in every Jive had ulceration of the epiglottis and larynx, and nearly one 
in three had ulceration of the windpipe. Hence it would appear that, if we except 
the effects of the syphilitic poison upon the larynx, ulceration of that part is almost 
peculiar to phthisis pulmonalis. 

I have told you that consumption is not merely a lung disease. Its local ravages 
are most obvious, indeed, in the thorax ; but it leaves in the abdomen, also, traces of 
its destructive agency, not less definite and scarcely less constant. You know that 
the surface of the intestinal canal is strewed throughout with separate mucous folli- 
cles, and that the lower portion of the ileum is furnished with other follicles, collected 
together in oval or circular groups. When I come to speak of continued fever, I 
shall have much to say about the changes which these httle glandular bodies undergo, 
in one form at least of that disease. These same glands are the frequent seat of 
tubercular deposit in phthisis. Here and there you may see a solitary yellow tumour, 
not larger than a hemp-seed, projecting from the surface of the bowel. In other 
places the ripened little tumour has burst, the tubercular matter is goae, and a ragged 
roundish ulcer remains. More frequently the aggregated glands are affected ; and 
the ulceration, in them, varies much in form and extent. It often involves the whole 
patch, and then the shape of the ulcer is more or less elhptical. Louis met with 
ulceration of these glandulae agminatas in five-sixths of all the fatal cases of phthisis 
that he examined. Ulcers of greater magnitude were very nearly as common in the 
large intestines. And it is worthy of notice that, the disorganizing process being in 
these cases slow, nature has time (if I may use such metaphorical language) to pro- 
vide against the threatened perforation of the gut. The tissue that forms the base 
of the ulcer, whether it be the muscular or the peritoneal coat, is thickened and 
vamped ; or the bowel becomes adherent to some contiguous surface. Once only in 
my life have I known scrofulous ulceration, in phthisis, penetrate the serous tunic, 
and allow the contents of the intestine to escape into the sac of the peritoneum. 

It is fitting you should know — although the facts possess, as yet, no practical value 
— that the stomach is often much enlarged and thinned in those who die of consump- 
tion ; and that the liver is very apt to undergo a remarkable change, almost peculiar, 
I beheve, to that disease. It, too, enlarges, and becomes full of adipose matter, 
greasing the hands and scalpel of the anatomist, and yielding, when heated, an oily 
substance, which makes a grease-spot on paper placed in contact with it. The 
whole gland partakes in the alteration, is of soft consistence, loses its natural red tint, 
and assumes a pale fawn colour. No profession contributes so much as ours to the 
introduction of new, barbarous, and dissonant words into the English language. We 
have accordingly invented an epithet for this kind of liver. We call it (not \he fat, 
but) the fatty hver. In three years, Louis met with this fatty liver forty-nine times; 
and forty-seven of the patients died phthisical. It occurred in one-third of the whole 
number of the victims to consumption ; whereas, among two hundred and twenty- 
three cases, not phthisical, there were two examples only of this hepatic change. 
Its presence is revealed during life by no symptoms, except that the enlargement 
belonging to it may sometimes be ascertained by percussion and pressure with the 
fingers. 

Let us now inquire what modifications of the healthy sounds arise from the 
altered conditions of the lungs in phthisis. Most of them are such as you would 



PHTHISIS. 



633 



naturally expect. Whether a portion of lung be rendered solid by common inflam- 
mation, or by the presence of tubercles in it, the result, so far as the ascultatory signs 
are concerned, will be the same. In such a piece of lung, supposing the solidifica- 
tion complete, no vesicular breathing can be heard ; but bronchial breathing and 
bronchophony will be audible, in each case, if the solidified portion encloses a con- 
siderable bronchus, and comes near the surface of the chest. And percussion will 
give a dull sound, whether the lung lying beneath the part struck be hepatized, or 
blocked up by tubercular matter. On these points, therefore, after what was said in 
a preceding lecture, I need not dwell. But the excavations, the empty or half-empty 
vomicae — these are something new. We have hitherto met with no condition ex- 
actly similar to that of a large cavity. And accordingly I have to make you 
acquainted with two or three new sounds : or sounds which are modifications of 
those formerly described, and in most instances sufficiently distinct from them to 
have acquired peculiar names. You will remember that what we have called large 
crepitation depends upon the passage of air through liquids ; the liquids being con- 
tained in tubes ; those tubes the bronchi and their ramifications. But when pus or 
vitiated mucus, or liquid of any kind, is collected in a vomica, which communicates 
freely with the trachea through pervious bronchi, the bubbles produced by the 
entrance and exit of air will be still more numerous and large ; and a sound is then 
produced which the word gurgling expresses well. Laennec calls it gargouille- 
ment. This sound is heard, too, in a circumscribed space ; and not diffused, as large 
crepitation usually is. Whenever, therefore, we hear gurghng during respiration, 
or during the act of coughing, there, we conclude, exists a cavity. But the cavity 
is not necessarily a vomica. In ninety-nine cases out of a hundred, it will be so ; 
but in the hundredth case perhaps it will not. Bear in mind what was formerly 
stated of dilatation of the bronchi : how sometimes they terminate in a considerable 
globular expansion ; sometimes belly out and contract again several times alternately: 
and you will see that cavities containing liquid, or liable to contain hquid, belonging 
equally to the one condition and to the other, and the sound in question depending 
solely on the intermixture and agitation of air wnth liquid in a cavity, we cannot be 
sure from mere gurgling respiration, or gurgling cough, that we have a tubercular 
excavation beneath our ear; or that the case is one of consumption. Gurgling may 
also proceed from that very rare morbid condition, abscess, the result of common 
inflammation of the lung. These constitute the only sources of fallacy in the matter. 
The fallacy seldom interposes ; but it does sometimes interpose ; and therefore it 
must qualify om conclusion from this symptom of gurghng, in respect to cases other- 
wise doubtful. 

Again, the vomica may be empty of liquid ; and then we hear, as the patient re- 
spires, not vesicular breathing of course, nor yet exactly bronchial breathing ; it is 
something more than that when the cavity is large, something different in character 
from it when the cavity is small : but whatever the character of the sound, as ws 
believe it to take place in a vomica or cavern, we call it cavernous respiration. It is 
a hollow sound, especially when the cavity is of considerable size ; an exaggeration 
of mere bronchial respiration. But the cavity may be small. The moment a por- 
tion of tubercular matter is separated and discharged through a neighbouring bron- 
chial tube, the cavity has commenced ; and the sound produced through these little 
cavities during the breathing may be of various kinds. It may be, and it often is, a 
chck, like the opening and shutting of a valve ; or a chirp ; or a creaking ; or like 
many other well-known sounds: but, as all these sounds, under certain circum- 
stances, denote the formation of a vomica, it is best for simpHcity's sake, to call them 
all by the same name — cavernous respiration. 

Dr. Latham explains in a few words the causes of these differences. "The vari- 
eties of cavernous breathing are doubtless owing to different sizes, and forms, and 
situations of cavities, and to different conditions of the surroundmg lung. A cavity 
may be very large or very small. Several bronchi may open into it, or only one. It 
may be a simple cavit}'-, or it may have many chambers. Its sides may be con- 
densed and equal, or rough and ragged. The lung around it may be sohd and in- 
durated, or pervious and vesicular. It may be near the ribs, or far from them : 



634 



PHTHISIS. 



adherent to, or separate from the- pleura. It is quite obvious that these different cir- 
cumstances, are calculated to modify the sound, which will, nevertheless, be always 
such as indicates a cavity." 

A tubercular cavity may be so large, and of such a kind, as to yield the metalhc 
sounds which are apt to be heard in pneumothorax. I show you a cavity in which 
those sounds were actually heard, most distinctly, by many persons, during the 
patient's life while he was under my care in the Middlesex Hospital. I was certain 
beforehand that these sounds proceeded, not from the cavity of the pleura, but from a 
tubercular excavation. Once subsequently, in a patient who was dying of phthisis 
and diabetes, I have heard the same sounds ; also, I am sure, in a. tubercular cavity. 
The patient insisted on leaving the hospital, and I lost sight of him before he died. 

I promised, when speaking of these metalhc sounds as arising (as they much 
more commonly do) from pneumothorax — a collection of air, or of air and fluid, in 
the sac of the pleura — I promised to point out the circumstances whereby you may 
tell which of the two conditions in question the sounds denote. Both of the conditions 
imply, in general, the existence of tubercular phthisis ; and therefore the observation 
of the ordinary symptoms of phthisis will not help us much. 

Now, in the cases seen by me, there were two circumstances that stamped them 
as being cases in which the sound proceeded from a cavity in the lung, and not 
exterior to it. One was the situation in which the sound was invariably heard. 
The other was, the absence of excessive resonance when that part was percussed. 
You know that when air is contained within the pleura itself, the sound yielded on 
percussing the chest in the corresponding spot is quite tympanitic, like that of a 
drum. But it is a well-asCertained fact, (though contrary perhaps to what you would 
suppose,) that the sound is duller over tubercular cavities, in nine cases out of ten, 
than over sound lung. The explanation of this fact is simple enough. It is that the 
layer of lung which still remains in such cases, thick or thin, is dense and solid, and 
damps the sound which the vomica might otherwise make resonant. But then again 
the situation of the metahic sounds was a guide. They occupied the upper part of 
the chest ; the very part where vomicsB are wont to be the most common, and the 
largest : and moreover a part where pneumothorax seldom or never exists. The 
summit of the lung is generally covered in phthisis with a cap of false membrane, 
which binds it to the ribs : and this, as I observed before, is the main reason why 
perforation of the pleura pulmonalis is so rare in that disease ; and it is also the reason 
why, when it does take place, it seldom takes place at or near the apex of the lung. 
In truth it is found by experience that (though the rupture of the pleura may hap- 
pen in any part) the place where it usually occurs is in the lower and back part of 
the upper lobe of the lung, opposite the angle of the third or fourth rib ; that is, just 
beneath the edge of the false membrane by which the summit of the lung is gene- 
rally adherent. But the sound, in the cases I refer to, was invariably heard at the 
very top of the chest. It did not shift, as that of pneumothorax may often be made to 
shift, when the patient changed his posture. Attention to these points will always 
lead you to an exact diagnosis. You mxay say, perhaps, " The complaint being in 
each case a mortal one, what is the use of so much refinement?" Why, there is 
this utility in it. We may sometimes, as I stated before, give great rehef to the 
patient, and save his life for a time, by tapping the chest of pneumothorax. The air 
may get in with each inspiration, and threaten immediate suffocation ; and the thorax 
being punctured it will issue in a blast. But no one would think of tapping a tuber- 
cular cavity. 

To give out the amphoric resonance and the metallic sounds, the vomica must, I 
presume, be a large one. That which is before you, the only one I ever saw in 
which those sounds had been heard, is very large. Its inner surface is smooth : it 
adheres to the ribs externally by at least two-thirds of its circumference : and the 
medium of adhesion is very thin. Quite low down, a single bronchial tube, of about 
the third division, may be seen to enter it. 

So much, then, for the modification by a tubercular cavity, of the sounds heard 
during respiration. But the voice will also be modified, if the cavity be of consi- 
derable size, and near the surface, and have dense walls, and be empty. Then we 



/ 

PHTHISIS. 635 

hear, in that part, when the patient speaks, the sound which is called pectoriloquy : 
as if the voice proceeded from the chest. The words are distinctly ar^culated into 
the ear of the hstener. But I need not trouble myself or you by attempting to de- 
scribe pectoriloquy. You may any day hear the exact sound that word is intended 
to denote, by placing a stethoscope over the trachea of one of your friends, applying 
your ear to the other end of it, and getting him to speak : just as you may obtain an 
exact notion of bronchial respiration by listening then to his breathing. 

For some time after the first appearance of Laennec's great and original work on 
the diseases of the chest, pectoriloquy was deemed to be the pathognomonic and 
infallible sign of a vomica. "Oh," the young auscultator would say, "1 detect pec- 
toriloquy beneath the clavicle. There can be no further doubt about the nature of 
the disease. My patient has not only tubercles, but a cavity, in his lung." So I 
long thought ; and so some, I fancy, think still. Yet the evidence afforded by mere 
pectoriloquy of the presence of a vomica, or even of the presence of tubercles, is far 
from being certain or trustworthy. Experience had taught me this before 1 knew 
that many others, studying under the same schoolmaster, had learned the same truth. 
Among my hospital patients some years ago was a man who laboured under phthisis. 
Percussion gave a dull sound under his right collar-bone, and in the same spot loud 
and distinct pectoriloquy was audible. I well recollect inviting the particular atten- 
tion of the pupils to this case, as affording an exquisite specimen of pectoriloquy ; 
and I predicted very confidently that after the patient's death, v/hich was obviously 
at hand, a large excavation would be found in the summit of his right lung. My 
prediction did me no credit. The left lung indeed was hollowed by cavities, but 
there was nothing hke a cavity in the right. The upper part of the lung was tho- 
roughly and uniformly solid ; filled with hard, gray, tubercular matter. The large 
bronchial tubes were pervious, and the voice descending into them had been con- 
ducted by the soHd lung with perfect and almost painful distinctness to the hstener's 
ear. This was a useful lesson to me : and I mention it that it may be a lesson to 
you. Remember that solidification of the summit of the lung wiU modify the sound 
of the patient's voice, very much in the same manner as a large vomica there situ- 
ated. It is stated, indeed, and perhaps truly, that a practised ear can discriminate 
between the loud, diffused, thougTi articulate, resonance of the voice produced by 
sohd lung, and the circumscribed, whiffing, pectoriloquy of a cavity. But the dis- 
tinction is too nice for the average of practitioners. Now since the pulmonary tissue 
may be rendered dense and sohd by other causes than tubercles, pectoriloquy does 
not always indicate the existence of consumption. The fallacious condition does not 
often occur ; for common inflammation is seldom hmited to the upper part of the 
lung ; and the whole of that part is seldom completely hardened by crude tubercles. 
But whenever it does occur, it is apt to mislead or puzzle. I was consulted last year 
about a gentleman in whom this phenomenon of pectoriloquy was strongly marked. 
Two excellent auscukators had been led, by this symptom, to the belief that a cavity 
existed in the lung. Remembering the case 1 have just mentioned, and learning that 
the patient had been ill for a few days only, and had not previously suffered cough, 
nor any apparent pectoral complaint, I was of opinion that the summit of his right 
lung had become hepatized by acute pneumonia. And it was so. The patient died; 
and the diagnosis I had formed was verified upon the inspection of the lung. Dr. 
Latham relates one or two examples to the same purpose. Dr. Stokes goes so far 
as to consider pectoriloquy the least important and most fallacious of all the physical 
signs of phthisis. Taken alone (he says) it is absolutely without value. Dr. Forbes 
has come to similar conclusions. Certainly cavernous respiration is a much more 
alarming sound. 

Wherever actual pectoriloquy from a cavity is heard, there also will be heard 
cavernous respiration. But the converse of this is not necessarily true. There may 
be, and there often is, cavernous respiration and a cavity, yet no pectoriloquy. The 
cavity is not large enough, or not near enough to the surface of the chest, or not of 
such a kind as to reverberate the voice. 

Often when pectoriloquy is absent, and cavernous respiration is doubtful, and gurg- 
ling even cannot be heard (because the communication with the bronchi is not free)j 



636 



PHTHISIS. 



a slight splashing sound will occur when the patient coughs : nay, you may some- 
times hear it, if he holds his breath, with every beat of his heart, which causes a 
little succussion in the cavity : but its contents must then be thin. 

Now when the sounds I have been engaged in describing are well marked, they 
denote the existence of a vomica. The only source of fallacy is that which I formerly 
mentioned : the same sounds may arise from a cavity in the lung, whatever be its 
nature ; and therefore they may arise when the bronchi are expanded into cavities. 
But I jepeat that this is a deceptive condition which you cannot calculate upon meet- 
ing with often. 

When the sounds are not well marked, take time before you pronounce a decided 
opinion respecting them. Strong bronchophony comes very near to weak pectorilo- 
quy : bronchial respiration may closely resemble some varieties of cavernous breath- 
ing : large crepitation, confined to a small spot, may simulate gurgling. It is better, 
when the sounds are thus equivocal, and when they may denote conditions so very 
different in their nature and tendency, to suspend one's judgment, and to give a 
guarded opinion. A httle time in such cases will clear away the doubt. 

I am afraid of being tedious about these sounds ; but really they are of immense 
importance. Upon their exact appreciation, and correct interpretation, will depend 
the opinion you will be called upon to express : and that opinion will, in many cases, 
be a sentence of life or death in respect to the dearest friends of those who hear it. 
A correct diagnosis is also very important, in early periods of the disease especially, 
for another reason. It is in those early, periods alone that we can hope to arrest the 
progress of the complaint by art, or by change of climate. 

I must now consider the general symptoms of this most afflicting disease : and 
while doing so, I shall point out how the physical signs confirm or confute their lan- 
guage, in cases which might otherwise be doubtful. 

The general symptoms of phthisis are cough, dyspnoea, expectoration, haemo- 
ptysis, wasting, hectic fever, hoarseness, or loss of voice, diarrhoea ; and there are 
some other symptoms which mark often some of its stages, and to which I shall 
incidentally advert. I shall speak of them all as briefly as is consistent with 
clearness. 

Cough is one of the earhest symptoms of consumption ; and it is that which com- 
monly first attracts the attention, and awakens the fears of the patient, or the patient's 
friends. Generally at first it is slight, occasional, and dry : it occurs upon the 
patient's getting out of bed in the morning ; or if he makes any unusual exertion in 
the course of the day. It feels to him as if it was caused by irritation about the 
throat. Sometimes it will cease for a while, as in the warm weather of summer, 
and recur in winter when the external temperature is lower. By degrees it begins 
to be troublesome in the night : and to be attended with more or less mucous ex- 
pectoration. 

Now when such a cough steals upon a person gradually, and when no reason can 
be assigned for its occurrence, that circumstance alone is enough to excite suspicion 
as to its true nature and cause. But chronic cough may exist without any tubercular 
disease of the lungs ; as you well know. It may depend upon a disordered state of 
the stomach; the pneumo gastric nerve may be irritated there. It may be the 
cough of chronic catarrh; it may result from disease of the heart ; it may be the 
nervous, barking, importunate cough which I formerly mentioned as of frequent oc- 
currence in hysterical girls. And bearing these circumstances in your mind, you 
will inquire and you will generally make out without much difficulty, whether there 
be any unnatural or deranged state of the digestive organs; or chronic catarrh; or 
cardiac disease ; or hysteria. These are points on which I need not further insist. 

I may observe, here, that as chronic cough may exist when there is no consump- 
tion ; so consumption may sometimes exist, and even* prove fatal, and large portions 
of the lungs may be disorg-anized, without there having been any cough ; or at least 
without the occurrence of cough enough to draw the notice of the patient or his 
friends to it. This is not common, however : cough is usually present more or less, 
during all the stages of phthisis, and it is often that symptom which most distresses 
and harasses both the patient and his family. 



HHTHISIS. 



637 



Great attention used to be paid to the expectoration in cases of suspected phthisis. 
It was thought that if a patient spat pus, he was in a state of confirmed consump- 
tion : and whole volumes have been written, and prizes awarded to their authors, 
respecting the means of distinguishing pus from mucus. But we now know that, 
so far as the diagnosis of phthisis is concerned, this is a very idle inquiry. The 
inflamed bronchial membrane may secrete pus ; so that the presence or absence of 
pus in the sputa is no test at all of the presence or absence of tubercles in the lungs. 
If you are, nevertheless, curious to know how pus may be recognized, one easy 
criterion is that proposed by the late Dr. Young. You are aware that pus, like the 
blood, contains globules ; and these globules, when examined through transmitted 
light, will exhibit prismatic colours ; appear surrounded by rings of colours, some- 
what resembling those of the rainbow, but differently arranged, and often beautifully 
briUiant. Mucus having no such globules, affords no such coloured rings. The 
way to make the examination is, to put a minute quantity of the fluid between two 
small pieces of plate glass ; to hold the glass close to the eye ; and to look through 
it at a distant candle, having a dark object behind it. A yet readier, and I believe a 
better test is furnished by the liquor potassx, which converts pus into a viscid stringy 
mass, while it liquefies mucus. 

Whether the expectoration be puriform or not, has ceased, however, to be a ques- 
tion of much importance as regards the diagnosis of phthisis. A portion of the 
matter expectorated comes from the surface of the bronchi, and consists of altered 
mucus : and therefore the sputa brought up in phthisis, and the sputa brought up in 
bronchitis are, in a great degree, the same. These are partly composed of a stringy 
transparent fluid, in which opaque masses of a yellow or greenish colour are seen to 
float ; and intermixed also with which there may be a good deal of froth. The 
froth is a measure of the difficulty with which the mucus is brought up : and it is 
usually less abundant and conspicuous in phthisis than in bronchitis. The heavy 
sage-leaf sputa that we sometimes see, belong to both diseases. 

You may occasionally find portions of tubercular matter in the expectoration ; a 
circumstance quite decisive, when we are sure of it, of the nature of the case: dull 
yellow streaks, or little curd-like fragments involved in the mucus. But small opaque 
specks of that character are sometimes formed in the follicles of the tonsils ; and 
this makes the appearance more equivocal. The sputa most characteristic of tuber- 
cular disease consist of globular flocculent masses, which look like little portions of 
wool more than any thing else. Nummular sputa the French call these, because 
when spat into a vessel not containing water, they assume a flat circular form, like a 
piece of money, and remain separate and distinct from each other. When they are 
spat into a glass of water, you perceive that some of them subside to the bottom — 
some float on the top, suspended, apparently, by healthier mucus in which they are 
entangled, or by bubbles of air — and some remain stationary at different depths. 
When stirred and agitated in the water, they render it shghtly milky. This kind 
of expectoration commonly marks a confirmed and advanced state of the disease ; 
but it will continue for weeks sometimes. It is not perfectly pathognomonic, but 
nearly so. On onb occasion I found expectoration of this nature from a man whom 
I did not' very dihgently examine by my ear ; and I set the case down as one of 
phthisis chiefly on the observation of that symptom. The patient evidently had not 
long to live. Our apothecary at the hospital, Mr. Corfe, had more time to explore 
the condition of the chest : and he came to the conclusion, that the disease was not 
tubercular phthisis, but extensive chronic bronchitis : and sure enough he was right. 
When we came to examine the lungs after the patient's death, not a tubercle could 
be found. I am satisfied that there is no kind of expectoration which indicates 
phthisis with perfect certainty ; but that which I have just been describing very 
seldom occurs except there is phthisis. Louis appears to have noticed these round, 
separated, woolly masses twice only unconnected with tubercles ; and once the same 
thing has occurred to Ghomel : so that, when the other symptoms are obscure and 
doubtful, this will materially augment the gravity of the prognosis. Flies appear to 
be more attracted by the sputa of phthisis than by any other. 

Hxmoptysis is a kind of expectoration ; the expectoration of blood. I have 

3 D 



638 



PHTHISISi. 



already spoken of this symptom as connected with phthisis, and have stated my 
belief on that subject; viz., that if a person spits blood who has received no injury 
of the chest, in whom the uterine functions are healthy and right, and who has no 
disease of the heart, the odds that there are tubercles in the lungs of that person are 
fearfully high. Excluding cases of amenorrhoea, and of mechanical injury to the 
thorax, Louis did not meet with a single example of haemoptysis among twelve hun- 
dred patients, except in such as were phthisical. 

I touched, at the same time, upon the question, whether hsemoptysis, which some- 
times precedes for a while the manifestation of any other symptoms of consumption, 
is ever really the cause of it, as the old authors maintained. You will understand 
my persuasion to be that, occurring in connection with tubercles, pulmonary hemor- 
rhage is always the consequence, and never the cause, of their presence in the lung. 
Andral relates a curious case, from which the contrary opinion might be argued. 
"A man, ill of chronic peritonitis, had been for nearly two months in La Charite, 
and had never presented any morbid symptom which had relation to the organs of 
respiration. He had no cough, and he breathed easily. One evening, for the first 
time, he suffered some dyspnoea ; and in the course of that night he spat up a large 
quantity of florid and frothy blood. For the five following days the hcsmoptysis 
continued abundant, then it diminished by degrees, and at length stopped. But the 
patient continued to cough, and to breathe with difficulty, and at length he died. In 
the right lung there were found several masses of a brownish-red colour, exactly 
circumscribed, and constituting, in short, that condition which Laennec has called. 
' pulmonary apoplexy.' One of these masses contained a considerable number of 
granulations of a yellowish-white colour, and having all the characters of minute 
tubercles in ah early state. Two other of the red masses contained each a very 
small number of these white granules ; and in the remaining masses no tubercles at 
all could be discovered, nor was there any trace of them in other parts of the lungs ; 
but they were numerous in the false membranes of the peritoneum. 

Andral argues, that in this case the partial collections of blood that were found in 
the lung could not have been occasioned by the presence of tubercles, because in 
the majority of these masses no traces of tubercular matter could be perceived. On 
the other hand, their existence appears connected with that of the apoplectic masses, 
because, except in the midst of some of these, no pulmonary tubercles could be seen. 
But such a case as this hardly bears out the conclusion that pulmonary hemorrhage 
is ever the cause of tubercles. There were tubercles in the abdomen before ; there- 
fore, the disposition to tubercular disease pre-existed in this individual ; and then 
tubercular matter was deposited in the places where blood was extravasated ; just as 
we know it is deposited in the blood itself, in the spleen sometimes ; or, what I think 
more probable still, the cluster of granulations provoked the hemorrhage from the 
spot they occupied, and other lobules of the same lung became blocked up by the 
reflux of blood in the manner formerly explained. 

Prior to the age of fifteen, hemoptysis, even in phthisical children, is extremely 
uncommon. 

Dyspnoea is not a very important symptom in phthisis. It is seldom extreme till 
towards the termination of the disease, and not always then. Patients who fear, and 
et are unwilhng to believe, that they are consumptive, will fetch a deep breath, and 
id you remark how thoroughly they can distend their lungs ; and they expect you 
to say that there can be no disease in those organs. I have been told that the late 
Dr. Baillie died of pulmonary phthisis ; and that even he was accustomed to delude 
himself by this test. However, though phthisical persons do not in general suffer 
much from dyspncea, their breathing, though they may not be aware of it, or choose 
to acknowledge it, is generally, in some degree or other, short, or hurried. You 
may wonder that a disorder in which so large a portion of the breathing apparatus is 
often effectually spoiled, should be attended by so little distress in respiration ; so 
little dyspnoea : but your surprise will be diminished if you consider the insufficient 
manner in which consumptive patients are nourished, in consequence of abdominal 
disease ; and the extent to which their blood is wasted by diarrhoea, and by perspi- 
ration. The mass of blood is thus kept down to that measure which, passing through 



PHTHISIS. 



639 



the still pervious portions of the lungs, is capable of being arterialized without any- 
great deviation from the ordinary mode and frequency of breathing. 

Neither is pain of the chest a very important symptom in consumption. In some 
cases severe pains are complained of, resembling those of rheumaiism, in the sides, 
or beneath the clavicles. In others, no pain at all is experienced. When sharp 
pain occurs, it may be supposed that the pleura is inflamed and beginning to adhere 
in the painful part. 

There is, however, one contingency of which the two symptoms last mentioned are 
sometimes very significant. When, during the progress of phthisis, violent pain of 
the side, and extreme dyspnoea and anxiety, set in suddenly, they denote, Mrith much 
certainty, perforation of the pleura, and its serious consequences. 

The hectic fever which accompanies phthisis is of much greater moment. It often 
creeps upon the patient insidiously. He feels chilly, perhaps, towards evening ; 
and in the night his hands and feet are dry and burning; and in the morning he 
perspires. The most marked symptoms of the hectic are to be found in the perspi- 
ration, and in the state of the pulse. The perspiration ^s usually out of all proportion 
to the previous chilliness and dry heat. It seems to have a close connection with 
tne sleep of the patient : it seldom comes on while he continues to be awake ; but 
after sleeping he wakes, and find that he is sweating. The perspiration is generally 
most copious on the upper part of the body, the chest and head. Sometimes it is 
moderate ; sometimes the patient is drenched and drowned in it. There is a good 
deal of uncertainty about this symptom, and of obscurity as to its cause. Generally 
speaking, it belongs to the more advanced stages of phthisis ; but occasionally it 
accompanies its early period. It will cease without any apparent cause ; and 
return again with the same capriciousness. A poor friend of mine, who died 
with phthisis, and was particularly harassed by the nocturnal perspirations, took it 
into his head that posture had something to do with them ; and slept for several nights 
in succession sitting in an easy chair : and during those nights he certainly did not 
sweat, though he had been doing s.o profusely before. Louis found that one patient 
in ten escaped this symptom. 

This is a symptom which is often very distressing to the patient, making him even 
dread to go to sleep ; it tends also to the rapid exhaustion of his strength ; and 
betokens, it is believed, when copious or persistent, a short duration of the disease. 

Frequency of pulse is a symptom so generally present in tubercular phthisis, that 
too much importance has been ascribed to it as a diagnostic sign. I mean, it has 
been too much the opinion that the lungs are safe, when the pulse does not rise above 
its natural standard. Sometimes it remains steady nearly up to the period of disso- 
lution. Such cases are, I beUeve, generally slow in their progress. 

Very recently I lost a friend whose lungs were full of cavities and crude tubercles. 
He had been a valetudinarian for 5^ears ; but the pulmonary disorder had been mani- 
fested by decided symptoms during a few months only. At no period did his pulse 
exceed sixty-eight beats in the minute. Commonly, however, the pulse is habitually 
above ninety ; and often it is much more. When there is nothing to account for this 
increased frequency of pulse, it is a suspicious symptom. 

Diarrhoeai^ a common, and an ugly symptom in phthisis. When it occurs early, 
as it sometimes does ; when a patient, having habitually costive bowels, becomes 
habitually relaxed ; and you suspect only, from other causes, that he may have inci- 
pient phthisis ; this change often sets its seal upon the nature of his disorder. Usually, 
however, diarrhcea does not become urgent until the disease is far advanced, and has 
already declared itself by other and unequivocal symptoms. When it so occurs, it 
is apt to harass the patient excedtlingly ; and rapidly to waste hrs strength and flesh. 
He appears to mek away under the influence of the purging ; which is therefore said 
to be colliquative. It used to be held that the diarrhcea and the perspiration bore an 
inverse ratio to each other: that when one of them abated, the other always increased. 
But the more exact observations of Louis and others have proved that this is not so : 
that neither in phthisis, nor in other diseases, have these symptoms any such regular 
reciprocal relation. One reason, perhaps, fk this error, may be found in the cir- 
cumstance, that acids, which have the effect often of checking the perspiration, tend 



640 PHTHISIS.' 

I 

also, as is well known, to produce diarrhea. Louis found that this symptom began i 
early in the disease, and continued through its whole course, in one out of every 
eight patients ; and in one case only in every twenty-two was it wholly wanting. It 
depends most commonly, if not always, upon scrofulous ulceration in the small intes- 
tines and in the colon. In Louis' experience, there were, invariably, large ulcers, 
whenever the diarrhoea had been chronic and abiding, and the stools had been 
numerous. In the small intestines the ulceration evidently commences in the 
mucous follicles ; the glandulae sohtarise, or the glandulas agminataae ; and sometimes, 
though not often, the ulcer perforates the bowel. It is probable that in the large in- | 
testine ulceration begins in the same v/ay, by the deposit of tubercular matter (which 
is subsequently removed) in the sohtary glands : but when once begun the ulcerating 
process extends itself indefinitely to the surrounding mucous membrane. 

I should have stated before that, with this disease of the intestinal canal, there is I 
often found enlargement of the corresponding glands of the mesentery, which are ' 
frequently filled also with tubercular matter. 

Several of the symptom.s that I have been mentioning — the state of the digestive 
organs, which interferes with the due assimilation of the food ; the drain imphed in 
the profuse sweats, and in the habitual diarrhoea ; — conduce to cause another cori- 
stant accompaniment of phthisis ; and that is emaciation. — You know that the wasting 
in this complaint, when it is not cut short by some accidental complication before it has 
reached what may be called its natural termination, is extreme. It often is one of ' 
the earliest, as it is one of the most alarming, of the symptoms which the patient 
resents ; and it frequently becomes excessive before any perspiration or purging 
ave taken place to account for it. If, without any apparent cause, a person grows 
thin and his pulse is quick, and his breath at all short — these are intimations which 
seldom prove unfaithful, that tubercular disease is at work in the lungs, and in the 
abdomen. 

(Edema of the ankles, and even some puffiness of the hands and face, are circum- 
stances which seldom fail to appear in pulmonary consumption : but they are among 
the latest of the symptoms. (Edema does not tell us what the disease is in such 
cases. We have been satisfied as to that some time before. But (unless there is 
some marked disease of the heart) it tells us that the disease is about to terminate. 
It is worth attention as a prognostic symptom merely. 

And the same may be said of aphthae. This is one of the last of the symptoms : i 
but it does not always occur at all. I have lately described this morbid condition 
of the mucous membrane of the mouth and tongue, and have nothing more to say ; 
of it at present. It has the same relation to phthisis as to other chronic disorders : I 
it marks, for the most part, the approach of their fatal termination. i 

It is always interesting to couple changes of structure with their appropriate signs. \ 
I will therefore take this opportunity of telhng you what Louis has observed of this 
relation, in respect to the larynx and windpipe. 

Ulceration of the epiglottis was often latent ; gave no appreciable signal of its i 
existence. The symptoms that belong to it are, a raw, or pricking, or burning sen- \ 
sation at thg upper part of the thyreoid cartilage, with occasional dysphagia, and the j 
rejection of liquids through the nose, while the tonsils and pharynx present no visible 
alteration. 

Ulceration of the interior of the larynx is marked, when slight, by trivial pain in j 
that part, and some variation from the natural voice ; when deep, by severer pain, I 
and abiding aphonia. 

Ulceration of the trachea is seldom revealed by any symptom. And this is worth 
remembering : for patients are continually persuaded by medical men who know no 
better, that their symptoms are all tracheal. | 

There are still a few other circumstances which, when they occur, accumulate 
conviction as to the nature of the disorder. The catamenia are suspended in women : ^ 
and the hair falls off'. There are certain physical peculiarities too, which are strongly ' 
indicative of a tendency to consumption ; or perhaps I should say of the scrofulous 
diathesis. Largeness of the pupil, with a sluogish iris — in other words, a nor. very 
sensible retina — constitutes one of these. A clubbed state of the ends of th^ f^igers 



PHTHISIS. 



with convex and adunque nails, forms another. Yet this last is not peculiar to tuber- 
cular consumption. I have heard of one case in which it was strongly marked : the 
patient died after a long illness — chronic puriform discharge from the pleura after 
paracentesis thoracis : but there were no tubercles. 



LECTURE LVII. 

Phthisis, continued. Diagnosis. Forms and varieties of Phthisis. Ordinary 
duration. Age at which it is most frequently fatal. Influence of sex ; and 
of occupation. Question of Contagion. Treatment. 

In a former lecture, the twelfth of this course, I entered somewhat fully into the 
pathology of scrofulous and tubercular diseases in general. I pointed out the fact, 
that though such diseases affect vast numbers of persons, and are most extensively 
fatal, yet that they affect almost exclusively certain classes of persons. That while 
some are so prone to tubercular disease, as to fall into it upon the operation of the 
slightest external causes, or even spontaneously — nay, in spite of every care to the 
contrary — others, again, who are constantly exposed to influences hkely to call 
scrofulous disease into action, either do not suffer therefrom ; or if they do become 
scrofulous, it is only when the external circumstances most favourable to the pro- 
duction of such disease have been intense in degree and protracted in their appli- 
cation. 

At the same time I showed you how commonly the disposition to scrofula de- 
scends in families : and I told you what observation has collected in respect to the 
causes which may excite scrofulous disease in persons hereditarily disposed to it. I 
shall not, therefore, go over that ground again. What I then said of scrofulous dis- 
ease in general is true of tubercular consumption in particular. I will merely 
remind you that these exciting causes are essentially causes of debility. Whatever 
tends to depress the vital powers, and permanently to weaken the body, tends also, 
in a predisposed frame, to engender or to call forth this fearful and most destructive 
malady. 

With respect to the detection of tubercular disease in the lungs, it is sometimes 
very easy, sometimes extremely difficult. It is easy when the tubercles are numerous, 
large, or far advanced : difficult, sometimes, when they are crude, scanty in number, 
and thinly scattered, and individually small. In the latter case they may not cause 
any appreciable deviation from the natural resonance of the chest on percussion, or 
from the natural smooth equable rustle of the breathing. It would be tedious to 
travel over again all the auscultatory and other symptoms, with the view of pointing 
out their bearing upon the diagnosis. I touched upon that point incidentally, when 
discussing the individual symptoms, in the last lecture. Many of the symptoms tell 
their story so plainly that any attempt to expound or interpret them would be quite 
superfluous. One or two cardinal points, however, which have rather been hinted 
at before than expressed, I may just advert to. 

The fact that tubercles occupy the upper part of the lung by preference, is of 
great moment in relation to the diagnosis. When the symptoms are equivocal; 
when, as far as they are concerned, the case may either be one of chronic bronchitis, 
or of tubercular consumption ; a careful examination of the superior regions of the 
chest will often decide the anxious question. The sound resulting from the first 
gentle tap upon or beneath the clavicle, often rings in the physician's ear the knell 
of his unfortunate patient. Even unusual distinctness of the sound of ea?piration, if 
heard at the summit of the lung, and a fortiori if at the summit of one lung only, 
warrants the terrible suspicion that tubercles are breeding in that luna^. It may, 
indeed, be laid down as a rule, which is diversified with but few exceptions, that if 
you find dulness on percussion; or coarse or insufficient breathing; or undue reso- 
41 3d3 



642 



PHTHISIS. 



nance of the voice ; or a click or morbid noise of some sort when the patient respires, 
or speaks, or coughs ; if you find this day after day and always, between the clavicle 
and the mamma in front, or between the clavicle and upper edge of the scapula, 
over the top of the shoulder, and nowhere else ; and more especially if these devia- 
tions from the healthy sounds be limited to one side, or greater on one side than on 
the other, or different in quahty on the two sides ; you may set the case down as a 
case of tubercular phthisis. On the other hand, if in the same parts you still distin- 
guish all the natural sounds of the respiration, and can still obtain a clear sound on 
percussion, you are not to condemn the case, nor to despair of recovery, whatever 
its other circumstances may be. The worst symptom certainly, when auscukatory 
signs are wanting, is hgemoptysis. 

Incipient consumption is most liable to be confounded with chronic bronchitis. 
Yet the leading features of the two are well contrasted. The morbid sounds belong- 
ing to chronic bronchitis are chiefly audible in the lower lobes of the lungs : those 
of phthisis in the upper. Some degree of expectoration attends the cough of bron- 
chitis from the first : the cough of phthisis is often, for a long while, dry. Simple 
bronchitis is not accompanied by hasmoptysis. The pain that occurs in bronchitis 
is felt beneath the sternum : in phthisis pain most commonly affects the sides, and 
the space between the shoulders. It is enough, I trust, to have drawn your atten- 
tion to these points, without dwelling upon them longer. 

Dr. Latham, in the little work which I have several times referred to, has laid 
down certain distinctions most deserving of your notice, in respect to the various 
forms of phthisis. This portion of his book is quite original. The facts, indeed, 
have long been known ; but they have never before, that I am aware of, been made 
so instructive, by being clearly disposed, and exhibited in their proper bearings. 

Fle first divides phthisis generally into two forms, which he calls mixed phthisis 
and unmixed phthisis. And he illustrates what he means by those terms very 
simply and skilfully. He takes the case of an absorbent gland in the neck, affected 
with scrofulous disease. The changes which are liable to take place in it are 
wrought before our eyes. We have the privilege of watching them. Now, such a 
gland will sometimes enlarge, in consequence of the deposition of tubercular matter 
in its substance : it will grow large and hard without there being any pain, or heat, 
or redness, observable ; and it may remain in that state for weeks, or months, or 
years. 

But, in the majority of instances, the absorbent gland, after remaining for a certain 
time in this condition, will undergo, and cause, other changes. Pain, heat, and red- 
ness, will ensue ; the hard gland will soften ? the integuments will grow thin, and 
at length give way; the softened tubercular matter, mingled with pus, will escape; 
and then the pain and heat and redness — the inflammation, in short — will disappear; 
and the abscess will heal, leaving behind it nothing more than a slight scar. This 
process may happen to one such gland, or to more than one, simultaneously ; or to 
several in succession. 

In this case there has been no more inflammation than was just enough to accom- 
phsh its purpose of removing from the body the tubercular matter. The inflamma- 
tion has not transgressed what Dr. Latham has called its specific limit. 

But again it may go beyond that limit ; it may be both more severe and more 
extensive than is necessary for the removal of the tubercular matter in the diseased 
gland. It may pervade the whole neck, giving rise to diffused redness, and swell- 
ing, and pain ; and the whole of the subcutaneous areolar tissue between the angle 
of the jaw and the clavicle may be loaded with effused serum and pus. 

All this you may see almost any day in the wards or waiting-rooms of a hospital. 
And Dr. Latham has happily chosen this affection of the cervical glands to elucidate 
what happens when the tubercular matter is deposited in the lungs, where one can- 
not see the changes it is suffering or producing. 

Tubercles in the lungs may remain for an indefinite period of time, in their crude 
state-;, never softening at all, or softening only at a ver}^ late period. Or they may 
give rise to just so much of inflammation, and no more, in the pulmonary tissue sur- 
rounding them., as is sufficient to bring about their own sofiening and subsequent 



PHTHISIS. 



643 



expulsion. Or, lastly, the tubercles may excite much more inflammation of the lung 
around them than is requisite for their elimination : inflammation of every degree, 
and of any extent. 

Now, to the first two cases, when they occur, he gives the name of unmixed 
phthisis : the third he calls, on the other hand, mixed phthisis. We learn from aus- 
cultation whether the case be one of mixed or unmixed consumption ; i. e., we hear, 
in the unmixed forms, the sounds or modifications of sound which result from the 
presence of tubercles or of vomicEe ; and we hear these morbid sounds only : in every 
part of the lung where they are 7iot audible, we. hear the vesicular murmur of 
health. But in the mixed form we also hear these sounds. True, and we hear other 
morbid sounds beside. The tubercular disease is mixed with common inflamma- 
tion ; and we hear the sounds that denote common inflammation of the mucous 
membrane, or of the substance of the lung — sibilus, or large or small crepitation — 
we hear these sounds mixing themselves with the sounds which belong to the tuber- 
cular affection. 

This distinction is of considerable importance, for it concerns the treatment of the 
malady. The tubercular disease, when estabhshed, is beyond our power. The inflam- 
mation which is incidental to it, we may hope to alleviate or to remove. It is in the 
stage of vomicae that the disease commonly assumes the mixed character; and some- 
times the bronchial or vesicular effusion upon which the added sounds depend, may 
be got rid of by the seasonable application of a few leeches, or of cupping-glasses, 
or of a blister, or by a moderate bleeding from the arm, and the disease be brought 
back again,. for a time at least, within its specific limits, and the patient be reheved 
from much distress and imminent danger. It is upon this principle that Dr. Latham 
explains the fact that most consumptive patients improve considerably, soon after 
their admission into the wards of a hospital. The poor are necessarily much ex- 
posed to those causes which tend to complicate the tubercular disease. The tuber- 
cular disease may as yet be slight and limited ; but the superadded mischief, the 
bronchial and vesicular eflbsion, may be immense; and this being submitted, often 
for the first time, to treatment, upon their admission to a hospital, is for a vrhile 
removed. 

Now, if we had not the advantage of the method of auscultation, we could not 
ascertain these differences, nor detect them when they existed. You will perceive, 
I am sure, their practical importance. 

Of course, the more ready the surrounding lung is to take on inflammation — in 
other words, the stronger the disposition in the complaint to assume the mixed cha- 
racter—the more rapidly fatal is it likely to be. 

But of the unmixed form of phthisis Dr. Latham has made two interesting varie- 
ties ; and the truth of the distinctions he has drawn will be more manifest to you, the 
more you see of this terrible disease. In one of these varieties the lungs are appa- 
rently tenanted by a multitude of tubercles, which remain crude and unaltered for a 
considerable length of time. In the other, successive crops of tubercles appear to 
form; or at any rate the tubercles ripen and are expelled in successive crops; and 
there may be long intervals between each crop and the next. 

Dr. Latham thus describes the former of these two varieties : — "An individual 
loses the complexion of health, and becomes thin ; he coughs a little ; but perhaps 
he has no notable fever, and no constant acceleration of pulse." Upon auscultation 
of his chest, it is found that there is dullness beneath one or both clavicles, or about 
one or both scapulfe, and an indistinct respiratory murmur in those parts ; but the 
vesicular breathing is free and perfect in every other part of the lung. Here we 
have tubercles, crude, and in the upper lobe alone ; and this state of things may 
endure for years, without variation ; the patient remaining always a great valetudi- 
narian. " To such a patient (says Dr. Latham) it is a continual puzzle why he does 
not get well. He-consults an infinite number of medical men ; and it is remarkable 
that he gets no comfort or satisfaction from those who understand his disease the 
best, and the greatest comfort and satisfaction from those who understand nothing 
about it. Those who know what it is, out of kindness do not tell him the truth ; 
and they cannot asseverate a falsehood stoutly enough to carry any weight with it ; 



644 



PHTHISIS. 



whereas they who know nothing about it affirm boldly and unhesitatingly that it is 
all stomach; really beheving that the whole and sole disorder is in the stomach, and 
that it is within the reach of an easy cure." 

But at length — perhaps after a very long period — vomicse are formed ; and then 
the pati-ent sinks rapidly, and his lungs after death are found riddled by cavities and 
stuffed with tubercles ; but every part of them not occupied by tubercles or vomicae 
is crepitant and healthy. In these cases, disease hngers long in the crude stage; 
new tubercles are added, probably, year after year ; but none of them soften. They 
do not excite inflammation in the lung around them. You recognise the presence 
of the tubercular matter b}^ the ear ; but there are no vomicss. At last vomicse are 
formed, many at the same time, or in rapid succession, and the patient presently 
succumbs. 

The other variety of unmixed phthisis may be just as protracted as this ; but its 
character and progress differ materially. In the former case the patient's condition 
was one of invariable ill health ; in the one I am about to mention he has fits of ill 
health, and fits of comparative good health. He spits for a time considerable quanti- 
ties of puriform matter, and then ceases from expectorating altogether. He has hectic 
fever, and then throws it off, and then suffers it again : wastes, and recovers his 
flesh, and again loses it. You will find such cases common enough ; and in these 
cases the morbid sounds will be correspondent to the symptoms. During the fits 
of illness you will hear gurghng respiration or gurghno- cough at the apex of one or 
both lungs : and during the fits of good health you will hear cavernous respiration, 
or pectoriloquy, in the same parts ; but everywhere else you will hear a clear sound 
of vesicular breathing. Here the tubercular matter excites just enough inflamma- 
tion around it to achieve its own expulsion, and no more. The lung is destroyed 
bit by bit. Fresh portions of tubercular matter are deposited ; these ripen and soften, 
and are expectorated, and a vomica is the result : and then there is a period of quiet. 
And there being still a large portion of each lung to breathe with, the patient regains 
more health and strength in the intervals of his attacks, than the former patient pos- 
sessed habitually. 

But in this form of unmixed pulmonary consumption, a period at length arrives 
when the patient does not revert to the former state of apparent heal;,h. The 
quantity of lung that has now been destro3'ed forbids it. You may hear the sounds 
proper to tubercular disease over a large space, between the clavicle and the 
mamma, or anywhere about the scapula, .on one or both sides ; yet still that part of 
the lung which is free from tubercles and vom.icce is pervious and healthy : but the 
hectic continues, the emaciation increases, and the strength declines ; and the fatal 
consummation arrives. 

Of these two varieties of genuine and unmixed consumption, the first is the most 
hopeless. The tubercles are numerous ; they probably go on increasing in number 
though they do not soften ; there is not, and there cannot be, any even temporary 
return to health, either real or apparent. 

Whereas where the tubercles come singly, or in successive crops, and rapidly 
soften, and are expectorated ; and where some long time interposes between the 
crops ; the health and strength return, and there is just a chance that no !i»)re 
tubercles may form. It is in this variety of unmixed phthisis that a natural cure, 
by the contraction and cicatrization of a vomica, may by possibility take place. 
We cannot expect, and we must not permit ourselves to encourage hope, that the 
disease will cease in that manner : but if it ceases in any form of the malady, it is 
in this. 

[In regard to the curability of pulmonary consumption, Dr. Wood, in his Treatise on the 
Practice of Medicine, vol. ii., p. 109, remarks,as follows: — ■ 

" I am not one of those who believe that phthisis is in all cases necessarily fatal. On the 
contrary, I believe that, in one stage or another, it is occasionally cured, or at least ends in 
perfect recovery. It is no very unfrequent event to see threatening symptoms of phthisis 
give way under suitable treatment. It cannot be proved, with absolute certainty, that these 
symptoms were tuberculous; because the evidence of dissection is wanting, and the phy- 
sical signs are not sufficiently positive, in mild cases of early phthisis, to authorize a certain 
conclusion. But they are undistinguishable from symptoms, which, in otbf i cases, are the 



PHTHISIS. 



645 



forerunners of confirmed phthisis; and we have abundant evidence from dissection, that 
tubercles are capable of undergoing favourable modifications. The probability is, that the 
tuberculous matter is absorbed, and sometimes, as shown by dissection, replaced by calcare- 
ous matter ; and, if the diathesis be so far subdued as to prevent the deposition of other tu- 
bercles, before these have completely run their course, the disease may be said to be cured. 
The circumstance that such remains of tubercles are not unfrequently found in the lungs of 
old persons, who have died of other diseases, would seem to show, that these cures are 
sometimes permanent. 

"But this is not all. It occasionally happens, that consumptive symptoms disappear en- 
tirely even in the second stage of the disease, after the formation of a cavity. This event, it 
is true, is comparatively rare ; but some such cases have probably fallen within the notice of 
almost every j)ractitioner of extensive experience. Even should the disease ultimately return, 
still, the case may be said to have been cured ; as the occurrence of a second attack of pneu- 
monia is certainly no proof that the first was not cijred. But there have been cases in which 
no return of the symptoms has taken place during the residue of life, even though consider- 
ably protracted. Two instances of this kind have occurred in medical men of this city. 
One of the patients was affected, v/hen a young man, with all the symptoms of phthisis, 
including frequent attacks of hgemoptysis, severe cough, hectic fever, &c., from which he 
completely recovered, and continued exempt up to the time of his death, which occurred 
many years afterwards of typhoid fever. (See N. Am. Med. and Surg. Journ., viii. 277.) The 
other was my preceptor and friend, the late Dr. Joseph Parrish, who in early life laboured 
for a time under the symptoms of phthisis, and after his death, at an advanced age, was 
found to have several cicatrices of the upper part of one lung, which were obviously the 
remains of tuberculous cavities. (See Am. Jour, of Med. Sa'., xxvi. 256.) The probabilities 
upon the whole are, that each tubercle has a tendency towards health, and, if alone, would 
in time end in perfect recovery; so that the great fatality in phthisis consists in the continued 
predisposition which causes the constant or frequently repeated deposition of other tuber- 
cles, before those first deposited have had time to run a favourable course. We may, there- 
fore, always entertain some hope, if applied to in the early stage, in cases of no great se- 
verity, of seeing a cure effected ; and, even in the second stage, when the diathesis is not 
very strong, or the local disease extensive, there is no reason for absolute despair. Even in 
cases which appear to offer no chance of ultimate recovery, we may hope to be able very 
much to prolong the duration of the complaint, and sometimes even to add years to a valua- 
ble life. There is an individual now pursuing an active business in Philadelphia, though 
with a cavity in his lung, who eight years since was under my care with severe cough, co- 
pious purulent expectoration, night-sweats, hectic paroxysms, and great emaciation and debi- 
lity. When the second stage is clearly established, with severe constitutional symptoms, and 
the physical signs of extensive disease in the lungs, there is scarcely any ground for hope. 
If to the ordinary symptoms, in such instances, are superadded continued vomiting and 
diarrhcEa, the case may be considered as quite desperate ; and speedy death may be ex- 
pected." — C] 

This grouping of the different characters under which pulmonary consumption 
may appear, has been performed by Dr. Latham with perfect fidelity. There is 
nothing overstrained or fanciful about his sketch ; it is after nature ; and it is by the 
hand of a master. And there is something very refreshing in original views of this 
kind. Vastly more instructive too they are, than those presented by a dull compi- 
lation. I therefore again recommend you to study his httle volume. I am sure 
that / have derived much useful and usable knowledge from it ; and so also 
may you. 

There is another form still of tubercular consumption which Dr. Latham has not 
omitted to notice ; but his observations on this form are not so new. It is a strikins:, 
but not very common form ; and it is sure to arrest the attention of the practitioner 
when it does occur. I have met with three or four examples of it. The phenomena 
are of this kind. The patient has difficulty of breathing, cough, haemoptysis per- 
h.ips, night-sweats, and much hectic fever: the symptoms, in short, which constitute 
the acute phthisis of some authors. But if you listen to the chest, you do not hear 
the sounds that are peculiar to phthisis : you do not find dullness confined to the 
upper lobes, or pectoriloquy, or gurgling respiration : but you rather find the super- 
added sounds which accompany mixed phthisis; small crepitation all over the 
lungs, succeeded by an absence or deficiency of the proper breathing everywhere. 
Meanwhile there wiU be none of the expectoration which is characteristic of phthisis. 
In short, you would not suppose that the disease was phthisis at all. Yet it must 
be called such, for after death you find the lungs thickly bestrewed everywhere with 



646 ' PHTHISIS. 

what I spoke of before as the granulations of Bayle ; nascent tubercles, myriads of 
them, gray and minute : what many persons call mihary tubercles. The tubercular 
matter, from some cause which w^e know nothing of, is thickly and uniformly sown 
over the whole of tlie air-passages, or throughout the entire extent of the lungs, and 
its sudden presence there in such abundance excites inflammation, which masks and 
conceals the specific disease ; and the true nature of the case is not suspecied until 
after the patient's death. All the instances that I have seen — three or four only in 
number — were supposed by me to be cases of extensive inflammation of the lungs ; 
and so indeed they were, but they were something more. The tubercles, doubtless, 
were the cause of the inflammation ; and not the inflammation the cause of the 
tubercles. 

From what I have been stating you will perceive how difficult it is to say what is 
the ordinary duration of phthisis ; concerning which a question was put to me at 
the close of the last lecture. The disease may be present for some time without 
declaring itself by any marked or unequivocal symptoms ; and therefore without 
attracting attention. But taking the cases as they occur, and estimating the duration 
of the malady from the time when it first manifests itself in a decided form, we find 
there is quite enough of variation to warrant the distinction that has been made by 
authors between chronic and acute phthisis ; or, to use the more popular and more 
expressive phraseology, between slow and galloping consumption. The following 
tabular statement of the resuhs observed by Bayle and Louis, will give you a some- 
what more precise notion of the general progress and duration of the disease. The 
whole number of cases noted was 314. Of these 24 died within three months ; 69 
between three and six months ; 69 also between six and nine months ; B2 between 
nine and twelve months ; 43 between twelve and eighteen months ; 30 within from 
eighteen months to two years ; 12 between two and three years ; 11 between three 
and four years ; 5 between four and five years ; 1 between five and six years ; 3 
betw^een six and seven years ; 1 between seven and eight years ; 3 between eight 
and ten years; and 11 between ten and forty years. 

You will remark that, as far as this account goes, more than one-half of the whole 
number died within nine months from the time when the disease first became mani- 
fest. This agrees with the experience of the late Dr. Gregory, of Edinburgh. He 
used to state that the ordinary duration of phthisis was about six months ; that some- 
times it lasted only two or three months ; and that he had seen one case which 
proved fiital on the seventeenth day after the symptoms were first observed. On the 
other hand, he had known one man who was at least 72 years old when he died, in 
whom symptoms of phthisis first appeared at the age of 18, and who was never 
free from them during all the intervening period ; being often hectic, and frequently 
spitting blood. The average or mean duration of consumption has been computed 
to be about two years. This is a different thing, you will please to observe, from its 
ordinary duratfon. 

There are many other points in the statistical history of phthisis well worthy of 
attention and inquiry ; but I have not time to go into them in any other than a sum- 
mary manner. This part of the subject is very well worked up in Sir James Clark's 
lucid and sensible book upon Consumption : but you w^iil have perceived, from the 
references I have so frequently had occasion to make to M. Louis, that his work is 
the great storehouse or treasury of tabular information, in respect to the facts of tuber- 
cular phthisis. 

It is an interesting question to determine at what period of human fife consump- 
tion numbers the most victims. There are two short tables, one drawn up by Louis, 
containing observations relative to 123 cases, and the other by Bayle, respecting 100 
— which throw some light on the question. The two tables agree, in the main, 
very closely. Thus, from the age of 15 to that of 20, Louis met with 11 deaths 
from phthisis, Bayle with 10 ; from 20 to 30, Louis met with 39, and Bayle 23 ; 
from 30 to 40, Louis 33, Bayle 23 ; from 40 to 50, Louis 23, Bayle 21 ; from 50 
to 60, Louis 12, Bayle 15; from 60 to 70, Louis 5, Bayle 8. You see from this 
account how erroneous the common notion is, that consumption does not occur at an 
advanced period of life : that a person who has reached his thirtieth or fortieth year 



PHTHISIS. 



647 



is thenceforth safe from that disease. From these two tables, and others collected 
by Sir James Clark, it appears that, taking decennial periods, the greatest number 
of deaths from phthisis happens betvv^een the ages of 20 and 30 : the next greatest 
number from 30 to 40: the next from 40 to 50: and that, after these, it is a 
doubtful matter whether more perish of consumption between 50 and 60, or between 
15 and 20, which last is only one-half a decennial period. These calculations refer, 
as you will remark, to human life after the age of puberty. Before that age, tuber- 
cular disease is fearfully common, especially in infancy and childhood. Among 920 
children (532 girls and 388 boys) who died from the age of 2 to that of 15 years, 
no less than 538 (nearly three-fifths of the whole) were affected, Dr. Papavoine tells 
us, with tubercles. 

As far as numerical observation has hitherto been extended, it would appear that 
more women than men die of consumption. Statistical .researches are of still greater 
interest, perhaps, when they elucidate the influence of different trades and occupa- 
tions in calling phthisis into existence. Sir James Clark has brought together much 
curious information on this point. There are certain occupations which appear to 
provoke pulmonary consumption by the direct apphcation of local irritants to the 
lungs themselves : and there are others which tend indirectly to bring on phthisis, 
by lowering the tone of the general heahh : by producing debility and cachexia. 
But these two causes often go together: and it is difficult to estimate with accuracy 
their separate effect. The workmen whose employments have a directly irritating 
operation upon the respiratory organs, are stone-masons, miners, coal-heavers, flax- 
dressers, brass and steel polishers, metal-grinders, needle-pointers ; and many others 
who of necessity inhale during their labour an atmosphere loaded with irritating 
particles of matter. But, then, most of these men work also in towns, and remain 
for many hours day after day in a constrained position, in crowded or in close apart- 
ments. Moreover, some of these occupations, being sedentary, and requiring no 
great muscular power, are unfortunately selected, for that reason, by persons who 
are naturally of feeble or delicate constitution. On the other hand, butchers, fisher- 
men, and their families, and farm-servants, are said to be comparatively free from 
phthisis. Beddoes ascribed this exemption to the use of animal food by these classes; 
but much of their better health is due, no doubt, to their habits of active exercise in 
the open air ; and to the circumstance that such employments demand a certain 
amount of bodily strength and energy, and therefore are not hkely to be adopted by 
weak and scrofulous individuals. It is obvious that the whole inquiry is beset with 
sources of fallacy. We know, however, on the evidence of undoubted facts, that 
cenain occupations do tend to induce pectoral complaints, and to shorten life. Dr. 
Knight, of Sheffield, informs us that fork-grinders, who are what are called dry 
grinders, die there of the grinder^ s asthma, or grinder'' s rot, before they are thirty- 
two years old. Razor-grinders, who grind wet and dry, live a little longer: the 
moisture diminishes, of course, the number of floating particles of metal. Table- 
knife grinders work on wet stones, and survive till they are between forty and fifty. 
I must refer you to Sir James Clark's book for similar facts in respect to the inhala- 
tion of silex, of the dust of mines, and so forth. Without pretending to assign to 
each alleged injurious influence its precise contribution of mischievous effect, we 
must be content, at present, with the practical inference, that such employments 
should, if possible, be avoided by all those who show any tendency to scrofulous 
disease. 

Is phthisis contagious? No : I verily beheve it is not. A diathesis is not com- 
municable from person to person. Neither can the disease be easily (if at all) gene- 
rated in a sound constitution. Nor is it ever imparted, in my opinion, even by one 
scrofulous individual to another. Yet in Italy a consumptive patient could not be 
more dreaded and shunned if he had the plague. And in this country the suspicion 
will now and then arise that the disease may be infectious. A girl dying of phthisis 
is nursed by her sister, who afterwards droops and dies of the same complaint. 
Here the presence of peculiar diathesis is strongly presumable. But the parties may 
be different in blood. A wife watches the death-bed of her consumptive husband, 
and presently sinks herself under consumption ; and there may be no traceable or 



648 



PHTHISIS. 



acknowledged example of scrofula in her pedigree. Yet even here the latent dia- 
thesis may fairly be presumed to have existed. Very few families are perfectly 
pure from the strumous intermixture. The predisposition may be slight; it may be 
dormant for a generation ; or, like other inherited peculiarities, it may light caprici- 
ously on some individuals only of the kindred. Tn both the supposed cases there 
have been other influences at work, more authentic than the alleged contagious pro- 
perty, in calling forth the fatal malady. Watching, the want of rest, confinement in 
the unwholesome air of a sick chamber, and, above all, protracted mental anxiety, 
than which no single cause perhaps has more power to foster and forward the inbred 
tendency to phthisis. The disorder, I am satisfied, does not spread by contagion. 
Nevertheless, if consulted on the subject, I should, for obvious reasons, dissuade the 
occupation of the same bed, or even of the same sleeping apartment, by two persons, 
one of whom was known to labour under pulmonary consumption. 

, The treatment to be adopted, and the plan of regimen to be observed, in respect 
to tubercular phthisis, resolve themselves into the methods of prevention when the 
disease is likely to occur ; of arresting its progress when that disease is incipient 
or limited in extent; and of alleviating the most distressing symptoms, when no 
hope remains of stopping its course, or averting its fatal close. 

With regard to iha prevention of the disease, in those, who, by inheritance, or by 
circumstances, are predisposed to it, a great deal might be said ; but the subject 
belongs rather to the head of medical police, or hygiene, than to the practice of 
physic. We deem that a person has that predisposition, which is almost a neces- 
sary condition of the development of tubercular disease, when we observe those 
marks of the scrofulous diathesis which I pointed out in an earlier part of the course : 
or when we know that the parents possess that peculiarity of constitution ; or when 
brothers have displayed it. It would be well indeed for society if the multiphcation 
and diffusion of the strumous diathesis could be checked by a prudent avoidance of 
ill-assorted marriages. But we cannot say — no legislature could say — to a scrofu- 
lous man or woman, you shall not marry, and propagate scrofula. It is reasonable, 
however, to conclude, and the conclusion is amply borne out by the observation of 
facts, that where both parents are strumous, the child will, in all probability, be 
doubly so ; or that, at any rate, its chance of escaping the scrofulous disposition will 
be small. It is very desirable, therefore, that correct notions on these subjects should 
be generally prevalent : and that persons who are conscious that scrofula in any of 
its shapes exists in their family, and, a fortiori, they who know that it exists in their 
own corporeal frame, should avoid allying themselves with such as are in the same 
predicament: and this prudence might be enforced if they could be made to foresee 
the suffering and misery its neglect is calculated to inflict upon their offspring. In- 
termarriages of persons of the same family, when that family is subject to tubercular 
disease, are earnestly to be deprecated. But on these points our advice is seldom 
asked. 

We are hable, however, to be consulted respecting the mode of warding f>jf scro- 
fulous disease in those who have derived an hereditary tendency to it from their 
ancestors. Now the first, and most effectual prophylactic in such cases, is residence 
in a warm climate : and next to that is the avoidance of all causes likely to foster 
the morbid tendency. I need not repeat what I formerly told you on this subject. 
Pure air; nourishing, but unstimulating food; moderate exercise; early hours; 
cleanliness; warm clothing; and abstinence from excessive study, from severe bodily 
toil, and from vicious and exhausting indulgences of all kinds : these are the topics 
upon which we much insist, when our advice is sought for respecting the means of 
preventing consumption in children or others, who are in danger of contracting it. 

But when the disease is present — when tubercles actually exist, and are ascer- 
tained to exist in the lungs — may the progress of the disorder be ever suspended by 
a change of climate? Indeed I beheve it may: but only in certain cases, and in 
certain stages of the disease. When phthisis occurs in either of its slow and un- 
mixed forms, the question of a change of sky will be worth entertaining. In that 
form in which tubercles remain long in the crude state, I believe life may be pre- 
served or lengthened by leaving this country, and residing under a higher and more 



PHTHISIS. 



649 



equable temperature, provided that no softening of the tubercular matter has yet 
taken place. And in the other form — when a vomica or vomicae have occurred, and 
the strength is apparently restored, and the remainder of the lungs gives out the 
sounds of health — m that case also I would recommend a voyage to a milder chmate 
to those persons who could afford to migrate, and to whom it was a matter of im- 
portance that they should prolong their earthly existence. I believe there is no place 
to which such persons could go with more hope of benefit than to Madeira. There 
are, however, places on our own coast that ofl^er no ineffectual substitute for Avarmer 
lands beyond the sea, to those who cannot so conveniently expatriate themselves. 
Hastings, for instance ; the Isle of Wight ; and more especially Torquay on the 
coast of Devonshire ; and Penzance, or its neighbourhood, in Cornwall. In those 
sheltered spots the patient may sometimes pass the colder weather of our winter and 
spring months in comparative security. If, however, the lungs are already in a state 
of rapid disorganization, no benefit, but on the contrary much inconvenience and 
useless expense will result from change of place, unless that place in which the 
patient is residing be notoriously unhealthy. When I am asked about removal, 
either to another country, or to some distant part of our own, and the state of the 
patient is such as I have just alluded to, I always advise that he should not forego 
the comforts of his home — and leave his family and friends — to seek advantage 
which he will not find, among strangers, and amid the discomforts of a lodging per- 
haps, or an incommodious dwelling. I think it cruel .and wrong to send people 
away merely to die : and that many are so sent to this place and that, in the almost 
certain prospect of their never returning, no one, I think, can doubt. 

You will find a great discrepancy of^ opinion among authors, and among practi- 
tioners with whom you may converse, in respect to the regimen, which consump- 
tive persons should follow. One man gives all his phthisical patients beefsteaks and 
porter; another restricts all his to vegetables and asses' milk: and each will boast, 
and bring forward most triumphant examples, of the success of his system. Now it 
is quite obvious that for a sick person who receives benefit from the one of these 
plans of diet, the contrary plan could scarcely be otherwise than injurious; and 
reason at once suggests that there must be some distinction between tiie cases that 
get better under the one system, and those that improve under the other. Doubtless, 
we must have regard to the constitution and habits of the patient ; and sometimes 
trial alone will show which plan is the most beneficial ; but I believe the best clue 
to lead us out of the difficulty will be found in Dr. Latham's division of phthisis into 
mixed and unmixed. The object is, to sustain the patient's strength without exciting 
inflammation in his lungs. If, with the specific disease, there be conjoined an in- 
flammatory condition of the pulmonary substance around the tubercles, or of the 
bronchial membrane ; in such cases an antiphlogistic diet is the proper one. On 
the other hand, when the disease manifests no tendency to trangress its specific limits, 
then the diet should be generous and full: and it may be so without being over- 
stimulant. Debihty, however induced, adds to the disposition to the deposit of tuber- 
cular matter ; and therefore the debility arising from insufficient nutrition is to be 
avoided as carefully as is compatible with the other indication, which is, to obviate 
inflammation of the lung. With these hints, you will be able, I trust, to strike the 
balance between the risk of augmenting the local mischief directly, on the one hand, 
and that of depressing the general strength, and so increasing the local mischief mdi- 
rectly, on the other. Milk is a sort of animal diet, and it is both nutritious and un- 
stimulating; therefore milk may, in many cases, form the staple of the food, if the 
patient hkes it, and it agrees with him : but there is much variety in this respect in 
different persons. I repeat, that you will too often find prejudices entertained, on 
the one side or the other, in regard to the diet proper for consumptive persons : but 
the commonest error of the two is, I believe, that of reducing the patient's strength 
by a needless restriction of his nutriment, lest inflammation should ensue. 

Louis, should you refer to him, would be hkely to lead you into the opposite mis- 
take ; for he affirms, that neither bronchitis, nor pneumonia, nor pleurisy, have any 
effect in exciting tubercular phthisis. But this opinion is quite opposed to the general 
sense of most men of experience. Many a case of consumption can be traced back 

3£ 



650 PHTHISIS. 

to a severe catarrh, and no further. Many, which ran a short course, were dated, 
within my own knowledge, from the last visitation of influenza. If M. Louis had 
meant that thoracic inflammation will not produce tubercles in the lungs of a person 
who has not the scrofulous diathesis, and that tubercles may and do arise without 
any previous inflammation, I should quite agree with him. But he draws his con- 
clusions from cases of phthisis. I have no doubt whatever that the dormant predis- 
position is often awakened into actual disease, and that latent tubercles are often 
accelerated in their progress, by inflammation of the pulmonary tissues. Whether 
this happens directly from the local inflammation, or indirectly from its effects in 
lowering the vital powers, is a question which no one can solve, and of which the 
solution is not of much consequence. What we are sure of is, that every one who 
bears a real or suspected taint of scrofula in his frame, should scrupulously guard 
against every known and avoidable cause of catarrh, pneumonia, or pleurisy. I hold 
M. Louis's doctrine on this head to be unsound and unsafe : and I mention it only to 
admonish you against it. 

In offering you a few final observations on the remedies of phthisis, I shall take 
leave to abstain from weighing the pretensions of a number of specifics, that have 
from time to time been highly recommended ; but which never have come into 
general use, as they would have done, no doubt, if they had been entitled to such a 
denomination. 

In the first place we must satisfy ourselves as to the kind of case we have to deal 
with; whether it be mixed or unmixed. We must watch our patient: and keep 
him on low diet, and take blood either in small quantities from the arm, or by leeches 
or cupping from the chest, whenever inflammatory symptoms arise; whether they 
are discovered by observation of the general or of the physical signs. The bleedings 
must of course be small — and palliative only of the symptoms. 

Emetics, frequently repeated, have been recommended in the early stage of 
phthisis : partly on account of their reputed efficacy ; partly on theoretical grounds ; 
it being supposed that the tubercular matter may be thus removed from the mucous 
surfaces as fast as it is deposited. Of the value of this emetic plan, I am unable to 
speak from any experience of my own. 

Counter-irritation is often of undoubted service : mustard-poultices to the chest 
when it is painful ; or a blister or succession of bhsters, or pustulation by tartar- 
emetic ointment, to encounter local symptoms. The effect of counter-irritaiion upon 
the progress of the tubercular disorder is apparent sometimes by accident. Dr. 
Abercrombie has related an example in which cerebral disease operated in this way; 
the previous symptoms of phthisis disappearing. In some cases mania seems to 
have a similar consequence, obscuring the manifestations, and probably retarding the 
course, of consumption. It has been often remarked — you will find this stated by Sir 
B. Brodie — that after amputation of a scrofulous leg, phthisical sj^mptoms, very little 
noticed before, have rapidly increased. And there is another fact, in relation to 
phthisis, analogous to these, which it is fit you should know and attend to, viz. 
that the progress of consumption is often suspended by pregnancy : — and when a 
mother is suckling her child, if the suckling be not too long continued, so as to ex- 
haust the mother. I suppose there is no doubt that women disposed to phthisis have 
been kept alive by successive pregnancies and sucklings. It is a very rare thing 
for a pregnant woman to die of phthisis. I have known only one instance of it. 
One of my patients in the hospital, a French woman, died of that disease ; and we 
found suppurating tubercles in her lungs : and a fostus of about five months in her 
womb. 

Riding on horseback has been strongly advised in the earlier periods of the dis- 
ease. Its main advantage seems to arise from its alloAving the enjoyment of fresh 
air, and of exercise, without putting the patient out of breath ; and these advantages 
are great. It is affirmed that many phthisical patients remain free from cough, and 
those affected with haemoptysis cease to spit blood, so long as they continue to take 
exercise on horseback. Gestation in a carriage, or in a boat, has the same good 
effects, but in a less degree. W^e are not able, however, to look upon equitation as 



PHTHISIS. 



651 



so certain a cure in consumption as Sydenham did, who says that riding on horse- 
back is as much a specific in phthisis, as the Peruvian bark is for an ague. 

Iodine and its compounds, and especially the iodide of potassium, have been 
much praised of late years for their reputed efficacy in phthisis. Given in small 
doses, I beheve that they often have a beneficial influence upon the general health. 
I vv^ish I could tell you that I had ever known them operate a cure of the manifested 
disease. 

Often— too often — all that we can attempt to do is to relieve the most urgent or 
distressing symptoms, and to make easier the patient's decline. One symptom 
which is both distressing and weakening is the4nocturnal perspiration. The com- 
mon remedy for this is the dilute sulphuric acid ; and a very good remedy it is, but 
it is not equally adapted to all cases. If the bowels are costive — or if the bowels 
have not, as they often have, a tendency to be relaxed— then the sulphuric acid may 
be freely given ; and it will often have very good results. It may be exhibited three 
or four times a day, in doses of from twelve to twenty minims. But when this fails, 
or when the bowels are. irritable and will not bear it, we must have recourse to other 
means. One of these is sponging the surface of the body at bed-time, or before the 
patient settles himself for the night, with tepid vinegar and water ; using twice as 
much water as vinegar. And if the bowels are at the same time purged, I find the 
compound kino powder of the Pharmacopoeia an admirable medicine. It certainly 
has much power over the perspiration ; and it has these further advantages, that 
(containing opium) it tends to control the diarrhoea, and to calm the cough. 

Steel is another substance which exercises a marked influence sometimes over the 
hectic fever. It was its efficacy in this way that gave celebrity to the famous anti- 
hectic mixture of Dr. Griffith, the Mistura Ferri Composita of the Pharmacopoeia. 
Certain it is, that when steel is borne in the advanced stage of consumption, it often 
does a world of temporary good ; — but in many cases it is not borne well. It in- 
creases the cough, occasions headache, and distresses instead of reheving the patient. 
Nor is it always easy to say beforehand, whether it is likely to suit the case or not. 
I apprehend it will at length be found most applicable to the unmixed forms — the 
uninflammatory forms, that is — of phthisis. I have frequently, however, succeeded 
in checking the wasting sweats by the tinctura ferri muriaiis^ given in doses of 
twenty minims thrice a day, after other expedients had failed me. 

When the cough is very troublesome, and especially when it breaks the patient's 
rest at night, we must endeavour to quiet it ; and there is no drug, I fear, that we 
can depend upon for that purpose, but opium. The old paregoric has been, and is, 
a favourite form for giving opium to ajlpease cough ; and old-fashioned apothecaries 
will tell you that the alteration which was made by leaving the aniseed out of this 
compound tincture of camphor, in the last Pharmacopoeia but one, impaired its effi- 
cacy. Whether it was so or not, I cannot tell ; but Dr. Prout is of opinion that 
aniseed has considerable power in allaying the irritation on which the cough depends. 
He infuses three drachms, or half an ounce, of the bruised seeds in half a pint of 
distilled water at a temperature not exceeding 120°, and lets it stand till it is cold. 
On his strong recommendation I have tried this, as a vehicle for paregoric, when the 
same dose in other vehicles had failed ; and I must say that it has frequently been 
followed by a marked abatement of the frequency and violence of the cough. The 
aniseed is restored in the paregoric of the last Pharmacopoeia, that of 1836. Hy- 
drocyanic acid has sometimes a very soothing effect upon this harassing symptom. 
However, at last, opium will be found our sheet-anchor, not merely for the cough, 
but for the diarrhoea which is so seldom absent in the later periods of phthisis. The 
diarrhoea depends, as I have told you, upon an ulcerated state of the bowels. In 
those cases in which it could scarcely be kept in check at all, I have always found 
very extensive ulceration in the large intestines ; but the diseased condition is often 
seated higher up, in the ileum or jejunum. Catechu is of great service in these 
cases, combined with laudanum and with the officinal chalk mixture ; — or a few 
grains of the confedio opii may be given in peppermint water, after every loose 
evacuation ; or, in obstinate cases, a pill composed of a quarter of a grain of the 
sulphate of copper, and the same quantity of opium, will often answer well, though 



652 



MELANOSIS.' 



it sometimes gripes. I mention these several expedients, for you will often require 
them all. The injection of a small quantity of starch, as much as the rectum will 
receive and retain, with ten or twenty drops of laudanum, generally affords the 
patient most sensible comfort, and suspends the further action of the bowels for a 
considerable time. 

These, I think, are the principal means by which we may endeavour to smooth 
the pillow of the patient dying of consumption. Sometimes very little pain or dis- 
tress is felt at all, from first to last ; ihe intellect remains free, and the patients are 
proverbially sanguine about the issue of their disorder. In other cases, do what we 
will, the patient suffers greatly. One harassing incidental combination of symptoms 
is nausea and vomiting. I should have stated before, that when, in phthisis, these 
symptoms last long, and are accompanied by pain and tenderness of the epigastrium, 
they denote, almost always, a thinned and softened condition of the mucous mem- 
brane of the stomach. They may be alleviated by a few leeches — by a blister — by 
the efTervescing draught ; or the prussic acid may be used ; that is a medicine which 
certainly tranquillizes an irritable stomach, and it now and then seems to allay an 
urgent cough. Sometimes, again, the bones of the miserable patient are laid bare, 
in consequence of pressure upon parts in which the circulation is already very feeble. 
We cover these with soap-plaster ; take off the pressure by arranging cushions ; or, 
what is much the best of all, we put the patient upon the water-bed, invented by Dr. 
Arnott. 



LECTURE LVIII. 

Melanosis of the Lung ; true, and spurious. Accidental intrusion of solid sub- 
stances into the air-passages. 

I YESTERDAY adverted to certain calhngs which are unhealthy for various reasons, 
and among the rest for this : that the work-people engaged in them breathe habitu- 
ally an atmosphere loaded with particles of matter which clog or irritate the pulmo-- 
nary tissues. There is one morbid condition, so produced, which hitherto, or till 
lately, has scarcely been mentioned by writers on disease, but which deserves a mo- 
ment's attention ; for although it is very uncommon in many parts of this country, 
it is by no means rare in some others. The»texture of the lungs is spoiled by mat- 
ters carried in with the air, in the acts of breathing. This morbid state has been 
called spurious melanosis. The lungs are found after death to be throughout of a 
black colour, more or less uniform. Sometimes the pulmonary substance is dry and 
friable, as well as black ; sometimes moist, oedematous, infiltrated with an inky fluid ; 
not unfrequently broken down into irregular cavities of various sizes ; and these 
cavities are often full of the same black liquor. 

You are not to confound these appearances, when you happen to meet with them 
— (and as you will probably scatter yourselves, some here and some there, over vari- 
ous parts of the kingdom, some of you are very likely to meet with them) you must 
avoid, I say, mistaking these black appearances and products, for true 7nelanosis. 
The disease so denominated is a singular one. It vi-as first fully described and named 
by Laennec in 1806. It consists in a morbid product, presenting a black or deep 
brown colour of various degrees of intensity, moist generally, unorganized, and dif- 
fering in the form it assumes, and in its consistence, according lo circumstances. I 
shall take this opportunity, for I am not likely to have a better, to tell you the little 
that has been ascertained in regard to this kind of disease ; and having done so, I 
shall revert to a short account of spurious melanosis. 

These black deposits take place most frequently of all in the areolar tissue, and in 
the adipous tissue : and they occur in greater abundance, and in larger masses, ac- 
cording as these reticular tissues are more plentiful, and more lax. They are met 
with also in the compound organs of the body ; especially in the liver. Less fre- 



MELANOSIS. 



653 



quently in the lungs. Sometimes in the eye. Occasionally m the brain. The serous 
membranes are obnoxious to the same kind of disease ; the mucous very little so. 
The black or dark-coloured matter may also exist, in ahquid condition, in the natural 
cavities of the body. And lastly, the melanotic material is sometimes mixed up with 
scirrhous and brain-like malignant tumours. 

With respect to the shapes in which it appears — it is sometimes dotted, the sur- 
faces ditiected by it looking as if they had been thickly sprinkled over with coal-dust 
or soot. But more commonly melanosis assumes the form of solid tumours, of vari- 
able magnitude. These tumours are largest, where reticular tissue is most loose and 
abundant. They may be no bigger than a pin's head, or they may be as large as a 
man's head. Masses of this kind have been found in the horse, weighing as much 
as six-and-thirty pounds. In the human subject they may attain the size of an 
orange. These large tumours (hke large pulmonary tubercles) are usually formed 
by the union and agglomeration of several smaller ones, and hence they have gener- 
ally a lobulated surface : while the shape of the separate smaller tumours is mostly 
spherical. Sometimes the areolar tissue lying around the melanotic masses is con- 
densed into a kind of cyst : more generally the black matter is in naked contact with 
the tissue, whatever that may be, in which it is lodged. 

From the serous surfaces, especially from the pleura and peritoneum, knobs of a 
dark colour are seen in some instances to project ; in others, the round tumours, as 
big as peas, or cherries, hang from these surfaces by a sort of peduncle. The omen- 
tum is a common habitat of melanotic tumours. 

Occasionally, I say, the black matter is found spread in a continuous layer upon 
the serous membranes ; or is collected in a liquid state in their cavities. But this, 
compared with the occurrence of solid tumours, is rare. 

When this remarkable disease is met with in one tissue or organ of the body, it 
is met with in others. It is never confined to one part, but pervades several : re- 
sembling in this respect both the scrofulous matter which constitutes tubercle, and 
the matter of cancer. Miilier indeed considers melanosis to be a species or variety 
of carcinoma. 

Scattered notices of these singular and striking changes in the animal frame occur 
in the works of Morgagni and of Haller ; but since the period when Laennec first 
drew the special attention of the profession to the subject, the black matter has been 
carefully analyzed by several expert chemists. Without going into any tiresome ^ 
detail, which you could scarcely remember, as to its exact composition, it is interest- 
ing to know that it is very like that of the blood : and no doubt the material is some- 
how deposited from the blood. Very httle, however, has been ascertained about its 
primary origin and cause. Some have supposed that the melanotic matter is ana- 
logous to the natural pigments which are found in the animal economy ; all of which 
are known to be rich in carbon. It is a curious fact that the disease has been more 
often observed in white or gray horses than in others. (I should tell you that the 
complaint is not at all uncommon in various quadrupeds : examples of it have been 
noted in the horse, ox, dog, cat, rabbit, rat, and mouse.) It has been conjectured that, 
in white animals, the colouring maiter of the surface, and of the hair, has been di- 
verted, by some morbid process, from its proper locahty. But the very same disor- 
der occurs also, though not so often, in dark, or bay, horses and cows : and certain 
pathologists imagine that in these cases there has been an undue accumulation, in the 
blood, of the carbon which is destined to colour different parts. In the one case, you 
see, they hold that the pigment is misplaced ; in the other that it is excessive. What 
value these speculations as to the nature and origin of the disease may possess, time 
alone can determine. 

When the tumours are divided, and moist, or when they are rendered moist by 
admixture with water, they freely impart the colouring matter ; staining white paper, 
and blackening one's fingers, just as Indian ink might do. The disease most fre- 
quently happens, when it happens at all, in the decline of fife. 

The changes to which the melanotic tumours are liable, are very much like the 
changes which tubercular matter is apt to undergo. In certain situations where the 
secreted black material is subject to pressure, and is poured out in a soft consistence 

3e2 



654 



SPURIOUS MELANOSIS. 



the watery parts are sometimes absorbed, and the mass becomes hard and firm. 
On the other hand, the pressure occasioned by tiie tumour sometimes provokes 
inflammation in the tissues surrounding it ; and then it is Hable to be broken down, 
exactly in the same way as that in which tubercles soften prior to their expulsion 
from the lungs. 

The injurious effects of these collections of black matter arise from the pressure 
they occasion; and they may evidently thus cause pain, irritation, ulceration; and 
according to their situation, number, and extent, they may materially interfere with 
important functions. And in this manner they do, in fact, at length destroy life. 

There are no symptoms that I know of, distinctive of this disease, except the ap- 
pearance of the black masses upon the surface of the body. Nor can I pretend to 
point out to you any cure for it, w^hen it is ascertained to exist. 

Yet it is right that ^^ou should be aware of what pathologists have learned re- 
specting this curious morbid state ; although that be little, and not very satisfactory. 
And I have introduced this brief consideration of melanosis here, somewhat irregu- 
larly, perhaps, to enable you to distinguish from it that puhnonary disease to which I 
referred in the outset of the lecture, and to w^iich I shall now return. This, I say, 
has been called spurious melanosis : and it has doubtless been mistaken for the spe- 
cific disease of which I have just given you a sketch ; for real melanosis. 

It is, however, a very different affection. 

Laennec had conjectured that certain kinds of black discoloration of the lungs 
were of extraneous origin; were owing to the introduction of black matters from 
without ir. che process of respiration ; and Mr. Pearson, in this countr}?-, had thrown 
out the same idea. But this was first ascertained to be actually the case in Edin- 
burgh. Dr. J. C. Gregory had a patient who died in the infirmary of that city, and 
whose lungs exhibited the following appearances : — They both presented one uni- 
form black carbonaceous colour, which pervaded every part of their substance. The 
right lung was broken down, in its upper and middle lobes, into irregular cavities ; 
and the walls of these cavities were black ; and they contained a considerable quan 
tity of a black liquid like ink. Portions of the pulmonary substance were dense, 
hepaiized, and friable. The rest of this lung was cedematous; and when the serum 
which then rendered it thus cedematous was pressed out, it also, the serum I mean, 
was quite black. The left lung was infiltered, in the same manner, with black serum. 
No tubercles could be detected. The bronchial glands were not enlarged, but they 
were stained of the same sable hue as the substance of the lungs. No other organ 
of the body presented any trace of this black discoloration. 

Dr. Christison, who is known to be a very exact and able chemist, midertook an 
analysis of the black matter contained in the serum expressed from these lungs. I 
shall not follow out the details of his researches (you may read them at length in the 
109th number of the Edinburgh Medical and Surgical journal), but content myself 
with stating their result. And I may state it in Dr. Christison's own words. "la 
the product of this experiment (he says) it is scarcely possible not to recognize the 
ordinary products of the distillation of coaL A gas of the same quality was procured, 
and likewise a naphthous fluid holding in solution a crystalline principle, analogous 
to, if not identified with, naphthaline." 

Now the man, whose lungs presented the appearances I have described, had, for the 
last ten or twelve years of his life, been employed in the coal-mines at Dalkeith. He 
had been exposed, therefore, to the habitual inhalation of coal-dust into his lungs in 
breathing: and taking this circumstance in conjunction with the resuk of the analysis 
of the black matter contained in the lungs, and nowhere else throughout the body^ 
we cannot doubt that the carbonaceous substance so abundant in these organs was 
introduced from without. In truth we have now a large amount of evidence in 
proof that it must have been so. In the twenty-first volume of the Medico-Chirur- 
gical Transactions, Dr. Wilham Thomson has recorded the results of extensive 
inquiry into the subject. Thus he gives ten examples of black sputa going along 
with pulmonary symptoms during hfe, and of black infikration of the lungs disco- 
vered after death ; and of the ten persons who were the subjects of these observations, 
nine had been engaged in working coal-mines, and the tenth was a moulder at the. 



SPURIOUS MELANOSIS. 



655 



Carron iron-works. He gives also six cases of black infiltration of the lungs, all 
occurring in persons exposed to the inhalation of carbonaceous matters (one of them 
was an engineer, and the others were all colliers); but in these six cases there had 
been no black expectoration noticed during life. 

That such carbonaceous particles, floating in the atmosphere, may be, and must 
be, and actually are, drawn into the lungs during inspiration, no one who has been 
long in this smoky town can doubt. Many persons remark that they expectorate 
during winter, and while in London, a little mass or two of dark gray, dirty mucus, 
every morning; but when in the country, in the summer, the mucus so spat up is 
transparent and clean. So I have noticed, and pointed out to some of you, that the 
crachoirs of the patients in the hospital often bear witness that there has been during 
the previous twelve hours, one of our dense and dirty fogs, which come with an 
easterly wind and bring with them a vast quantity of blacks, and soot, and smoke. 
Immediately after the prevalence of one of these fikhy blankets of vapour, we find 
the contents of each of the little vessels given to the patients whose expectoration is 
kept for inspection, to be deeply tinged with black. And I had, in the year 1832, a 
patient whose sputa were remarkably loaded with dark matter. He came into the 
hospital complaining of cough, and shortness of breath, and a sensation at the lower 
part of the right side of the chest, as if it were pierced by needles ; and he was spit- 
ting a considerable quantity of thick mucus, which was almost black. This colour 
never entirely left the expectoration while he remained in the hospital; but it very 
greatly diminished in proportion as his ailments were relieved. Now this man was 
a stoker at one of the gas-works. And he attributed his illness, which had come on 
gradually, to the great alternations of heat and cold to which his occupation exposed 
him : and the blackness of the sputa he ascribed to the continual inhalation of coal- 
dust. And no doubt he was right. 

It may seem strange, if the inhalation of atmospheric air loaded with minute par- 
ticles of coal or other carbonaceous matter be sufficient to produce this remarkable 
condition of the lungs, and the characteristic black spit, that the change, and its 
nature and cause, should not have been earlier made out ; considering the vast 
number of men who are employed in our mines and collieries, it appears, however, 
that a great repugnance has existed, and probably still exists, among the labourers 
in the coal-mines, to allowing their dead to be opened and examined. And it ap- 
pears also that the pecuhar state of the lungs which I have been speaking of is pro- 
duced in a comparatively small number of those who are so employed. The precise 
cause, why some are thus affected, and some are not, is yet to be discovered. Dr. 
Thomson has circulated among medical men residing in the coal-districts, a hst of 
queries (which he gives in his paper), respecting various points of interest in relation \ 
to this pulmonary condition : and we may expect to obtain, by degrees, more exact 
information about it. I recommend it as an interesting subject of inquiry to such 
among you as may have opportunities of prosecuting it. Jt has been conjectured 
that the specific change taks-s place, in a marked degree, only in lungs that were 
previously unsound. It is a question whether the cavities met with in the pulmonary 
substance, in the fatal cases, were the result of spurious melanosis ; or of the explo- 
sion of tubercular matter which had co-existed with the melanotic state. It is a 
. curious circumstance that the black spit, as it is called in those districts, sometimes 
1 does not make its appea#ance until some time after the labour in the coal-mines was 
j given up. Certainly this is a complaint that ofTers several interesting points of re- 
I search, and requires further investigation. 

j You will remark that the spurious melanosis is distinguished from the true, by its 
I occurrence in those persons only who are somehow exposed for a certain length of 
j time to breathe an atmosphere which is largely encumbered with carbonaceous par- 
I tides; whereas true melanosis may occur in any locahty. The spurious discolora- 
i tion never affects any other organs than the lungs and bronchial glands ; the true 
i black deposit of melanosis is never confined to a single organ or tissue. Moreover, the 
' one disorder is absolutely beyond remedy ; the other, as soon as its presence is ren- 
dered probable, by the black expectoration, and the pulmonary distress, may be 
mitigated, checked, perhaps gradually cured, by removing the patient from the ope 



1 



4 



656 



INTRUSION OF SOLIDS 



ration of the exciting cause, and pursuing such other measures as the symptoms maj'' 
seem to require. The distinction is not a matter therefore of mere curiosity : it bears 
upon the treatment to be followed, which is our proper business. It is connected 
also with medical police or hygiene, which we should all of us cultivate as exten- 
sively as we may : as a science intimately related to our strictly professional pursuits, 
and to the welfare of the community. 

Other forms of disease, unquestionably cancerous, occasionally infest the lungs. 
Their chief symptoms, when the malady does not reach the surface of the body, 
result from the pressure which the carcinomatous masses exercise on the parts in their 
neighbourhood. I shall postpone a more particular consideration of these effects of 
intra-thoracic pressure, until I come to aneurismal tumours, which have a similar 
mechanical influence. 

There is yet another affection of the breath-machine, to which I must briefly direct 
your attention : a casualty that is apt to befal the air-tubes, I said nothing of this, 
indeed, last year ; but having since witnessed an example of the accident to which I 
allude — the entrance, namely, of some solid substance into the windpipe — I have 
thus been reminded of my former omission, and taught at the same time the neces- 
sity that every medical man should have well considered such cases. I was taken 
to Elentish Town, in the autumn (1837), by a professional friend, to see a child, into 
whose trachea a smaU nail, what is commonly called a tack, was thought to have 
passed. When 1 saw the boy, he seemed to have nothing the matter with him : but 
he had been subject, ever since the accident, to paroxysms of most violent choking 
cough; alarming the parents and his attendants for his life. There was good reason 
for concluding that the nail, which was missing, and which he said he had swal- 
lowed., had really got into the windpipe, and was still there, or in the lungs ; and the 
question was much discussed, what ought to be done in such a case? The resuh 
was, that nothing was done : but that, after the lapse of several weeks, the nail was at 
length coughed up. 

Now there are some interesting points arising out of this sort of mischance. The 
instance I have just referred to will probably be published ; and therefore I dwell 
upon it the less. Dr. Stokes has devoted a short chapter to the consideration of 
foreign bodies in the air-passages : and examples of that accident are more common 
than you might suppose. 

It is, at first sight, a surprising circumstance, that a solid body of any considerable 
magnitude (a molar tooth for instance), should be able to pass at all through the nar- 
row chink of the glottis. But, supposing the chink to be plugged by the sudden 
entrance of a passing substance, just at the commencement of a forcible endeavour 
to inspire, when, of course, the opening is at the widest, that substance must neces- 
sarily sustain, as the chest expands, a strong degree of pressure from the external 
atmosphere : strong enough, often, to force it through. If you cork a bottle that con- 
tains air only, and sink it sufficiently deep in the sea, the pressure of the water will 
push the cork into the bottle. The condition of the lungs, in the case supposed, and 
the condition of the bottle, are analogous. A vacuum beyond the plug is attempted 
by the act of inspiring, and obviated by the displacement of the plug, inwards. 
There are no such powerful forces called into action to driv^ the intruding substance 
out again. 

The matters which have been actually thus caught in the rima glottidis, and 
forced through, are, as you might almost expect, oddly various in kind. Morsels of 
food : the stones of fruit ; of these there are many instances : teeth ; three such are 
referred to by Dr. Stokes : portions of bone : pebbles : a piece of money : a nut : a 
nut-shell: a button: a musket ball: a large shot: a fragment of nutmeg: iron 
nails : kidney beans : ears of grass or corn ; of these, four examples at least have 
been noticed : one is mentioned by Dr. Stokes, two are recorded in the Gazette 
Medicate, and I show you a monument of the fourth, in this interesting preparation, 
for the history of which I am indebted to Mr. Mayo. The young son of an English 
nobleman v/as riding in a carriage, in or near Paris, and had an ear of rye in his 



INTO THE AIR-PASSAGES. 



^57 



mouth. The carriage made a sudden jolt, and the ear of rye disappeared. Little 
was thought about this at the time : but soon afterwards symptoms of pulmonary 
irritation set in, attended with hectic fever, and with the most foetid expectoration. 
The boy gradually sunk. The ear of rye lay, as you may perceive, in an abscess 
which was common to the right lung and to the hver, through the diaphragm. 

If any of you have tried the boyish trick of sHpping beneath your wristband an 
ear of bearded corn, you will have no difficulty in understanding how and why, 
with every movement of the parts in contact with it, the ear will travel onwards ; 
and how improbable it is that such a substance should ever be expelled from the 
lungs by coughing. Yet, in one of the cases, recorded in the Gazette Medicale^ by 
a physician whose sister was the subject of the accident, an ear of barley was so 
rejected, seven years after its entrance. During that long period she had suffered 
repeated attacks of copious haemoptysis. Her recovery was perfect. 

The very enumeration which I have just made may convince you that the acci- 
dent is not a very unfrequent one ; and it is more than probable that fatal cases hap- 
pen, the nature of which escapes detection. 

The results of the accident are various also. 

In the first place, it sometimes causes speedy death by apnoea. 

2dly. It may be followed by inflammation of the lung, and perhaps abscess ; and 
so destroy life. 

3dly. Death may ensue, after symptoms resembling those of chronic phthisis. 

4thly. The "foreign body," as we oddly enough call it, may be expelled through 
the glottis, after a variable period of time. Sometimes, yet not always, its expulsion 
is the condition and the harbinger of the patient's recovery ; but he is never safe 
while it remains. 

, Death may take place in a few seconds when the substance sticks in the glottis. 
Death has occurred within three days, when the substance had passed the glottis : 
and in eleven days when it had reached the lung. The intruding piece of matter 
has escaped, through the natural passages, after remaining imprisoned for seventeen 
years. In that case, the patient died, hectical and emaciated, a year and a half 
afterwards. 

It may be worth our while to consider these particulars somewhat more closely ; 
and to inquire what, in different cases, becomes of the foreign body which thus, to 
use a common phrase, " goes the wrong way ;" and what the symptoms are to 
which it gives rise. 

First, then, I say, it may get wedged in the slit of the glottis, and produce imme- 
diate suffocation. I mentioned, before, the frequency of this kind of death by mis- 
adventure. If you are summoned to any one whom you find comatose, or apparently 
just dead, and you learn that he had been suddenly attacked with choking during "a 
meal, lose no time in examining his pharynx and gullet. You may chance to save 
a life so. The accident often happens to persons who ar.e drunk. No doubt it hap- 
pens oftener than we are aware of. The attack is very Ukely to be mistaken for an* 
apoplectic seizure. 

In these cases of sudden choking, the morsel of food is not always caught in the 
rima glottidis. If it be large enough to stick fast in the pharynx^ it may provoke, 
through a reflex action, an abiding spasm of the httle laryngeal muscles, and so pro- 
duce death by apnoea. The remedy for such an emergency, as Dr. Marshall Hall 
truly observes, must be immediate : and this is what he tells us should be done. 

" Pressure being made on the abdomen, to prevent the descent of the diaphragm, 
a forcible blow should be made by the flat hand on the thorax. The effect of this is 
to induce an effort similar to that of expiration; the larynx being closed, cesophageal 
vomiting takes place, and the morsel is dislodged." 

" If this plan fail, not an instant being lost, the pressure should be kept up on the 
abdomen, the finger should be introduced into the throat, and the same smart and 
forcible blow made on the thorax as before. By the irritation of the fauces the 
cardia is opened, and by the blow on the thorax (firm pressure being made on the 
abdomen) an effort similar to that of expiration, with a closed larynx, is made, and a 
direct vomiting ensues, and the morsel of food is carried away." 
42 



658 



INTRUSION OF SOLIDS 



2dly. The substance, if small, may, after it has passed the chink, remain in the 
larynx: entangled in its ventricles, or between the chordse vocales. In that case 
it usually occasions very severe laryngeal symptoms — spasmodic gasping cough, 
choking sensations, croupy respiration, and pain in the larynx — symptoms which 
harass the patients without intermission, until death ensues, or until the substance is 
driven upwards into the pharynx, or passes downwards into the windpipe. There 
is, however, one instance on record, in which a piece of gold was lodged for years 
in the ventricles of the larynx, without these distressing consequences. 

odly. Having passed the upper part of the larynx, it may stop, and become fixed 
beneath the cricoid cartilage, or in the trachea. In these situations, imless it quite 
blocks up the passage, its presence may be productive of but little distress. A 
wheezing or croupy sound during one or both of the movements of respiration, and 
some degree of pain and tenderness of the part where the substance was lodged, 
have constituted all the evidence of its position in the air-passages, in more than one 
instance. A very singular and whimsical case of this kind, related by Professor 
Macnamara, is referred to by Dr. Stokes. A boy had made a whistle, by perforating 
a plum-stone, and extracting the kernel. This, during a strong inspiration, passed 
from between his lips, through the glottis, and became fixed transversely in the 
larynx. So little inconvenience did it create, that the boy, finding that he still 
whistled as he breathed, went about for some hours, pleased to display this new ac- 
complishment. For three days he continued to occupy himself in his childish 
amusements, suffering now and then a seizure of suffocating cough. He was then 
taken to the Meath Hospital. Fie had no pain in deglutition ; but he said when the 
cough was severe, it caused pain in his throat. He had also uneasiness in the epi- 
gastrium, a bloated countenance, and a frequent pulse. The chest sounded well on 
percussion, and the vesicular murmur was natural. The fits of coughing were fol- 
lowed by white frothy expectoration. Lar3^ngotomy was performed; but during the 
struggle and the convulsive cough which took place when the opening was made, 
the stone (so the patient declared) was coughed up, and swallowed. The symp- 
toms were reheved ; and the whisthng ceased. But it was found that, as the wound 
healed, the distress and the whistling sound returned ; which showed that the stone 
lay above the opening ; and that the disappearance of the symptoms had been owing, 
not to its dislodgment, but to the admission of air below the point where it was fixed. 
Soon after this, however, it changed its place, passed down into the right bronchus, 
and then up again towards the larynx. By a second operation it was extracted; 
and the lad recovered without any bad symptom. 

4thly. The substance may get i3eyond the trachea, into one of the bronchi, and stay 
there. And it is a very curious fact, and one which has evident importance in respect 
to diagnosis, that it is almost always the right bronchus which the substance enters. 
Dr. Stokes has explained why it is so. The septum that divides the extremity of 
the trachea into two branches, is not placed in the middle of the channel, but de- 
cidedly towards the left ; so that any solid body falling down through the windpipe, 
is naturally directed into the right bronchus. Perhaps tliis tendency is aided by the 
more vertical direction, and by the somewhat greater capacity of that tube, com- 
pared with its fellow. Now you will readily apprehend what sort of symptoms would 
be hkely to result from the impaction of a sohd body in either of the primary bronchi. 
It would be very apt to excite inflammation of the corresponding lung, which inflam- 
mation w^ould reveal itself by its proper signs; but it would produce peculiar aus- 
cultatory phenomena, prior to and independent of such inflammation. It would 
prevent, panially or altogether, the entrance of air into the lung of that side. Hence, 
when we have other reasons for thinking that a solid bod}^ has passed the glottis, 
if we find the vesicular murmur suspended or enfeebled in one lung, while percus- 
sion gives out its usual clear sound, we may conclude that the intruder is lodged in 
the bronchus belonging to that lung. 

Dr. Stokes believ'es, and his opinion is fortified by his own experience on the sub- 
ject, that smooth bodies (beans or shots, for example), are more calculated than such 
as are rugged and uneven to cause urgent distress when impacted in one of the 
bronchi ; inasmuch as they more completely plug and obstruct the tube, thereby 



INTO THE AIR-PASSAGES. 



659 



depriving the patient at once of the use of half his lungs. An irregular substance, 
which can neither seal the passage up, nor be closely grasped by its spasmodic con- 
traction, will probably occasion less dyspnosa, and at the same time will be less likely 
to be dislodged by the effort of expiration. Under these circamstances we look for 
more chronic symptoms. 

5thly, and lastly. The intruding substance may not be fixed anywhere, but may 
shift its place from time to time ; and this, in fact, is what most frequently happens : 
and when it does happen, it gives rise to a very striking and distinctive series of 
symptoms. Paroxysms of suffocating cough and extreme distress, when the sub- 
stance is driven up into or near the lar3mx; with intervals of comparative quiet, and 
sometimes indeed of apparent health, when it subsides into the trachea or bronchi. 
But during these intervals, the signs that sometimes mark its situation in those tubes 
may perhaps be discoverable. 

There are, then, a set of general symptoms, which lead us to beheve, or to suspect, 
that some solid body has entered the air-passages : and there are other sets of par- 
ticular symptoms, which inform us, with more or less certainly, whereabouts it is 
fixed, or that it is not fixed at all. A person, previously in good health, is seized 
with violent cough and choking dyspnoea, suddenly, during a meal, or while he had 
in his mouth some loose substance, which he fancies he has swallowed. This is a 
sufficient clue to the probable nature of the case : and we next inquire for a sense of 
soreness in the windpipe, and wheezing respiration ; for signs of bronchitis or of 
pneumonia, especially in the right lung ; for signs of obstruction of the bronchus on 
one side, and especially on the right side, or of alternations of suffocating cough, 
with intervals of outward calm. In the last case, we may expect to find the bronchus 
unstopped during the periods of laryngeal irritation ; and vice versa. 

When we know that a sohd body has been entrapped in the air-tubes, our business 
is plain ; there is no room, in my opinion, for hesitation ; we must let the substance 
out through an artificial wicket. There is danger, so long as it remains in these 
vital passages, of speedy suffocation ; of fatal damage to the larynx, or to the lungs ; 
of cerebral mischief during the violent paroxysms of coughing. Convulsions and 
apoplexy have, under such circumstances, actually occurred. Against these perils 
there is no security, except in the early performance of tracheotomy. If the in- 
cluded substance be loose and smooth it will presently be shot forth at the new 
orifice ; if it be fixed, or angular, it may generally be extricated by a skilful and 
dehcate hand. 



Even while this sheet has been passing under the press, (May, 1843,) another 
instance has occurred of the same accident, and excited a degree of anxious interest 
in the pubHc mind, scarcely less than is accorded to a royal illness. It befel a gen- 
tlem&n whose name was previously famous. Mr. Brunei, in amusing the children 
of a friend with some, tricks of legerdemain, put a half-sovereign into his mouth ; 
and the coin shpped, as from its size and shape it might easily do, through the chink 
of the glottis. It seems to have occasioned no very urgent distress. The patient 
was made aware, by some internal sensation, that it lay towards the right side. After 
more than three weeks had passed, the trachea was opened ; but the piece of money 
did not come forth. Probably its weight prevented its being driven up and down in 
the windpipe ; and its form, when it lay edgeways, did not oppose much impedi- 
ment to the breath. The same weight, however, brought it back to the larynx when- 
ever Mr. Brunei placed himself with his head downwards. In some of these 
experiments, coming crossways I suppose, it produced most violent cough, and feel- 
ings of impending suffocation : but in a final and happier trial, at the end of six 
weeks, it dropped out again, through the natural passage — ^just as a coin may some- 
times, by good luck, be shaken out of a box through a slit in its hd. 



660 



DISEASES OF THE HEART. 



LECTURE LIX. 

Diseases of the Heart : usually 'partial. Changes in its Muscular Texture. Me' 
chanism of those changes. Natural Dimensions of the Heart. Natural 
Sounds. Modifications of these by Disease. Review of the Physical and 
General Signs that accompany Cardiac Disease. 

You will perhaps accuse me, gentlemen, of a disposition to magnify the import- 
ance of every new class of diseases at which we arrive, in our survey of the morbid 
conditions of the various parts of the body in succession. There are few complaints, 
in truth, which are not important ; either from the discomfort to which they give 
rise, or from their tendency to abbreviate the span of human existence. Yet of the 
strictly vital organs the derangements are necessarily the most perilous ; and there- 
fore, to us, the most interesting. Two props of the tripod of hfe we have passed in 
review, and seen how they may be weakened, and how they may fail altogether. 
The office of the heart is not less essential to life and health, than that of the brain, 
or of the lungs. The well-being of every portion of the frame depends upon its 
being duly supplied with arterial blood, and duly relieved of that which has become 
venous: and this supply and relief require that the central organ of the circulation 
should be sound in its structure, and perfect in its working. But it is frequently 
otherwise. I can remember, indeed, the time when disease of the heart was thought 
to be a very rare thing ; but it is now well knoAvn to be one of the commonest of 
disorders, and it connects itself with a variety of other affections, with which it was 
formerly supposed to have no relation. 

Like other organs that are complex of structure and formed of different tissues, the 
heart is subject to partial disease. Its lining membrane alone may, in the first in- 
stance, become the seat of inflammation, with its various effects ; or its investing 
membrane only may undergo morbid alterations ; or the muscular substance that 
constitutes the organ itself may be gradually changed in its qualities, in its bulk, or 
in its proportions. 

But the morbid conditions of the investing and lining membranes do not always, 
or immediately, cDmpromj!f:e the life of the patient. They are final at length, in 
ninety-nine cases out of a hundred, through the alterations to which they lead in the 
muscle wherewith they are connected. It may be practically useful therefore to 
consider, first, these ultimate morbid states which are incompatible n'ith the con- 
tinuance of life ; and then to trace them back to the next hnk in the chain of their 
causes, which will be found, in a very great number of instances, to consist in some 
antecedent morbid state of the exterior or of the interior membrane. 

The heart, you know, is a hving forcing-pump ; a hollow muscular engine; Avith 
its chambers and their outlets, its contractile walls and their strength and thickness, 
so admirably adjusted, that the healthy balance of the circulation is continually main- 
tained, under many varying outward influences and inward emotions which tend to 
destroy it. In treating of disease of the heart we have to consider, therefore, the 
modes in which its mechanism may be spoiled or deranged : and the effects of such 
derangements. 

Not only the component tissues, but different portions also of the organ, may be 
separately diseased. It seldom happens, indeed, that the whole heart is affected : 
although that is probably the vulgar behef. The left side is much more obnoxious 
to morbid changes than the right": and when both sides are implicated, the altera- 
tion is almost always more decided and conspicuous in the left than in the right 
chambers. 

In the rapid sketch which I attempted of general pathology, in the outset of the 
course, I pointed out the various kinds of alteration to which the tissues and organs 
of the body, and therefore the heart among the rest, are subject. One or more of 
the chambers of the heart, you will remember, may become larger or smaller than 
is natural ; or have their walls increased or diminished in thickness, and consequently 



DISEASES OF THE HEART. 



661 



in power ; or one or more of its outlets and orifices of communication may be widened 
or contracted : and the purposes and function of the organ will be more or less im- 
paired by these changes. 

In order, then, to have a clear conception of cardiac disease, it is necessary to 
analyze it, and to investigate the derangements of the several parts of the heart. 
And I begin with hypertrophy ; augmentation of bulk in its muscular substance. 
And I must first of all define one or two phrases which are current among patholo- 
gists in respect to this condition. 

The muscular tissue of one, or more, of the chambers of the heart may become 
thicker and stronger than natural, while the capacity of that chamber, or of those 
chambers, remains unaltered. The hypertrophy in that case is said to be simple. 

But, while the muscular parietes are thickened, the corresponding chamber may 
become unnaturally large. This constitutes the active aneurism of the heart of 
Corvisart, the eccentric hypertrophy of more modern writers. 

On the other hand, it has been supposed that the capacity of a cavity of the heart 
may diminish in size as its walls increase in thickness : that the hypertrophy may 
take place at the expense (as it were) of the chamber. This has been called con- 
centric hypertrophy. 

Now of these three reputed forms of hypertrophy, considered in their relation to 
disease, two only, the simple and the eccentric, have any real existence. The third, 
or concentric form, never occurs, I believe, except as a congenital malformation. 
And of the two genuine species of hypertroph3% the eccentric, which is plainly a 
compound affection, consisting of hypertrophy ivith dilatation, is much the most 
comm.on. The reason of this is to be found in the physical cause of the morbid 
condition, in most instances. The physical cause, in nineteen cases out of twenty, 
is some obstacle, mechanical or virtual, to the perfect accomplishment of the func- 
tion of the chamber ; some obstruction opposed to the free and thorough exit of the 
blood from it ; or something which hinders the easy play of the organ : hence, in 
the first place, a gradual yielding, or tendency to yield, in the sides of the affected 
chamber, from the continual and unwonted pressure of the accumulated blood against 
them, and in the second place, a striving action of the muscle to overcome the 
hindrance, or to counterbalance the obstacle ; and consequently, according to the 
law formerly announced, an augmentation in the bulk of the muscle whereof the- 
function is thus increased. If the hypertrophy, which is the result of a truly con- 
servative process, keeps pace exactly with the amount of the obstacle and exactly 
balances it, no dilatation happens, or next to none. But this is c. mparatively seldom 
the case. According to the principles of mechanics, a httle distension of the sphe- 
roidal cavity must require an increase of force to propel from it a given quantity 
of blood, in the same time, through a given discharging orifice. So that incipient 
dilatation becomes (in addition to the supposed obstacle) an efficient cause of hyper- 
trophy : and the two, the dilatation and the hypertrophy, commonly make progress 
together. 

Cruveilhier appears to have been the first to reject concentric hypertrophy from 
the catalogue of cardiac diseases. The smallness of its cavity, with a proportional 
increased thickness of its wahs, was regarded by him as a transient condition of the 
ventricle, depending upon the mode of death. He found these phenomena very 
strongly marked in the hearts of all those whose bodies he had examined after de- 
capitation by the guillotine; "Les parois ventriculaires se touchaient dans tons 
leurs points." It is therefore his opinion that the hearts which had been thought 
by others, to present examples of concentric hypertrophy, were in reality " hearts 
more or less hypertrophied, which death had surprised in all their energy of con- 
tractility." 

This question has since been considered by Dr. Budd, in a communication to the 
Medical and Chiruraical Society, which you may read in the twenty-first volume of 
its Transactions. He has lately favoured me with a statement of his matured views 
upon the subject. 

The semblance of concentric hypertrophy is most common in the left ventricle ; 
and depends upon the ventricle being nearly empty at the time of death, and upon 

3f 



662 



DISEASES OF THE HEART. 



the corpse being examined while the heart is contracted by the rigor mortis. The 
fallacious appearance is accordingly noticed in cases where, from the manner of 
death, the left ventricle, or the entire heart, contains but Httle blood, and where, from 
the muscular power not having been previously exhausted, the rigor mortis is of long 
duration. 

"In all these concentrically hypertrophied hearts (writes Dr. Budd) the ventricle 
may be readily dilated by means of the fingers, and always dilates of itself when the 
rigor mortis goes off." 

" Tn the published cases of concentric hypertrophy, in which, there was no disease 
of the valves ([ have given eight such cases in my paper, and could now add a long 
list to them) there were no signs, or only very slight signs, of disease of the heart, 
during the hfetime of the patient. This circumstance is sufficient proof that the 
cavities of the heart in these cases could not have been during life permanently in 
the contracted state in which they were found after death. A left ventricle that 
could scarcely contain an almond (a common form of expression in the description 
of these cases) would surely have caused a great impediment to the circulation." 

Moreover, concentric hypertrophy could answer no mechanical purpose ; nor 
could its formation be accounted for on mechanical principles. But " concentric 
hypertrophy of a ventricle, in a high degree, with obstruction at its discharging 
orifice, and an extraordinary channel for the passage of the blood, occasionally 
exists as a congenital malformation ; and, in most cases, the right is the ventricle so 
affected." 

To resume. Recollect that tbere may be two distinct kinds of physical cause of 
excessive action of the heart, and therefore of hypertrophy. In the one kind, there 
is some mechanical obstruction to the exit of the blood from one or more of the cavi- 
ties ; a constricted state of the orifices is the most common condition. In the other 
kind, without any such mechanical bar or dam to the fluid, there is something to 
hinder the free and sufficient play of the organ ; an adhering pericardium, it may 
be, or mal-position pf the heart. If the heart be pushed, for instance, out of its pro- 
per place and posture by effusion into the pleura, or by distortion of the chest, it will 
not work with the same ease as when all is perfect and symmetrica] ; and the unu- 
sual labour imposed upon it fully to execute its office, will lead to hypertrophy. 
The causes of hypertrophy may therefore be situated within the heart itself, or with' 
out and beyond it ; but in all those cases in which the effect of the hindrance or 
obstacle is to detain the blood in one or more chambers, the hypertrophy will be 
likely to be accompanied by dilatation: and, generally speaking, the hypertrophy 
and dilatation result from disease in some part which lies beyond the affected cham- 
ber, in the order of the circulation. Thus, either a narrowing or a dilatation of the 
aorta at its commencement, will tend to cause hypertrophy and dilatation of the left 
ventricle. 

That contraction of the aorta, or of the aortic orifice, may have this consequence, 
you will have no difficulty in perceiving. The blood cannot so readily pass through 
the narrowed channel ; hence it will tend to accumulate in undue quantity in the 
ventricle, therefore to stretch and dilate it ; and the increased muscular efforts neces- 
sary to drive the delayed blood onwards, tend also to thicken the muscle itself. But 
it may not be so obvious that dilatation of the mouth of the aorta — a wider channel 
of egress — would also virtually prove an obstacle to the emptying of the ventricle. Yet 
it certainly would, in two ways. In the first place, dilatation of the entrance of the 
aorta implies a diminution in the elasticity of that vessel ; and the blood, after it has 
left the heart, is urged onwards by the healthy elasticity. But, again, dilatation of 
the mouth of the aorta commonly implies an imperfect closure of that vessel by the 
sigmoid valves ; so that, during the diastole, a part of the blood is apt to regurgitate 
from the aorta, and to keep the ventricle morbidly full. You see, therefore, that a 
deviation from the healthy state of the aorta, and of the valvular apparatus which 
lies at its mouth, may obstruct the course of the blood, and lead to hypertroph}^ and 
dilatation, whether the deviation be in the one way or in the other; whether, I mean, 
the natural size of the vessel be increased or diminished. Again, disease of the 
n/itral valve, obstructing the flow of the blood at that point, will lead to an accumu- 



HYPERTROPHY. 



663 



lation in the left auricle, in the pulmonary veins, and in the lungs them- 
selves. The auricular action is always less regular and energetic than the ven- 
tricular, so that we less frequently meet with hypertrophy of the auricles ; but very 
often with dilatation. And if we go to the-other side of the heart, we find hyper- 
trophy with dilatation, and more especially dilatation of the right ventricle, when, 
from some reason or other, the blood passes with difficulty towards or through the 
lungs: either from disease of the pulmonary artery, or from disease in the substance 
of the lungs — emphysema, for instance : and if the difficulty be great, the accumu- 
lation and distension will affect successively the right auricle, and the venas cavse ; 
and then we have, in most cases, general dropsy. So that, I repeat, disease in the 
heart tends to propagate itself in a direction contrary to that of the circulation. Fur- 
thermore, if the muscular tissue of the heart be pale, flabby, soft, and weak — as it 
frequently is in feeble, ill-nourished, cachectic persons — it will the more readily yield 
to the centrifugal pressure of the blood it embraces. In this way we may have dila- 
tation without any hypertrophy. I am anxious that you should in the outset com- 
prehend the mechanism by which the natural dimensions and relative proportions 
of difTerent parts of the heart may be altered in disease. 

One reason why disease of the heart used formerly to be overlooked, was that 
these natural dimensions and relative proportions were not ascertained or much 
attended to. It is not easy to form any very precise eslitnate of the size of a healthy 
heart. It is commonly held that if the heart be about the same size with the closed 
fist of the subject, its general dimensions maybe considered as being natural. Bouil- 
laud, who has taken much pains with this matter, weighing and measuring a great 
number of different hearts, states that the mean weight of that organ, with the ori- 
gins of its large vessels, and empty of blood, in adults from twenty-five to sixty years 
old, is from eight to nine ounces ; that in subjects from sixteen to twenty-five years 
old, it may be one or two ounces less ; and that, in very large and robust persons, it 
may rise to ten or eleven ounces. Also, what we should expect, that the weight is 
less in women than in men. 

So much for the general bulk of the heart. And we must have some standard 
whereby to estimate its relative proportions. Every one knows that the walls of the 
left ventricle are thicker than those of the right. Bouillaud found that the mean 
thickness of the walls of the left ventricle at its base was seven lines, while that of 
the right ventricle was two and a half lines. And taking the thickness generally, 
he says that the thickness of the parietes of the right ventricle has not a greater ratio 
to that of the parietes of the left, than two to five, or even than one to three. 

So again of the auricles; he lays it down that the mean thickness of the walls of 
the left auricle is, to the mean thickness of those of the right, as three to two. 

He holds, also, that the mean capacity of the right ventricle exceeds, by a little, 
that of the left ; and that the right auricle is larger than the left. You must always 
make allowance, in actual cases, for the possible distension of these cavities with 
blood, beyond the size to which they would have contracted if they had contained no 
blood. 

I may add, that the same author declares the rule I just no^v mentioned, which had 
been proposed before his researches were instituted — the rule, viz., which makes the 
bulk of the healthy heart equal to the fist of the subject — to be tolerably correct. 
By keeping in mind these general facts, you will be better able to appreciate the 
appearances presented by the heart when it is taken from the body to be examined ; 
but you will recollect that they relate to averages only. 

Now, having pointed out the modes in which the natural proportions of the heart 
and of its several parts may be morbidly altered ; and given you a rough standard 
which may enable you to estimate these proportions in the state of health, and the 
deviations from them in the state of disease ; I will go on to consider the symptoms 
by which the altered conditions are accustomed to declare themselves. And it is 
with respect to the heart, as with respect to the lungs ; there are general symptoms 
or signs, and there are physical symptoms or signs : and the information derived from 
these sources respectively is of variable utility. Neither of them can be safely ne- 
glected ; and it is often found that the indications derived from one of these, sets of 



664 



DISEASES OF THE HEART. 



symptoms are confirmed or corrected hy those collected from the other. I believe it 
will be best to pursue the same course in both cases, and to speak, in the first place, 
of the signs that are brought within our notice by the sense of hearing. 

But, in order that we may comprehend the morbid sounds of the heart, we must 
first make ourselves acquainted wiih those that belong to its healthy condition. 

The heart may be heard by the ear laid flat against the precordial region, or 
through a stethoscope, to beat over a certain space. That space, in ordinary cir- 
cumstances, corresponds to the inferior half of the sternum, and to the cartilages 
of the ribs, from the fourth to the seventh, on the left side. The apex of the organ 
may often be seen to pulsate between the cartilages of the fifth and sixth left ribs; 
about two inches below the nipple, and one inch from it towards the sternum. 

This is the space over which, in the sound state of the heart and lungs, the pulsa- 
tions of the former are plainly audible. But there are several diseased conditions 
both of the heart itself, and of the parts around it, which interfere with this rule. 

In the first place, if the heart be larger than natural, it \v\\\ be heard to beat over 
a proportionally larger space. In this way it may come to be heard all over the 
chest in front ; and behind on the left side of the spine ; and even, in extreme cases, 
on the right side of the spine. 

Again, the extent of space over which the heart may be heard to beat will be in- 
creased in proportion to the thinness of its walls; and diminished, caeteris paribus^ 
according to the thickness of its walls. So that when the heart is nearly its proper 
size, if its walls be thin, it will be heard beyond its natural limits ; and if its wails 
be morbidly thick, i. e., if it be affected with considerable h3'pertrophy, it will not 
be heard beyond, nor even to the extent of its natural limits. I will endeavour, pre- 
sently, to explain the reason of these differences. 

Again, and this it is of great importance to remember, the heart may be heard far 
beyond its natural limits, even when it is perfectly healthy, in consequence of the 
lung between the ear and the heart having become solid, and therefore a better con- 
ductor of sound : and the solidification may have resulted from hepatization, or from 
the presence , of a number of crude tubercles. The sound of the heart's action will 
also be conveyed to a distance by the liquid effusion in pleurisy. If we are not 
aware of these circumstances, we are continually liable to fall into mistakes. 

The heart is Hkewise heard more distinctly, and over a space which is compara- 
tively larger, in children than in adult persons ; and I need scarcely say that it may 
be heard over a wider extent of the chest Avhenever its action is augmented by exer- 
cise, by emotion of mind, or by febrile excitement. 

The impulse of the heart is another point w^hich you must attend to. In healthy 
persons who are thin, you may generally feel the stroke which the heart gives to 
the ribs, by placing your hand on the prtecordial region. In persons who are fat, 
you often cannot feel the heart at all in this manner. For obvious reasons, it is felt 
more distinctly, over a larger space, and higher up, while the person is stooping for- 
wards, or makes a forced expiration ; less distinctly, over a snrialler space, and lower 
dow^n, when he makes a deep inspiration, or is lying on his back. In proportion as 
the heart is enlarged by disease, it can be felt more extensively : and when there is 
hypertrophy, the force with which it strikes the parietes of the chest is sometimes 
extraordinary, and very instructive. You will see the ear and head of the listener 
distinctly fifted at every pulsation ; sometimes the whole of the patient's body, nay 
his very bed, is shaken b}'- the strong shock of the heart during its systole. There 
is no sign of hypertrophy so sure as that afforded by the heart's impulse. You feel, 
not a sma;{t, quick, and sudden knock, but a steady, heaving, irrepressible swell, 
which is perfectly characteristic. You may always infer increased thickness of the 
walls of the organ, when you meet with this regular heaving motion ; and the extent 
to which the whole heart is enlarged in such cases may be conjectured by the extent 
of space over w^hich the heaving impulse is perceptible. 

The sounds which we hear are two. One of them coincides, in point of time, 
with the impulse ; and barely precedes the beat of the radial artery. It happens, 
therefore, when the ventricles contract; during the systole. It is called, accord, 
ingly, the systolic sound, or the first sound of the heart. The other of the two 



NATURAL SOUNDS. 



665 



sounds coincides with the diastole, and is spoken of as the second or the diasioUc 
sound. It takes place at the instant when the heart reverts to that place and condi- 
tion in which it had been prior to the systolic movement. These two sounds occur 
m quick and regular succession, and then follows an interval of silence, after which 
the two sounds are repeated ; and so on. 

The two sounds are not, however, exactly ahke. They differ somewhat, both in 
quality and in duration. The first is a dulf, prolonged noise ; the second a shorter 
and smarter sound, having more of a clacking or flapping character. Attempts have 
been made to assign the respective duration of each sound, and of the period of re- 
pose. I confess that 1 have never succeeded in measuring them satisfactorily in my 
mind. Probably Dr. C. J. B. Williams' estimate is as near the mark as any. He 
divides the whole period, from the beginning of one pulsation to the beginning of the 
next, into five equal parts : and allots two of these to the first sound, one to the 
second, and the remaining two to the interval of silence. This order of succession 
is called the rhythm of the heart : and it may be perverted. 

Respecting the physical causes of these natural sounds, there have been much 
recent discussion and research. Our time, however, will permit me to do little more 
than tell you what \ believe to be the facts of the matter. And I take, first, the 
disastolic sound, as being the simpler of the two. It used to be ascribed to the 
contraction of the auricles : but that was quite a mistake. The contraction of the 
auricles, such as it is, happens immediately before each systole of the ventricles ; 
whereas the sound in question occurs immediately after it, and is succeeded by the 
period of silence. This we know from the visible movements of the organ when 
exposed in a living animal, in truth, the auricular contractions are very feeble, 
and not attended with any appreciable noise. I have no doubt that the second sound 
is produced mainly, if not altogether, by the sudden shutting of the floodgates placed 
at the mouths of the two great outlets of the heart. The recoihng blood forces back 
the semilunar valves of the aorta and of the pulmonarjr artery, as one unfurls an 
umbrella: and with an audible check as they tighten. There is no other tenable 
mode of accounting for the sound. Experimenters have contrived, by hooks and 
wires, to prevent these valves from unfolding; and then the flapping sound has been, 
converted into a hiss. Disease of the same valves demonstrates the same things ; 
as we shall presently see. Nevertheless, it is both possible and probable that the 
relapse of the whole organ to its former place may contribute an ingredient towards 
this second sound. 

The first, or systohc sound, is more complex. Partly it is owing, as I believe, to 
a similar cause with that which occasions the diastolic sound, viz., the abrupt closure 
of the orifices of communication between the auricles and ventricles, by the reflux 
of the blood against the ventricular surfaces of the tricuspid and mitral valves ; 
partly, sometimes, to the blow of the heart's apex against the ribs ; chiefly, however, 
it consists of the sound that results from the muscular contraction of the ventricles. 
The systolic sound commences with the tightening of the walls of the ventricles, 
including the valves ; and it is prolonged by the muscular noise. You are aware, 
I dare say, that the vigorous contraction of a large muscle is accompanied by audi- 
ble sound. If, during the stillness of night, when lying in bed, with your cheek 
and ear upon the pillow, you set your teeth firmly, you will hear a continuous dull 
rumbling, like the noise of carriage-wheels in the street, and evidently caused by 
the action of the masseter and the temporal muscles. Dr. Williams states that, 
with the help of a flexible stethoscope, one may hear the voluntary jerking con- 
traction of his own abdominal muscles ; the sound being as loud as that of the heart's 
sj^stole, and very hke it in character. That the systolic sound is essentially due to 
muscular contraction is proved by the fact, that when a heart is taken from the 
living thorax and placed upon a table, its contractions (which persist for awhile) are 
still attended with a noise similar to the natural first sound, though weaker. Here 
there is neither collision of the blood, nor valvular reaction, nor impulse against the 
ribs, to render the experiment ambiguous. 

If you acknowledge and comprehend this source of sound, you will understand 
without difficulty why the heart, ceteris paribus, is heard more clearly and exten- 

3f2 



666 DISEASES OF THE HEART. 

sively when its walls are thin, less widely and loudly when they are thick. " The 
transition (says Dr. Wilhams) of a thick muscle from slack to tight can never be so 
complete and sudden as that of a thin one. Where there are many fibres they 
choke and muffle each other's vibrations ; hence the sound is dull and prolonged, 
rather than loud and clear. If we observe the different sounds produced on tight- 
ening thin silk and thick baize or cloth, we find that the thinness of the silk gives a 
unity and briefness to the impulse which it receives, and the sound is short and loud; 
whilst in the baize the impulse is divided and prolonged in the complexity of the 
fibres, and the sound is dull and less brief : so, under similar circumstances, a thin 
ventricle will give a louder, sharper sound than a thick one." 

The natural sounds which I have been describing are liable to be changed, or 
modified, by disease. Some of the modifications, indeed, I have adverted to as I 
went along. But others, of a more striking and extraordinary character, are yet to 
be explained. Either sound, or both, may be accompanied by a noise, which, in its 
commonest type, very closely resembles that produced by the blowing of a pair of 
bellows. Four persons out of five, I should think, if they were asked what this 
sound resembled, when they heard it accompanying each systolic movement of the 
heart, would say that it was exactly like the repeated blowing of bellows in an 
adjoining room. It is called, accordingly, by the French, the ''bruit de soufflet ;" 
and, in homely English, a belloivs sound. This is the generic sound. It may be 
divided into species ; but it is scarcely worth while so to divide it. We are only 
likely to confuse our notions by over-refinement. So I y/iW only add, that, when 
this bellows sound is very harsh or rough, persons will tell you that it is more like 
the noise of a rasp, or a file, or a saw : but all the while it is some kind of bellows 
sound. These sounds are often denominated mimnnrs also. 

Now what is the cause of this singular deviation from the natural noises made by 
the successive contractions and relaxations of this hollow muscle, the heart ? The 
whole matter may, I believe, be briefly thus expressed. The blowing sound may be 
occasioned by any change which alters the due proportion between the chambers of 
the heart, and their orifices of communication with each other, and with the blood- 
vessels that respectively enter or leave them ; it may also be occasioned by a preter- 
natural velocity in the passage of the blood through a healthy and well adjusted 
heart. Dr. EUiotson, I think it is, who has offered this apposite illustration of the 
phenomenon. If the arches of a bridge have a certain relation to the quantity of 
water in the river, and to the force of the current, the water passes through them 
quietly, and without any noise. Diminish the size of the arches, and the water 
begins to go through them with an audible rushing or roaring sound. The very 
same thing will happen if the arches remain unchanged in size, but the quantity of 
water in the river, and therefore its velocity and force, be augmented by heavy rains. 
So it is in the heart. If one of its orifices — say the aortic orifice — be narrowed, by 
disease of the valves, or in any other way, the blood will not, as before, glide through 
it smoothly and without noise, but will yield that sound which we call a bellows 
sound. So also, if the orifice retain its natural dimensions, but the capacity of the 
cavity from which the blood is driven be augmented. Nay, the same blowing sound 
may be produced though the cavities and orifices are all healthy, and duly propor- 
tioned to each other, if the velocity of the circulating blood be increased beyond a 
certain measure. If you bear this explanation in mind, it will be found applicable, I 
think, to almost every case in which there is a blowing sound accompanying the 
systole of the organ. If, at the same time, the valves over which the blood must pass 
be rigid, or rough, or even loose and vibrating, those circumstances may modify the 
blowing sound and render it louder, or hoarser than it would otherwise be, and justify 
the appellations of bruit de scie, and bruit de rape, with which you will find the 
French books, and many of our English also, full. 

But this explanation applies to a systolic blowing sound only. What are we to 
say when there is a similar sound attending the diastoHc movement of the heart? 
Why a diastolic bellows sound will mostly, if not always, be found to accompany 
and denote some organic disease affecting the valves of the heart. Thus, if the 
mitral valve be converted, as it often is, from a loose flapping valve into a bony and 



NATURAL SOUNDS. 



667 



rigid unvarying ciiink, the blood which passes through it from the auricle to the 
ventricle, during the diastole, may (though it seldom does) cause a rushing or blow- 
ing sound. On the other hand, the reflux of blood through the unshut mitral orifice, 
j during the ventricular contraction, may also be attended with an audible noise ; and 
f thus we have another and not unfrequent source of a systolic murmur. Again, if 
! the aortic valves are imperfect, as they often are, and do not effectually close that 
! vessel, blood will regurgitate through them during the diastole, and produce a bellows 
I sound. That this is the true explanation of the diastolic murmurs, I am convinced, 
both by the observation of disease, and by the results of experiments on animals. 
I In some of Dr. Hope's experiments, which he w^as good enough to allow me to wit- 
! ness, the short clack of the diastole was at first distinctly audible ; then hooks were 
J introduced, so as to prevent the perfect closure of the sigmoid valves during the 
J diastole, and then the short smart clack was converted into a prolonged bellows 
li murmur ; and upon letting them go again, the short smart clack recurred. The 
presence of a diastohc bellows sound has repeatedly enabled me to foretell some dis- 
ease of the sigmoid valves, interfering with their proper function — that of forbidding 
the re-entry of the blood into the ventricle from the aorta ; and what I have thus pre- 
dicted during life, has been verified by observation after death. 

i Such are the principal sounds, natural and morbid, which are audible to the 
naked ear, applied to the prsecordial region, or which may be heard through the 

! stethoscope. But we derive assistance, m respect to cardiac disease, from percus- 
sion also. It enables us to measure, in some cases, the bulk of the heart ; in others, 
to ascertain that the pericardium is distended by fluid. In the perfectly healthy 
state of the viscera of the thorax, the heart is somewhat overlapped by the thin edge 
of the lungs ; and the sound elicited by percussion over a part of the precordial 
region is intermediate between the hollow sound rendered by lung, and the fiat sound 
yielded by the solid heart. In the centre of the prsecordial region, where the heart 
is not covered by lung, the sound is decidedly dull. When, however, the heart is 
enlarged by disease, a larger part of its surface is exposed, and a larger portion of 
the prsecordial region yields a dull sound on percussion. And when the pericardium 

I is full of hquid, which distends and expands it, you will sometimes find that not less 
than a third part of the anterior and lateral portion of the left side is quite dull : and 
it«s interesting often to measure, by percussion, the diminution or extension of the 
limits of the dulness, as the amount of fluid decreases or augments. 

What I stated before, concerning the effect of different positions of the body upori 
the space over which the healthy beating of the heart may be heard, felt, and some- 
times seen, applies, mw/a^zs mutandis, io the natural dullness which it causes when 
the prsecordial region is percussed. This dullness comprehends a space of between 
one and two square inches, reckoning from the spot where the impulse is felt, toward 
the left edge of the sternum. The dullness should diminish or disappear, in the 
supine position, and when a full breath is drawn ; and increase in degree and extent 
upon a forced expiration, and when the posture is prone. 

There is another physical sign which is much dwek upon by Laennec, and which 
is sometimes very striking. In certain conditions of disease, the hand placed over 
the situation of the heart perceives a peculiar thrill or vibration accompanying its 
movements. The sensation conveyed to the hand is really very much like what 
Laennec compares it to, viz., that tremor which you feel, when coaxing the back of 
a cat while it is purring with pleasure. Accordingly he calls this sensation, " fre- 
missement cataire," the purring thrill. You feel this vibration often when there is 
present also a loud and strong bellows sound ; and Dr. Davis is of opinion, that the 
bruit de soufiiet, and the fremissement cataire, constitute, in fact, but one phenomenon, 
which is rendered evident to the touch by the vibrations communicated to the hand ; 
and to the ear by the vibrations communicated to it through the solid walls of the 
chest. I know, however, that the fremissement cataire does accompany other sounds, 
as well as the bellows sounds : sounds of which I have not yet had any occasion to 
speak, but which I shall make you acquainted with when we come to the subject of 
pericarditis. And I pass from this general account of the sounds belonging to th?5 



668 



PALPITATION. 



action of the heart, in health and in disease, to consider the other symptoms by which 
we judge that such disease is present. 

Among the general symptoms, then, of cardiac disease, some are direct — as pain ; 
palpitation or excessive action of the heart perceptible by the patient ; irregular or 
intermittent action, which the patient may or may not be conscious of : and some 
are indirect, declaring themselves through the medium of other parts and organs — 
such are dyspnoea ; cough ; dropsical accumulations ; hemorrhages ; various affec- 
tions of the nervous system, especially an increased and morbid sensibility, what 
is usually called nervousness : and some others, which I will cursorily notice as we 
proceed. 

I shall take this opportunity of considering, once for all, some of these symptoms ; 
whether they really proceed from organic disease of the heart or not : for the deter- 
mination of the question, whether they do or do not indicate such disease, is often of 
great moment, and is not always easy. 

We are not, in general, sensible of the beating of our hearts : but when the pulsa- 
tions become inordinately forcible, they make themselves felt, and the sensation is, 
in many cases, a most troublesome and distressing one. Palpitation implies increased 
force, or increased frequency — or an increase both in force and in frequency — of the 
contractions of the heart. Every one has experienced palpitation in his own person 
who has run himself out of breath. The pulsations are sometimes tumultuous also, 
and irregular, as well as unduly frequent and forcible ; but this is by no means al- 
ways or necessarily the case. There may be great palpitation with perfect regularity 
of the heart's action. The increased beating not only can be felt internally by the 
patient, but it may often be heard both by himself and by others. However, we do 
meet with persons whose hearts throb with excessive violence, without their being at 
all aware of it. Such cases are always, I believe, cases of disease ; whereas the 
palpitations that annoy and harass the patient are very often connected with functional 
disorder only. 

Irregular action of the heart consists in some derangement or discord of its rhythmi- 
cal movements, and is discovered by the condition of the arterial pulse — by unna- 
tural fluctuations in the strength, or in the number, of its beatings, or in both. Some- 
times a few rapid and feeble pulsations occur at uncertain intervals, and are followed 
by others that are fuller and slower. Sometimes one or more beats are left out, and 
the next beat, as if to make up for this pause, is unusually strong. The pulse tis 
then said to intermit. The intermissions may be unperceived by the patient him- 
self; but in general they are attended with a singularly disagreeable fluttering, or 
trembling sensation in the breast. The pulse may intermit though the heart does 
not : the ventricle may now and then contract so faintly as not to propel a wave of 
blood so far along the artery. Intermission implies irregularity ; but the action may 
be irregular and disorderly without intermitting. 

Now, any of these deviations from the natural rhythm and action of the heart alarm 
people very much, and impress them with a belief that they have some fixed disease 
of that organ ; and you will continually be appealed to for your opinion on this point, 
1 suppose there are few medical students who have not, at some time or other, ad- 
mitted into their minds the apprehension that they had disease of the heart ; an 
apprehension engendered by its occasional palpitation or irregularity. For though 
there may be palpitation without irregularity, yet it is practically convenient to con- 
sider the two together. 

These deviations certainly belong both to organic disease and to mere functional 
disorder of the heart ; but I repeat, that in a great number, nay, in a great majority, 
of the cases in which they so distress and alarm the patient as to lead him or her to 
complain of them, they are unconnected with any change of structure ; and this it 
is of much importance that you should be aware of. 

Palpitation of the heart, and intermission or irregularity of the pulse, are often 
dependent upon some disordered condition of the stomach, and will cease at once 
when that disorder is rectified. It is curious that this may happen although the gas- 
tric affection does not manifest itself by any other symptom : and it is curious, too, 
how slight a cause may suffice to produce the irregular action, A friend of mine. 



I VENOUS MURMORS. 669 

a barrister, used to be very anxious about himself, because a fluttering sensation fre- 
I' quently occurred at his heart ; an intermission of one or two beats, and then a vio- 

lent throb when the organ again resumed its play. This is a sensation very famihar 
Ii to myself, and probably most persons have occasionally experienced it. However, 
\ it happened so often to the gentleman I speak of, that it made him very unhappy. 
I He persuaded himself that he had disease of the heart, and that he should some day 
I suddenly drop down dead. But there was no other symptom of cardiac disease 
i| direct or indirect, general or physical. He was accordingly told that the interrais- 
' sion depended upon some fault in his digestive organs ; and he was advised to leave 
I ofi' different articles of food and drink in succession, in order to discover whether 
j any one thing in particular offended the stomach, and gave rise to the 'symptom. He 
I began by abstaining from tea, which he had been in the habit of drinking in consi- 
I derable quantity ; and thereupon the fluttering of the heart ceased. After a while 
I he took to tea again, and then the fluttering returned. He repeated the experiment 

many times, and always with the same result, till at length his mind was satisfied ; 
! and by renouncing tea altogether he got rid of his palpitation and of his apprehen- 
' sions. I mention this instance, because it came within my own cognizance ; but 

it is only a sample of many such, and tea is frequently found to be the disturbing 

i substance. 
I must caution you, however, against the mistake, which is often made, of infer- 
. ring that the heart is free from organic change because its irregular movements are 
j accompanied by dyspeptic symptoms. Structural disease of that organ is very apt 
! to derange the digestive functions. You will commonly find that patients who 
I labour under such disease are exceedingly liable to flatulence of the stomach ; and 
I free eructation of the gas which plagued them mitigates wonderfully the cardiac dis- 
( tress. It does so, no doubt, by relieving the diaphragm from that upward pressure 
I which embarrassed the motions of the heart. 

j We judge that palpitations and irregularities are merely symptomatic conse- 
quences of gastric disorder, when they occur occasionally only; when the rhythm 
' of the heart is perfect during the intervals ; and when we fail to discover any other 
! physical or general signs that its texture has undergone alteration. 

Besides these overstrong or irregular movements, which are symptomatic of dis- 
order of the stomach, and are remedied by correcting that disorder, there are pal- 
pitations of a purely nervous kind. I mean, that they depend upon a peculiar and 
highly sensitive condition of the nervous system ; which condition is itself dependent, 
in general, upon a particular state of the vascular system. Persons of a "movable" 
constitution, whether male or female, are subject to these palpitations : but especially 
young women ; and, of these, such as are pale, exsanguine, hysterical, in whom the 
menstrual functions are deficient, or excessive, or somehow unnatural. Ansemia, if 
not a constant, is certainly a frequent and most remarkable feature of this nervous 
I state. The blood is aqueous ; poor in fibrin, and in red particles. The age, and 
i frequently the sex, of the patient form leading points in the diagnosis. Nervous 
I palpitations are apt to come on when the patient is quite at rest : palpitations that 
result from organic disease are, on the contrary, always mitigated by repose. The 
occurrence of palpitations m the night, however, is but an equivocal circumstance, 
for nervous persons w^ho dream, awake often with palpitation ; and the recumbent 
posture generally excites or aggravates the palpitations that are organic. Neither, 
in forming our diagnosis, can we trust entirely to the presence or absence of physi- 
cal signs. The heaving impulse of hypertrophy is indeed wanting ; but, as I told 
I you formerly, the short abrupt knock of chlorotic palpitation is often attended with 
i a bellows sound. The weak and flabby muscle dilates (I fancy), and the natural 
I proportion between the chamber and its outlet is for a time destroyed. The sound 
1 may partly depend upon the thinness of the blood in such patients ; and this reminds 
I me of another diagnostic clue which you should be acquainted with. In nervous, 
I susceptible persons, especially if they exhibit the pallor of anaemia, very curious 
I noises are often audible, by means of the stethoscope, in the neck. Continuous rush- 
I ing or roaring sounds, very like those which, are to be heard in shells, and which 
poets feign, and the vulgar beheve, to be the noise of the distant sea. 



I 



670 ^40^ 



DISEASES OF THE HEART. 



Sliake one, and it awakens ; then apply 
Its polished lips to your attentive ear, 
And it remembers its august abodes. 
And murmurs as tlie ocean murmured there. 

Sometimes the sound is more like the hum of a gnat, or the sighing of the wind 
through a crevice. Dr. Hope very truly states that it may be imitated by a pro- 
longed whispering pronunciation of the syllable who. Bouillaud, from its resem- 
blance to the whizzing of a v/ell-known toy, calls it the " bruit de diable." He sup- 
posed this singular sound to reside in the arteries of the neck ; but it is quite distinct 
from the true arterial bellows murmur ; and it has been clearly shown (first by Dr. 
Ogier Ward, of Birmingham,) that it is produced by the descent of the attenuated 
blood through the great cervical veins. The sound, though continuous, has often a 
marked and regular increase, or swell, which keeps time with the heart's systole, 
and is believed to depend upon the pulsating pressure of the contiguous artery. It 
is best heard on the right side of the neck, just above the clavicle, and just behind 
the posterior edge of the sterno-mastoid muscle. You must take care not to pro- 
duce these sounds, as you easily may, by pressure with the stethoscope. So, also, 
you may suspend them at your pleasure, by pressing, above the stethoscope, upon 
the track of the veins, so as to stop the current of blood through them, without 
arresting the pulsation of the arteries. This proves that the murmurs are venous. 
I have no leisure to go more into particulars concerning these sounds ; but when you 
meet with them, concurring with cardiac palpitations, in a young, nervous, anemic 
subject, the palpitations, ninety-nine times in a hundred, will turn out to be simply 
functional — independent of any organic disease. No doubt there may be co-existing 
change of structure ; but that is a rare exception, and, when it does occur, the signs 
proper to structural disease will be present, and will betray it. 

Now, these palpitations, and these musical or rushing sounds in the jugular veins, 
are to be cured by rem.edying the state of the blood. And the remedies are prepa- 
rations of steel, aloetic purgatives, animal food, the cold shower-bath, and exercise, 
short of producing great fatigue, in pure air. 

I have further to remark, with respect to intermissions of the heart's action, and 
therefore of the pulse at the wrist, that ihey are frequently connected, both in health 
and in disease, w4th feebleness, and also with unusual slowness, of pulsation. So 
that a slow pulse, which is likewise feeble, is often converted into an intermitting 
pulse by depletion ; by blood-letting, for example, or by an active purgative ; and 
the intermittence may be removed again by a stimulant. I mention this now, be- 
cause there is another and very different state of disease, in which the pulse is apt 
to intermit. 1 mean when there is plethora capitis, and cerebral mischief is present 
or impending. But then the pulse will be full and strong, and labouring. In these 
cases, a stimulant treatment would of course be injurious ; while blood-letting, which 
would cause the other form of intermission, is the remedy of this. 

Some assistance in determining between organic disease and mere functional dis- 
order of the heart, may perhaps be derived from observing the position of the patient. 
It is stated that when there is mere nervous palpitation, the patient lies as well, and 
perhaps better, on the left side than otherwise ; whereas, when the heart is actually 
diseased, the decubitus on the right side is more comfortable than that on the left. 
If there be any tenderness of the heart, or of its enveloping membrane, the posture 
on the right side is supposed to be the easiest, because the heart is further removed 
from the ribs, and impinges upon them during the systole with less force. How- 
ever, no great stress can be laid upon this symptom. 

Of the remaining general symptoms of heart-disease there is not much to be said. 
Dyspnoea and cough are indirect symptoms declared through the lungs, between 
which and the heart there is a close and obvious reciprocal influence. But dyspnoea 
and cough are direct symptoms of pulmonary disease ; and even of pulmonary disease 
they scarcely help the precise diagnosis. That disease of the heart may materially 
alter the quantity of blood that is sent to, or transmitted from the lungs, is too plain 
to require any formal proof ; and where the quantity of blood in the lungs is affected, 



DISEASES OF THE HEART. 



671 



the quantity of air necessary to ventilate that blood must vary : m other words, dysp- 
noea must ensue. Hjemoptysis is also an equivocal symptom. 

One very common effect of cardiac disease is an impeded and sluggish trans- 
mission of venous blood from the abdominal viscera. Hence congestions of various 
parts, and especially of the liver, which enlarges and grows tender; and the bihary 
secretion and functions are deranged. These symptoms are a fruitful source of 
mistake, leading the unwary practitioner into the belief that the whole of his patient's 
malady is hepatic ; whom he comforts accordingly with the assurance that " it is all 
liver." 

The circulation through the brain is also apt to be much disturbed in heart dis- 
eases ; and to this circumstance we must attribute the headaches and giddiness that 
often accompany them ; the dread and causeless apprehension which such patients 
frequently exhibit ; the cowardice and irritabihty which disease of the heart engen- 
ders in men who previously were intrepid, and of strong and firm nerves ; also that 
propensity to dreaming, and especially to distressful and frightening dreams, so com- 
monly observable in them ; and the sudden starling from sleep in horror and alarm. 
The relations that exist between apoplexy and organic disease of the heart, were 
fully discussed in a former lecture. 

One of the most common indirect symptoms of cardiac disease is dropsy; yet, ♦ 
sometimes, the disease of the heart may continue long, and even prove fatal, without 
giving rise to any dropsy. It will produce that symptom, or not, according as it 
leads to venous congestion or not. Hence, dropsy is more particularly connected 
with dilatation and attenuation ol the right cavities of the heart. But these are 
points to which I must revert. 

Having thus run over, gentlemen, the morbid changes to which the heart, as a 
muscular organ, is liable ; the alterations of thickness in its walls, and of capacity 
in its chambers, and the derangements of the natural relations between the several 
chambers and their orifices ; having considered, also, in a brief and cursory man- 
ner, the sounds which the heart gives out in its different movements during health, 
and the modifications to which these sounds are subject in disease ; and having, 
moreover, passed in review the general symptoms which frequently display them- 
selves in connection with cardiac disease, we shall be the better prepared, I hope, 
to investigate, when we next meet, some of the specific diseases of that important 
organ. 



LECTUEE LX. 

Diseases affecting the muscular texture of the heart ; and their treatment. Changes 
to which the valves of the heart are subject. Effects^ and diagnosis of those 
changes, Angina pectoris. 

I KNOW not how I can so well put you in possession of what I know, or think con- 
cerning particular structural diseases of the heart, as by taking them in succession, 
and offering a sort of running commentary upon them. The mechanism of those 
structural changes, and the altered sounds, and the other physical signs, arising out 
of them, I endeavoured to explain in the last lecture. Bear in mind that in this 
place T can do no more than draw broad outhnes. 

Simple hypertrophy of the left ventricle. This sometimes occurs when we can 
discover no mechanical obstacle to the passage of the blood out of the ventricle, 
which might account for it : none, I mean, by the closest scrutiny made even after 
death. Is it then possible that this change may be brought about by physical causes 
which are not permanent, and have no place Avithin the body : such as undue action 
of the organ for a length of time, in consequence of habitual bodily exertion ? A 
runner, for example, we may conceive to keep his heart beatino- with a degree of 
force and frequency beyond Vv^hat is natural, for the greater part of the day; and that 



672 



DISEASES OF THE HEART. 



for many days, or weeks together. Again, can simple hypertropliy grow out of that 
excessive action of the heart which may be kept up, day after day, for a long period 
by protracted mental emotion? It is difficult to answer these questions. But I pre- 
sume that causes of this kind — that any cause, in short, which implied long-continued 
increase in the function of the organ, — would suffice to generate hypertrophy. What 
is certain, however, is that such causes seldom do act with sufficient intensity and 
constancy to produce these effects: and simple hypertrophy of the left ventricle, 
with no physical obstruction to the flow of blood through the heart, and no impedi- 
ment to the free play of the organ, is rare. 

We ascertain its existence when it does exist, first, by the account which the 
patient gives of himself. He has a sensation of beating of his heart, which he 
ought not to have ; he feels it, and hears it beating as he lies awake in bed; or even 
^ at other times when he is at rest. The pulsations are regular. Hypertrophy has 
no tendency in itself to cause the pulse to intermit or to become irregular. There is 
no marked dyspncEa : the circulation of the blood through the lungs is not much af- 
fected by this alteration of the left ventricle ; they are in fact protected by the mitral 
valve : there is seldom any dropsy : but the arterial circulation being forced, there is 
a tendency to active congestion in the capillary vessels. As there is no mechanical 
♦ obstacle to bridle the excessive power of the muscle, the pulse is full and strong; the 
face is florid; the patient is liable to headache, to bleeding from the nose, to active 
hemorrhage, and to local inflammation. If you listen to the heart in such a case, you 
find that the systolic sound is less loud and clear than natural. It is not heard beyond 
the prcecordial region, nor even perhaps over its whole extent : but there is no bel- 
lows sound. And if you place your hand upon the left breast, you feel that steady, 
swelling, incontrollable impulsion, which I spoke of in the last lecture as the surest 
sign that I am acquainted with, of hypertrophy. Sometimes the prcecordial region 
, is manifestly bulging and prominent. 

If I were to preach for an hour concerning the treatment of such cases, I could say 
no more than this : that they require perfect quiet of mind and body ; undeviating 
abstinence ; in short, the strict observance of the antiphlogistic regimen as formerly 
described ; and some of the antiphlogistic remedies : particularly moderate topical 
bleedings, often repeated ; with a close attention to the functions of the digestive 
organs. These are the cases in which, if any, we may expect to cure hypertrophy. 

If simple hypertrophy of the left ventricle be rare, hypertrophy of the same 
chamber from a mechanical obstacle, or from some hindrance to the easy v/orking 
of the hydraulic machine, is exceedingly common. What difference, then, let us ^ 
inquire, is made in the symptoms, in the treatment, and in the prospect of recovery, 
by the presence of a physical impediment, out of which the hypertrophy has grown ? ' 

The mechanical impediment will frequently signify its existence, by causing some { 
unnatural sound: a systolic bellows sound most commonly, which is audible over I 
the sternum, along the course of the aorta. And the mechanical impediment will 
tend to cause faltering of the pulse; but generally the hypertrophy corrects that | 
tendency. So, on the other hand, the mechanical obstacle corrects the tendency of \ 
the hypertrophy to cause active capillary congestion : and when the obstacle is con- i 
siderable, it will prevent the pulse from being so full and strong as in the former 
case. If to the physical signs of hypertrophy of the left ventricle there be added a ; 
bellows sound, and a disproportionate smallness and feebleness of the pulse at the. j 
wrist, we may safely conclude that there is some impediment to the escape of the 
blood from the left ventricle into the aorta; and that this impediment has given ■ 
occasion to the hypertrophy. 

Now, in this case, the hypertrophy is really an endeavour towards health. The , 
increased power of the ventricle compensates for the bar which is opposed to the 
current of the blood. The blood would not be able to go on without the hypertrophy. 
There wouid ensue a tendency to stagnation in the circulation, a faltering pulse, im- 
perfect artorialization of the blood, blue cheeks and lips, dyspncea, dropsy ; but the ; 
augmentation of bulk and force in the impelling muscle obviates this ; obviates it at 
least for a while : puts off the evil day to a distance. Since this is the case, and !■ 
since we have no means of removing the mechanical impediment, we should be mad | 



DISEASES OF THE HEART. 



673 



to desire the cure of the hypertrophy, which is to a certain degree a remedy for the 
impediment; nor indeed could we cure it if we would. But we have to endeavour 
to keep it within due bounds. If the beating be troublesome to the patient, we may 
alleviate that symptom, and check what there may be unnecessarily active in the 
contractions of the morbid chamber, by abstracting blood from the praecordia by 
leeches ; and by soliciting the action of the kidneys, by means of cooling diuretics, 
a,mong which small doses of digitahs may find an appropriate place. The labouring 
action of the heart is sometimes calmed by the application of a belladonna plaster. 
In this variety, also, of the disease, it is of primary importance that no undue efforts 
of the body be made, and that the patient be protected, as much as possible, against 
all causes of mental emotion ; that scrupulous temperance be enforced; and that all 
the functions of the body be carefully watched and regulated. 

These are not cases in which we can look for recovery: but they are cases which 
bad management and imprudent habits may hurry on to a fatal termination; and 
which judicious treatment and a well-regulated course of living may render tolerable, 
and carry forwards for a considerable period. 

Under the same condition of mechanical impediment, we oftener have eccentric 
hypertrophy of the left ventricle ; hypertrophy, i. e., with dilatation. Of course the 
bulk of the whole organ is augmented by both of those conditions ; and sometimes it 
becomes enormous, as big as that of a bullock. The symptoms will differ somewhat, 
according as the hypertrophy, or the dilatation preponderates, and therefore it will 
be as well to state here what are the symptoms of simply dilated ventricles. They 
are a diminished impulse of the heart's action ; and therewith a clearer sound than 
is natural. The first sound approximates to that of the heart's diastole ; to the 
clacking second sound, and it is heard extensively. There is more or less tendency 
to fluttering palpitations and irregularities of the pulse, which is usually weak and 
small; to faintness and debility, and to coldness of the extremities: and when the 
right ventricle is dilated, there are some other symptoms which I shall notice 
presently. 

Now, I say, there will be a mixture or modification of the symptoms, when the 
left ventricle is both dilated and hypertrophic. The dilatation will aid the mechanical 
impediment in giving a tendency to irregularity and intermission of the pulse ; and 
the hypertrophy will tend to rectify that disposition. And we must trim our man- 
agement of such cases accordingly. If the pulse flutters, we cautiously administer 
tonics, or stimulants : if it is steady, and the signs that belong to sipiple hypertro- 
phy predominate, and are excessive and troublesome, we must starve the patient, 
take blood from his side, purge him, and give him diuretics ; but at all times keep 
him as tranquil as we can. 

Simple hypertrophy of the right ventricle is not a common disease. When it 
occurs, it results from some actual or virtual impediment to the passage of the blood 
from the ventricle into the lungs. The most extreme instance of it that I ever saw, 
was in the heart of a medical friend's son, who died at the age of seventeen ; having 
been for many years affected with the morbus cseruleus as it has been called, i. e., 
an habitual blue state of the cheeks, lips, and tongue, finger-nails, and the skin 
generally ; attended with shortness of breath, and augmented by every kind of ex- 
ertion. It is seldom that persons thus affected live so long as this poor boy did. 
The heart, as is usual under such circumstances, was malformed. The septum 
between the ventricles was imperfect at its upper part ; and the aorta belonged as 
much to the one ventricle as to the other. The pulmonary artery would not admit 
a goose-quill ; the walls of the right ventricle were as thick as those of the left. 

Authors tell us that hypertrophy of the right ventricle of the heart is a cause of 
pulmonary apoolexy. I explained to you in a former lecture why I cannot believe 
in this doctrftre? In the first place I say that the increased thickness and strength 
of the walls of that chamber supply a measure of the difficulty, and not of the free- 
dom and force, with which the blood is conveyed to the lungs. In the second place 
pulmonary apoplexy does not result from rupture of vessels by the vis a tergo, nor 
in general from rupture of vessels at all ; and therefore is a quite different lesion 
from cerebral appoplexy. It is simply an accident of pulmonary hemorrhage. Ana 
43 3o 



674 



DISEASES OF THE HEART. 



lastly, I never met with pulmonary apoplexy coincident with mere hypertrophy of 
the right ventricle. The right ventricle lies on this side the lungs, in the order 
of the circulation ; and accordingly, following the rule I mentioned in the last lec- 
ture, its morbid states are for the most part ejects, and not causes of pulmonary 
disease. 

The commonest affection of the right ventricle is dilatation without any increase 
of thickness, but with attenuation even, of its muscular parietes. This is in general 
the consequence of long standing pulmonary disease ; which has prevented the easy 
passage of the blood out of the right ventricle. It is often, or ultimately attended 
with dilatation of the right auricle, and of the jugular veins, \vhich stand out in 
relief from the sides of the neck, and exhibit an undulating sort of pulsation, pro- 
duced by the regurgitation of a part of the blood, whenever the ventricle contracts. 
I have taken from the neck of a person dead of such disease, veins into which I 
could pass my forefinger. With all this there is a fluttering action of the heart, an 
irregular pulse, great distress and shortness of breathing, a dusky skin, and blueness 
of the countenance, which is bloated and anxious : and a tendency to delirium and 
drowsiness ; while, sooner or later, the whole areolar tissue of the body becomes 
charged with accumulated serum. Some degree of this may now and then be 
noticed towards the fatal close of phthisis. Much oftener it accompanies the latter 
periods of extensive pulmonary emphysema. The same condition of the right cham- 
bers, producing the same afflictive consequences, is the very frequent sequel of 
organic changes that originated in the left side of the heart. 

Disease, such as I am now describing, in its advanced stages especially, is difficult 
to treat. If you stimulate, you run the risk of increasing the patient's distress ; if 
you deplete, you incur the hazard of producing fatal syncope, of bringing the heart 
to a pause from which it is never able to recover. Here, again, you must try to keep 
the kidneys active ; you must enjoin that, as far as may be possible, all causes of 
agitation or hurry, everything which has previously been found prejudicial to the 
...patient, may be sedulously warded off. I have found more benefit in these cases 
from steel cautiously employed, than from any other drug. Without forcing the 
heart's action, it appears to have the effect of increasing the tone of its muscle ; 
which it thus enables, /or a time, to compete more successfully with the load it has 
to carry, and the impediment w^hich it cannot overcome. We can do no more in 
such cases than palliate. 

Sometimes the parietes of one or of the other ventricle becomes so thin — either in 
consequence of dilatation with tenuity, or through ulceration of the muscular tissue-— 
as to bulge out into a pouch, or even to crack ; in which case the patient almost 
always dies suddenly, the motion of the organ being stopped and strangled by the 
effusion of blood into the pericardium ; so that to die of a broken heart, is not a mere 
metaphor. A clergyman from the country, whom I previously knew, called at my 
house in the autumn, and waited some time in my absence ; but went away at last 
without seeing me : and after consulting Dr. James Johnson, set out for his home, 
ten miles on the other side of Colchester. He had been unwell for some time ; had 
suffered occasional attacks of dyspnosa; and was unusually nervous and irritable. 
He must have been conscious of some severe distress, for he was extremely anxious 
to get home, and bribed the post-boys to drive fast. As soon as he reached his own 
house, he took some supper, and went to bed, apparently comfortable. Half an hour 
afterwards one of his servants went to him, and found him asleep. At the expiration 
of another half-hour, he was again visited, and was then a corpse. Among other 
changes, the pericardium was full of blood, which had escaped from the heart through 
a rent in the left ventricle, large enough to admit one's finger. That part of the 
ventricle which surrounded the laceration, was unnaturally thin, to the extent of a 
crown-piece. There are several specimens of rupture of the leff^f^ntricle in the 
Museum at St. Bartholomew's Hospital. George II. died of rupture of the heart. 
It is curious enough that a Duchess of Brunswick, of the same family with George 
II., died of the same disease. In her case an ulcer penetrated the parietes of the 
right ventricle, which in other respects was healthy. In most instances, the rupture 
lias taken place in the left ventricle. The same chamber is also liable to aneurisms 



DISEASES OF THE HEART. 



675 



that is, to partial distension of its walls into lateral cells or pouches. This form of 
disease has not been met with in the right ventricle. 

Hypertrophy — or dilatation — or dilatation and hypertrophy — may affect, in their 
various degrees and combinations, one chamber only of the heart ; or several at the 
same time ; or all of them together. It would be vain to attempt to represent, in 
verbal description, these complicated changes. Enough, I trust, has been said, to 
enable you to unravel them when they come before you; and to ascertain, with 
sufficient exactness, the general indications which they severally furnish, and the 
plan of treatment which they require. 

You will often find the muscular substance of the heart pale, soft, and flabby; 
easily broken down, or penetrated by pressure. This may occur with general de- 
bihty and looseness of tissue ; it sometimes accompanies a plentiful deposit of fat 
about the organ : and it is supposed to be sometimes also a consequence of inflam- 
mation affecting the muscle. Walls thus soft are likely to yield under pressure ; 
but I know of no particular symptom by which we can detect such a state of 
softening. 

The morbid conditions of which I have been speaking, involving the muscular 
substance of the heart, spring very frequently indeed from pre-existing morbid con- 
ditions of the membrane hning the heart, or of the membrane investing the heart. 
It is necessary therefore, in the next place, to inquire into the nature and history of 
these morbid changes : and I will first request your attention to the diseases of the 
lining membrane. The investing membrane is familiar to you as the pericardium. 
Of late years, since the diseased states of the internal membrane have been more 
studied and understood than they formerly were, z7 has been called the endocardium: 
a convenient enough name, vv^hich may occasionally spare us circumlocution. Now, 
certain parts of the endocardium are much more obnoxious to disease than others : 
those parts which enter into the fabric of the valves and orifices of the organ. The 
membrane is here in close contact with a dense fibrous tissue ; and participates in 
the changes to which that tissue is subject. And it is an important fact, that the 
valves and orifices of the left side of the heart are much more frequently affected 
Avith disease than those of the right side. I have adverted to this fact before. What 
is the prevailing cause of it I cannot tell ; but it seems to be a portion of a more 
general fact ; namely, that the arteries are more liable to chronic morbid changes 
than the veins. Some explain the difference by alleging that the left side of the 
heart has the heavier task to accomplish. But nature seldom executes her purposes 
so clumsily, as not to adjust the strength of her machinery to the labour it is destined 
to perform. Others remark that fibrous tissue is more abundant, and therefore the 
changes proper to that tissue are more numerous and extensive on the left side. And 
this may be the true explanation. Others, again, have conjectured that the arterial 
blood is more irritating than the venous. But there is no evidence of this : and it is 
better to content ourselves with noticing the fact, without attempting to account for 
it by mere gratuitous hypothesis. 

You are not, however, to suppose that the right side is exempt from valvular dis- 
ease. When there is much change on the left, we often find a less degree of the 
same kind of change upon the right. The valves of the pulmonary artery are, per- 
haps, the least frequently of all the valves found otherwise than healthy. 

Many of the alterations that take place in the internal lining of the heart result, 
apparently, from inflammation, which causes a deposit of lymph upon or beneath 
the serous membrane. The valves are apt to lose their thinness, and transparency, 
and pliancy. They become thick, stiff, puckered, curled up, or glued to each other, 
or to the opposite walls of the channel. On the other hand, quite independently 
of inflammation, they may become morbidly thin, riddled with holes, and even 
rent asunder. What are called vegetations or excrescences may also project from 
them, very much resembling warts. Or they may be converted wholly or partly 
into bone. 

Akerations of some kind or another are very frequent in the semilunar valves of 
the aorta. When they are of such a nature as to diminish the orifice during the 
systole, they commonly occasion a systohc bellows sound. When the diseased 



676 



DISEASES OF THE HEART. 



valves offer no obstruction to the exit of blood from the ventricle, but do not close 
again immediately afterwards, so as effectually to prevent the reflux of that fluid 
from the aorta, they commonly give rise to a diastolic bellows sound. When both 
these defects of function occur, there is often a double bellows sound ; a sawing 
alternate noise ; one murmur during the systole, another, distinguishable in tone and 
quahty, as well as in time, during the diastole. These sounds are conveyed along 
the tube in w^hich they are formed, and are therefore most audible in the track of 
the aorta, as it leaves the heart. If the sound be diastolic, it take the place of 
the smart clack of the second sound of the heart, or perhaps succeed it. Sometimes 
the new sound is very loud and curious. I had a patient in the hospital last year, 
in whom this diastolic sound was, in character and intensity, like the cooing of a 
pigeon. The patient could plainly hear it ; nay, it could be heard by a person 
standing near him, but not touching his body, even with a stethoscope. In that in- 
stance w^e found one of the aortic valves irregularly thickened, with its free edge 
loose and flapping, and unable to fulfil its function of closing the aperture. During 
the diastole it w^as retroverted, and vibrated in the regurgitating stream of blood ; 
and thus, no doubt, the musical note, heard alternately with the first sound, w^as 
produced. In March, 1837, I heard in a man (Henry Milton) who was under Dr. 
Latham's care in St. Bartholomew's Hospital, and w^ho had had acute rheumatism, 
a very shrill diastolic sound, like the repeated whining of an imprisoned puppy-dog 
wishing to be released. This remarkable sound was audible by means of the stetho- 
scope, even in the radial artery. The patient died at last in St. George's Hospital, 
and his case is mentioned in Dr. Hope's book on the heart. One of the aortic valves 
was torn dow^nwards to some distance from its edge, and formed a flap, which w^as 
perforated by a round hole. 

I need not again point out to you the manner in which such disease of these semi- 
lunar valves tends to produce hypertrophy and dilatation of the left ventricle. 

The mitral valve is often thickened ; and it is particularly subject, more so even 
than the aortic valves, to ossification. And the effects of the ossification are to pre- 
vent its closing the auricular orifice during the systole ; and to prevent its tyin^ flat 
against the w^alls of the ventricle, and allowing a free passage of the blood out of the 
left auricle, during the diastole. The orifice is often converted into an unvarying 
oval slit, wath puckered edges, and resembling a button-hole ; or the valve projects, 
like a thimble of bone, into the left ventricle. And it is remarkable how small the 
chink, which is thus permanent, may be, and yet life go on. The heart having been 
taken out of the body, and the auricle filled with water, I have seen the water pass 
into the ventricle, by its gravity, stillatim ; drop by drop. 

Let me just remind you, that the direct and necessary conseguence of constriction 
of the mitral orifice, is an accumulation of blood behind it ; i. e., in the left auricle, 
in the pulmonary veins, in the lungs. Hence so much mechanical congestion, that 
the blood bursts at length through the bronchial membrane ; hemorrhage, slow or 
copious, ensues from the air-passages ; and pulmonary apoplexy is formed. 

In extreme cases, where the mischief is chiefly confined to that valve, the blood 
necessarily reaches the ventricle in a penurious manner; that chamber contracts un- 
steadily and irregularly; and its cavity sometimes diminishes. This I think I have 
seen. But far more commonly there is disease of the aortic valves also ; and the 
condition of the left ventricle is that of hypertrophy with dilatation. 

When there is a permanent chink in place of the limber valve, there may be a 
double bruit. The first heard during the systole, and produced by the regurgitation 
of blood from the ventricle into the auricle, through the rigid slit. This is common. 
The second accompanying the diastole, and resuking from the mechanical impedi- 
ment to the free passage of the blood from the auricle into the ventricle. This is 
uncommon. The constriction must be great for the diastolic murmur to occur at 
ail : and when it does occur, it is faint ; from the comparative feebleness (I presume) 
of the auricular contractions. 

The form and the consistence of the altered valves being the same,- no difference 
whatever in the sounds, or in the general symptoms, will arise from the particular 
nature of the changes. It will, I mean, make no difference whether the obstacle to 



DISEASES OF THE HEART. 



677 



the flowing blood, or the imperfect closure of the orifice, depends upon mere thicken- 
ing of the valve by cartilaginous deposition, or upon ossification, or upon wart-like 
vegetations. These last may be found upon any of the valves, but, like other 
morbid states, they are less frequent on the right than on the left side of the heart ; 
md they are most common of all on the aortic valves. Ossification — the deposition 
of the phosphate of lime — is almost confined, I believe, to the left side. I never saw 
the tricuspid valve, or the semilunar valves of the pulmonary artery, converted into 
bone. 

The warts, or wart-hke excrescences, which are so often found upon the valves 
of the heart, are very curious things. Sometimes they are separate, hke rows of 
beads. Sometimes several appear to spring from a common base, which spreads 
out so as to exhibit a cauliflower appearance. And occasionally they hang in long 
strings from the valve into the adjoining chamber of the heart. In a patient of Dr. 
Hawkins', I saw a cylindrical excrescence of this kind which measured an inch in 
length. The valves presented slit-like perforations ; and from the edge of one of 
these slits in the mitral valve, this long vegetation dangled into the ventricle. The 
whole of the valves of the aorta were covered, on their ventricular surface, with 
similar but shorter excrescences. 

They vary much, these vegetations, in consistence. Sometimes they are soft, 
easily crushed, and capable of being readily detached from the smooth surface of the 
valve. Others are more firm, and yet separable from the valve without injury to it. 
Others, again, are so adherent, so rooted into the valves, that they can be removed 
only by tearing or cutting them off". They are found sometimes on the free edge 
of the valves; sometimes on their surface, or even on- the inner membrane of one 
of the chambers, especially of the left auricle. 

Much difference of opinion has prevailed respecting the nature and origin of these 
singular appearances. It was a common notion among the French, at one time, that 
they were really, what they so much resemble, venereal warts. What seems to be 
certain is, that they are somehow connected with inflammation of the internal lining 
of the heart; and of that which covers the valves in particular. But, then, are they 
lymph poured out from the inflamed membrane ? or are they fibrin deposited from 
the blood upon an inflamed membrane ? It is probable that the last is, sometimes 
at least, the true explanation of their origin. You know, that when the membrane 
lining a vein becomes inflamed, the blood in contact with it has a strong tendency to 
coagulate upon it, and to adhere to it. The fleshy excrescences found on the valves 
are often attached to the edges of slits in the valve : the broken surface having pro- 
bably been the especial seat of inflammation. When then the formation of vegeta- 
tions is recent, they are very soft and frangible. But the most interesting fact that I 
am acquainted with, in evidence of the mode in which these little projections arise, 
is one that accidentally came to light in one of Dr. Hope's experiments upon an ass, 
at which I was present. The aortic valves had been held back by a wire passed 
into the vessel, with the view of ascertaining the physical cause of the second sound. 
The animal was previously rendered insensible by a narcotic poison ; and the circu- 
lation was kept up — languidly, however, towards the last — by artificial respiration. 
Upon the final cessation of the heart's motions, the organ was removed from the 
body and examined : and the valve that had been mechanically irritated by the 
wire, was found studded with these little wart-hke appearances, which were so soft 
as to admit of being readily brushed off from the subjacent membrane. Here the 
deposit took place after the death of the animal, and while some of the functions of 
organic life alone were kept up by the artificial breathing. 

There are still some curious circumstances to be mentioned, connected, in some 
instances, with the formation of these warty vegetations. I shall not, however, enter 
upon them in the present lecture : but when I speak, at our next meeting, of rheu 
rnatic inflammation of the heart and its membranes. 

Any or all of the lesions that I have been describing may and must lead, at length, 
according to their places and magnitude, to some of those changes in the actual and 
relative dimensions of the heart that were considered in the last lecture. They 
obstruct the stream of blood when moving in its natural course, and when its ]3assao-e 

3g2 



678 



DISEASES OF THE HEART. 



ought to be free ; or they allow of its refluent course, when it ought to be effectually 
opposed : and the necessary results, in either case, are dilatation of one or more 
of the chambers of the heart, with thickening, or with attenuation, as the case may 
be, of its walls. I have already spoken of the symptoms, physical and general, to 
which these secondary changes give rise ; and of the treatment which they admit 
and require. , 

There being valvular disease, and that valvular disease giving rise to a bellows 
sound, can we distinguish the particular valve affected ? Generally, we can. Our 
skill in diagnosis outruns here, as indeed it too often does, our skill to cure. A few 
simple rules and considerations enable us, in most cases, to satisfy our natural curi- 
osity to penetrate the exact conditions even of changes that are incapable of repair. 
These rules relate chiefly to the time when the murmur is heard ; to the direction in 
which it is most audible ; and to the state of the arterial pulse. 

When a bellows sound accompanies the systole, it must be caused by a current 
passing out of a ventricle. But serious disease of the valves, sufficient to occasion 
a murmur, on the right side of the heart, is very rare. In nineteen cases out of 
twenty, valvular murmurs belong to the left side ; so that practically the distinction 
lies, almost always, between two orifices, the mitral and the aortic, the inlet and the 
outlet of the left ventricle. The natural inlet has become an outlet also : or the 
natural outlet is obstructed. Now if the sound be heard at the base of the heart, 
and along the track of the thoracic aorta, up towards the right clavicle, and even in 
the carotids ; and if it be less audible towards the apex, and if the pulse be steady 
and regular, the mischief is seated in the semilunar valves of. the aorta : there is 
some obstacle which produces a ripple in the onward stream of the blood. 

On the other hand, if the pulse be irregular, and if the sound be heard better 
towards the apex of the organ, on the left, it is owing to regurgitation through a dis- 
eased 77iitral valve. Such regurgitation is often attended with a purring thrill. 

When, what scarcely ever happens, the sound does result from injury of the 
semilunar valves of the pulmonary artery, it is heard plainest in the track of that 
vessel, up towards the left clavicle. So also a murmur produced by change in the 
tricuspid valve would be loudest towards the apex, on the right. The arterial pulse, 
for obvious reasons, is but little influenced by disease affecting the orifices of the 
right heart. 

Again, if the morbid sound be diastolic, it accompanies the entrance of blood into 
a ventricle ; and for similar reasons as before, the fault is most probably in the left 
ventricle. It may be owing to the direct, but impeded, passage of the blood from 
the left auricle through a narrowed mitral orifice : yet this very seldom occasions 
any audible noise. Or the diastolic murmur may proceed from regurgitation through 
the defective aortic valves : the natural outlet having become an inlet also : and this 
is exceedingly common. We attend, as before, to the situation and the track in 
which the sound is the loudest. We listen also for the smart clack of the natural 
second sound ; and if it is not to be heard, or is very indistinct, we have, in that cir- 
cumstance, corroborative evidence of an imperfect aortic flood-gate. Moreover, we 
are again assisted by the pulse. The pulse of aortic regurgitation is very striking 
and peculiar : sudden, like the blow of .a hammer, without any prolonged swell of 
the artery. It always reminds me of the vvell known chemical toy, formed by 
including a small quantity of liquid in a glass tube, exhausted of air, and hermeti- 
cally sealed. On reversing the tube, the hquid falls from one end of it to the other 
with a hard short knock, as if it were a mass of lead. The sensation given to the 
finger by the pulse, when there is much regurgitation through the aortic valves, is 
very similar to this. It is as if successive balls of blood were suddenly shot along 
under the finger. Dr. Hope calls this pulse a jerkins: pulse ; the pulse of unfilled 
arteries. And this abrupt pulse makes itself visible in the arteries : the wave of 
blood lifts, and moves, and sometimes contorts the vessel. When this kind of pulse 
occurs with a diastohc bellows sound heard in the track of the aorta, and the short 
clack of the second sound is absent or diminished, you may be quite sure that the 
aortic orifice is patulous during the diastole. The reflux of the blood, when the 
patency is great, is strong enough sometimes to produce a palpable shock or iog, 



DISEASES OF THE HEART. 



679 



called the diastolic impulse. And this refilling of the ventricle from the artery may- 
even provoke it to a supernumerary contraction. 

In a patient by whom I was lately consulted, the hard, sudd-en, hammering pulse 
led me to conclude that the blood regurgitated from his aorta; and accordingly, 
upon applying my ear to his chest, I discovered a loud murmur, coincident with the 
diastole, and most distinct in the direction of the right clavicle. The shock of this 
man's artery was plainly to be felt, through his clothes, by one's hand iaid lightly 
upon the bend of his arm. His wife told me that, for five years past, this jarring 
blow had made it uncomfortable for her to take his arm when they were walking 
together. The same kind of jerking impulse was strikingly perceptible in the 
femoral arteries, and in the carotids. 

Of regurgitant sounds belonging to the Vijrht side of the heart I can tell you 
nothing. I never heard one, that I know of, from the pulmonic valves. Through 
the tricuspid orifice the blood is beheved to be often refluent ; causing, as I stated 
before, turgescence and pulsation of the jugular veins. The structure of the valve 
permits this ebbing movement of the blood under circumstances which might other- 
wise be perilous. The tricuspid has accordingly been called the safety valve of the 
heart. But the reflux seldom, if ever, announces itself by a bellows sound. 

We cannot always thus rigidly connect morbid changes with definite signs. Dis- 
orders'arise, of which the symptoms are more cognizable and constant than the seat. 
"We assign a name to the peculiar assemblage of symptoms, and make it thenceforth 
a distinct object of our study ; tracing the symptoms, as well as we can, up to their 
organic causes and conditions. Now, the complaint called angina pectoris is one of 
this kind. It is, moreover, a very curious and interesting disorder ; and I shall de- 
vote the remainder of the present hour to its consideration. 

This disease was first accurately described, in this country at least, by the cele- 
brated Dr. Heberden, the author of the Commentaries. It had been adverted to by 
many writers before, but obscurely ; and Dr. Heberden's observations were quite 
original. The description that he has given of the complaint, in the second volume 
of the. Transactions of the College of Physicians, is very accurate and striking. He 
calls it a disorder of the breast ; and observes that "the seat of it, and the sense of 
stranghng and anxiety with which it is attended, may make it not improperly be 
called angina pectoris. 

" Those who are afflicted with it are seized whilst they are walking, and more 
particularly when they walk soon after eating, with a painful and most disagreeable 
sensation in tfie breast, which seems as if it would take their hfe away, if it were to 
increase or to continue. The moment they stand still, all this uneasiness vanishes. 
In nil other respects the patients are, at the beginning of this disorder, perfectly well ; 
and in particular have no shortness of breath, from which it is totally different." 
* Such is the brief description of the malady given by Dr. Heberden. You will 
observe that the distress occurs in paroxysms, and the patient at first has intervals of 
apparent health; and even when the disease is more advanced, he has periods of 
comparative ease between fits of suffering. The paroxysms are especially hable to 
come on when the patient is walking, and, above all, when he is ascending — going 
up a hill. He is then seized, all at once, with a painful sensation, which seems to 
be, in many cases, indescribable, but which is always referred to the heart, or its 
neighbourhood. Sometimes the sensation is spoken of as being a spasm, as giving 
the patient a notion of constriction ; but it also carries with it the impression that any 
continuance of the exertion, the stirring another step, would be fatal. Yet the patient 
is not out of breath. It is not dyspno3a that oppresses him ; for he can, and gene- 
rally does, breathe freely and easily. He lays hold of any neighbouring object for 
support. His face is pale and haggard ; and you would suppose, from his appear- 
ance, that he was actually at the point of death. But in the early stages of the dis- 
ease, the pang soon subsides, the distress is over, and the patient is entirely himself 
again. However, after the lapse of some time, generally of some months, the anguish 
does not so instantaneously cease upon standing still, nor does it always require some 
bodily exertion to bring it on. It will occur when the patient is quiet, even in bed. 



680 



DISEASES OF THE HEART. 



He feels as if the action of the heart was arrested ; and he is obliged to rise up, 
every night perhaps, for many weeks together. In exquisite cases it will be brought 
on by causes of an}^ kind that slightly accelerate the circulation : coughing, straining 
at stool, mental emotion. 

The pain, which is at first referred to the region of the heart, frequently extends, 
accompanied by a sort of numbness, from that part to the left shoulder, and down 
the left arm ; stopping short, in a curious manner, and from some inexplicable cause, 
either just about the insertion of the deltoid muscle, or at the elbow, or at the wrist. 
Sometimes, however, it runs down to the very extremities of the fingers ; particularly 
of the last two fingers, -following mainly the course of the ulnar nerve. And occa- 
sionally similar pains affect the right side and arm. There is (I say) no dyspnoea in 
the genuine form of the disease ; although you will find it stated by some modern 
writers of good repute, that the paroxysm is accompanied with difficulty of breath- 
ing. In the instances that I have seen, and they have been few, the patient was 
able slowly and fully to inspire and expire, even when the fit was on him. The 
truth I beheve to be, that other affections, more akin to asthma, have been confound- 
ed with angina p.ecioris ; and this confusion has led to the belief that it is not altoge- 
ther so dangerous a complaint as used to be thought; but in its genuine shape it is 
undoubtedly a very fatal disorder. Dr. Forbes, by a diligent search among authors, 
has collected some statistical facts respecting it which are worth remembering. Thus, 
out of eighty-eight cases, eight only, or one in eleven, occurred in females; The 
ages, in eighty-four of these eighty-eight cases, are recorded ; and of the eighty- 
four, seventy-two wera above fifty years ; and twelve, or one-seventh of the whole, 
under fift}^ years. It is a disease, therefore, for the most part, of advanced life ; and 
this alone would afford a strong presumption of its dependence upon some organic 
change. Again, the event of the disease was recorded in respect to sixty-four of the 
patients. Of these, forty-nine died, almost all of them suddenly; while fifteen reco- 
vered, or were relieved. And among the forty-nine fatal cases, there were only two 
of women. 

That the seat of the disorder is the heart, and that it consists in some structural 
change, can scarcely be doubted. Yet some pathologists are disposed to consider it 
a merely neuralgic affection, "commencing for the most part in the pneumogastric 
nerve, and spreading in different directions, as other nerves become involved." But 
this doctrine is scarcely consistent, in my judgment, with the facts — first, that the 
paroxysm is excited b}^ such causes as are "especially calculated to disturb the natu- 
ral action of the heart, bodily exertion, and mental emotion ;" and, secondly, that the 
disease is so very frequently and so suddenly faf a! . This is not at ai the character 
of mere neuralgic diseases in general. And when we add to these facts the further 
fact, viz., that, in a vast majority of instances, organic disease of the heart, or of the 
great blood-vessels, has been discovered after death, I think we shall be obliged to 
admit that the symptoms are often (for I will not say always) dependent upon cardiac- 
disease. One theory explains the " breast-pang," by supposing that the blood, when- 
ever its movement is accelerated by exercise or otherwise, arrives in the heart faster 
than it can be transmitted onwards, and, accumulating in its cavities, painfully dis- 
tends them. It is not improbable that the paroxysm ma}^ be sometimes so produced. 
The great Dr. Jenner took a most ingenious view of the matter, which was made 
public and further enforced by Dr. Parry. He had found, in examining the bodies 
of some who had died of Avell-marked angina pectoris, that the coronary arteries of 
the heart were ossified ; converted into bony canals, and constricted in their calibre. 
He thence concluded that the paroxysms result from the circumstance, that when 
some increase of the muscular contraction of the heart happens to be called for, the 
increased supply of blood, rendered necessary by the additional exertion, is not capa- 
ble of being furnished by the diseased nutrient arteries of the organ ; that the heart 
comes to a stand, because its muscular tissue is not duly injected with arterial blood ; 
and the phenomena of the paroxysm agree remarkably well with that theory. He 
calls the disease, accordingly, syiicope anginosa." And this simple and beautiful 
theory was for some time admitted as the true one. However, later investigations 
have abundantly shown that angina pectoris may occur in a decided form, without 



DISEASES OF THE HEART. 



681 



there being any ossification or other disease of the arteries ; and, on the other hand, 
i that the coronary arteries may be ossified, and yet no ano-ina pectoris be the result. 

j I may here again avail myself of the researches of Dr. Forbes, and give you a 
numerical account of the organic changes in the heart that have been found asso- 
ciated with this disease. The total number of instances collected by him, in which 
the body was examined after death, was forty-five. Of this number, there was dis- 
ease found in the liver only, in two instances : organic disease of the heart, or great 
vessels, in forty-three. Dr. Forbes, indeed, makes the last number thirty-nine, 
instead of forty-three, excluding four cases in which nothing morbid was found in 
or about the heart, except an excessive coating of fat. This Dr. Fothergill consid- 
ered the essence of the disease ; and certainly a heart cannot be said to be in a 
healthy condition which is thus loaded with adipous matter. The fat is generally 
deposited at the expense of the muscular substance, which is apt in such cases to be 
thin, pale, and soft ; atrophied, in short. Taking, however, the table as it is given 

! by Dr. Forbes, the thirty-nine cases in which there was no disease except in the 

I heart and great vessels, were thus distributed : — In ten of the cases there was organic 
disease in the heart alone : in three, organic disease of the aorta alone. In one 
instance only was the disease confined to the coronary arteries ; but there was ossifi- 
cation, or cartilaginous thickening of the coronary arteries, combined with other 

1 disease, in sixteen instances. Again, there was ossification, or other disease of the 
valves of the heart, in' sixteen cases also. There was disease of the aorta (ossifica- 

i tion, or dilatation, or both), in twenty-four cases ; and in twelve cases there was pre- 

i ternatural softness of the heart. 

' My friend, Dr. Latham, lately gave me this sketch of a case of angina pectoris, 
' which had fallen under his own observation. It is remarkable for the shortness of 
its course. A gentleman, about fifty years old, was recovering from the influenza, 
of which nothing remained but a slight cough, that troubled him at night. It was 
1 to relieve this that Dr. Latham was consulted. The gentleman looked perfectly 
Avell. After Dr. Latham had prescribed for this little ailment, the patient begged to 
see him the next day, to talk over with him (he said) a very strange affection he had. 
Accordingly, he then described a paroxysm of angina pectoris in terms that could not 
be mistaken ; dweUing especially upon the prascordial pain, the sensation down the 
left arm, the sense of approaching dissolution, and then the perfect recovery. This 
gentleman had, during the previous summer, performed a walking tour through 
Switzerland, and returned home in excellent health. The first notice of his angina 
was not more than a month ago, when he was walking up Hampstead Hill. It was 
then that he had his first parox^^sm. In the short period which had elapsed, the 
attacks had rapidly increased in severity and frequency ; occurring now every two 
or three days, or every day, or several times a day, with or without an exciting- 
cause. Dr. Latham made a careful examination of the chest, and found the respi- 
ration perfect, the heart free from all unnatural murmurs, and its beats rhythmical. 
The only thing that particularly attracted his notice was the exceeding feebleness of 
its impulse. In the afternoon of the next day. Dr. Latham visited him again, when 
he described a paroxysm he had suffered in the course of the morning, of much 
greater severity than any that he had hitherto experienced. Dr. Latham saw enough 
to convince him that his patient's existence was very precarious : and as he had pre- 
viously been a stranger to him, he inquired about his friends, and took down the 
address of a brother, intending to call and apprise him of what he feared. On reach- 
ing his own home, two hours afterwards, a messenger met him, announcing that his 
patient had fallen into another paroxysm, soon after he left the house, and was dead. 
The body was carefully examined by a thorough anatomist, Mr. Stanley. There 
was no disease of the aorta, or of the heart generally ; but the coronary arteries 
resembled tubes of coral, being completely ossified as far as they could be traced. 

The patient may even expire in the first or second paroxysm. This happened, 
I believe, in the case of the late lamented Master of Rugby school. 

You will perceive, from what has been said, that the prognosis of this singular 
and formidable afTection is extremely unfavourable. The cases are very rare in 
which no disease of the heart has been detected ; and the organic changes that 



682 



PERICARDITIS. 



have been found are remediless, and, for the most part, progressive ; and, in point 
of fact, the greater number of those who have laboured under the disease have died 
suddenly. 

It follows, also, as another corollary from the facts now brought before you, that 
there are very few cases in which we can dare to contemplate a cure. Our mea- 
sures must be preventive when the paroxysms are absent ; and our object will be to 
shorten the fit when it is present and protracted. 

Now, the preventive measures are simple and obvious. The patient must be cau- 
tioned to avoid the exciting causes of the paroxysm ; walking up hill, or against the 
wind, which has also been known to produce it. Whatever is likely to hurry the 
circulation, and therefore, among the rest, all mental emotion and anxiety, should be 
guarded against as much as possible. John Hunter died of angina pectoris : and 
the fatal seizure was brought on by a fit of anger. Care should be taken also to 
obtain and preserve a healthy state of the digestive organs. It is observable of this, 
as 1 mentioned before it is observable of other cardiac diseases, that they are often 
attended and aggravated by flatulence of the stomach and bowels. Persons labour- 
ing under a paroxysm of angina often experience great and sudden relief upon get- 
ting rid of a quantity of gas, by which the stomach had been distended. The flatu- 
lence acts, no doubt, by pressing the diaphragm upwards, and so diminishing the 
dimensions of the thorax, and impeding the play of the heart. It is upon the same 
principle that we must explain the fact, that the paroxysms are particularly apt to 
come on if the patient walks soon after a meal: also that they occur in the night, 
when he is in a horizontal position, and are relieved by his getting out of bed ; that 
is, by his assuming the vertical posture, and taking ofi'the pressure of the abdominal 
viscera from the diaphragm. 

In the paroxysm itself, bleeding has been fairly tried ; but, as T think might have 
been foreseen, it has seldom been attended with any benefit, and sometimes it appears 
to have done harm. The afiection has a nearer relation to syncope, and often to 
syncope by asthenia, than to any thing else. That is the way in which the patients 
die ; and consequently, cordials, stimulants, and antispasmodics, are found to be of 
service. Dr. Elliotson thinks prussic acid is the best thin^ you can administer. 
Dr. Davies has more faith in belladonna plasters than in most other things. Dr. 
Copland advises stimulant liniments externally ; and warm carminative or aperient 
medicines, as the circumstances may require, internally. The general condition of 
the sufferer will suggest, I believe, the proper treatment. Not that it will suggest 
any particular drug, but it will teach you the main principle on which you are to 
proceed. If auscultation reveal any of those morbid states of the heart which were 
noticed in the beginning of the lecture, the means which I pointed out as suitable 
for remedying them may be put in force. 



LECTURE LXI. 

Pericarditis ; its frequent connection with Acute Articular Rheumatism. Rheu- 
matic Carditis. Anatomical characters of acute Inflammation of the Pericar- 
dium; of the Endocardium. General symptoms. Auscultatory signs. Rela- 
tions of Carditis ivith Rheumatic Fever. 

I YESTERDAY Considered, cursorily indeed, but as fully as the limits of these lectures 
will permit, the effects of hypertrophy, and of dilatation with and without hypertro- 
phy, of the several chambers of the heart : and of the means we possess of obviating 
or alleviating those effects. I passed in review also the chronic changes to which 
the endorcardium, especially in those parts where it covers the valves, and the ten- 
dinous rings that give support to the valves, is liable ; and most of the circumstances 
which give origin to such changes : and I spoke of that singular and perilous affection 



PERICARDITIS. 



683 



, to which the name of angina pectoris has been apphed. I proceed this afternoon to 
I the diseased conditions of the pericardium. This membrane is often the seat of 
acute inflammation ; and the consequence of such inflammation is sometimes, though 
rarely, the speedy extinction of life. But in nineteen cases out of twenty, the dis- 
order proves fatal at a remote period ; destroying the subject of it more slowly, indeed, 
ij but almost as surely. Pericarditis is therefore, and has always been regarded as, a 
I very interesting disease ; and the more so, that it is in many instances a very insidious 
ij disease also. 

j Acute pericarditis is Hable to arise, like all other internal inflammations, after ex- 
1 posure to cold ; or when no exciting cause is to be discovered. But for one such 
' case of what may be called spontaneous acute inflammation of that membrane, you 
! will meet with a d^zen, or more, in which it occurs in connection with a disease that 
' we have not yet had bfefore us — acute rheumatism ; a febrile disorder, characterized 
j by inflammation of a specific character, affecting the structures that lie around the 
' joints, or enter into their composition — the fibrous tissues. I shall therefore consider 
I acute pericarditis with reference to its occurrence in rheumatic fever ; for in so doing, 
! 1 shall embrace all the practical points which belong to it under any form. But I 
j must tell you that when joencarditis happens, in the course of an attack of rheuma- 
j tfsm, so also, to the best of my belief, in almost every instance, does e?^f/ocarditis. 
i For this reason I shall include, in the account I am desirous to give you of rheumatic 
\ carditis, both these inflammations : inflammation of the investing membrane, and in- 
i flammation of the lining membrane of the heart. I mentioned in the last lecture, that, 
I in respect to the latter, to endocarditis, there were some peculiarities noticeable which 
I I should reserve for the present occasion. 

The pericardium is one of the serous membranes ; so also may the endocardium 
be considered. But the pericardium is also a shut sac ; and the primary effects of 
inflammation upon it are the same, mutatis mutandis, as upon the shut sac so near 
it, the pleura. The second series of effects is, however, much more formidable. 
Adhesion of the pleura does not necessarily abbreviate the natural term of the 
patient's life ; adhesion of the pericardium almost always does : and effusion into the 
cavity that contains the iung is far less serious than effusion into the bag that sur- 
rounds the heart. In the one set of organs the mischief may be great, but it is final; 
in the other, it leads, with unfaihng certainty, sooner or later, to worse changes, which 
at length prove incompatible with the further continuance of hfe. 

You will understand, then, without the necessity of my going again into much 
detail, that the pericardium, under acute inflammation, may undergo the same 
changes, which, on a former occasion, we saw that the pleura might undergo. 
Coagulable lymph may be poured forth from the entire membrane, and abolish the 
cavity by glueing the whole of the pericardium to the heart : or serous fluid may be 
effused, distending the bag of the pericardium, and keeping its smooth surfaces more 
or less asunder : or both serum and lymph may be effused together ; or fibrin, in some 
shape or another, may be deposited, for aught I know, from the homogeneous fluid 
which is thrown out by the inflamed membrane in the first instance ; and the result of 
this mixed effusion may here, also, as in the case of the pleura, be (he partial adhe- 
sion of the membrane to the heart. 

But in the majority of instances the inflammation spreads over the whole mem- 
brane, as it is apt to do in serous membranes generally ; and one of these two things 
happens : either there is a large quantity of liquid effusion, which is not reabsorbed ; 
and then generally the patient dies in a few days : or there is not much liquid effu- 
sion, or the liquid part is absorbed, and the pericardium becomes permanently agglu- 
tinated to the heart, and apparent recovery takes place. 

In the cases that have proved fatal at an early period, when the inflamed mem- 
brane has been unadherent, it has been found to contain serous fluid ; sometimes clear, 
oftener turbid, frequently tinged with blood : and it has been seen to be covered 
with a coating of the fibrinous or albuminous part of the blood ; what we call plastic 
or coagulable lymph. The deposited lymph assumes a variety of forms in different 
cases ; but in every case that I have seen, the prevailing character of the unattached 
surface has been that of roughness ; and this is a circumstance of some importance, 



684 



RHEUxMATIC CARDITIS. 



as we shall presently see. The lymph is not arranged in smooth layers ; but it is 
rugged, villous, or cellular. According to the fancy of different observers, it has 
been thought to resemble lacework, or a sponge, or a honeycomb, or some kinds of 
coral, or the interior of a calf's stomach. Sometimes it bristles with a multitude of 
small, short, pointed papillse : less frequently, it is softer and shaggy ; always it is 
rough and uneven. Dr. Hope, following Laennec, states that the surface looks some- 
times like that which would be produced by suddenly separating two flat pieces of 
wood, between which a thin layer of butter has been compressed. To my own eye, 
the appearance presented by the membrane, in its recent condition, has been more 
like the rough side of the pieces of tripe which you see in butchers' shops than any 
thing else. 

When, on the other hand, the patient dies, as he sometimes will do, soon after the 
whole of the membrane has become adherent, you will find the niedium of adhesion 
to consist of lymph, in which a number of bloody points or streaks are visible : but 
still the connecting substance is soft, and the agglutinated membranes can readily be 
torn apart. 

Such is the state of things on the outside of the heart in such cases. But what 
do we find within ? Why, here also, in all cases probably, certainly in by far the 
majority of cases, w^e discover evident traces of active inflammation ; and we dis^ 
cover them chiefly on the valvular apparatus. There does not appear to be such a 
tendency in endocarditis to difiuse itself over the whole membrane. Occasionally 
that naturally transparent portion of it which covers the muscular fibres is rendered 
whitish and opaque-; and occasionally some of the deposits that are common on the 
valves, encroach also somewhat beyond them, and even stud, here and there, the in- 
terior of one or more of the chambers of the heart, and especially of the left auricle. 
But the valves or the fibrous rings from which they spring, are the parts first and 
chiefly imphcated, especially the aoriic valves, and the mitral valve : not uncom- 
monly the tricuspid valve also ; and sometimes even the semilunar valves of the pul- 
monary artery. Inflammation thus affecting both the external and internal mem- 
branes of the heart, in acute rheumatism, I would call rheumatic carditis. 

The inflamed valves undergo two kinds of change, distinct from each other. They 
become thicker and natural ; they lose their transparency and pliancy, and are 
puckered. These changes depend upon the deposit of lymph beneath the mem- 
brane ; betvveen the membrane and the fibrous substance it covers. Sometimes they 
are folded down, and glued, as it were, to the opposite surface. This must be by 
coagulable lymph deposited on the outer side of the membrane. But more frequently 
than all, they present more or fcAver of those wart-like excrescences, or fleshy granu- 
lations, which I spoke of in the last lecture, and which are of course above the mem- 
brane. Sometimes these vegetations are scattered irregularly over the convex surface 
of the valve, or in its immediate neighbourhood ; but much oftener they have a more 
definite and curious distribution ; an arrangement which I have never seen noticed 
by any author, but which it has been my lot so many times to observe, that it has 
led me to remark an anatomical peculiarity with which it is connected ; and this 
piece of minuter anatomy I have looked for in vain in books, and have in vain sought 
information about it from all my anatomical acquaintances. They none of them 
have seemed to be aware of it, though they acknowledged that the fact was so when 
I pointed it out to them. Recently, indeed, I have been told that the peculiarity of 
structure to which I allude is somewhere adverted to by Morgagni. 

It becomes necessary, therefore, that I should describe this discovery of mine (if it 
deserves so grand a name) to you, as I have, for several years past, been in the habit 
of showing it to the pupils of the hospital in the dead-house. It derives its chief 
interest from the light it throws upon the morbid appearances to be spoken of pre- 
sently. You will find, then, if you examine closely the semilunar valves of the 
aorta, or of the pulmonary artery, that in each valve there may be distinguished two 
parts ; one thicker, the other thinner. The thicker part lies next the base of the 
valve, the thinner next its edge. And the valve does not become thin by degrees, 
but the difference is marked by a manifest line of separation between the thicker and 
thinner portions ; and this is not a straight, nor even one sweeping curved line, but 



PERICARDITIS. 



685 



it is a double curve. It consists of two semicircular lines, running each from the 
ji centre of the edge of the valve, from the sesamoid body there situated, to either extre- 
J mity of the edge, where the edge joins the side of the aoria. So that there are two 
1 segments, of a crescentic shape, thinner and less opaque than the remaining part of 
the valve, and lying near its free margin. This peculiarity of structure is uniformly 
present. It is less distinctly visible in the valves of the pulmonary artery than in 
those of the aorta; and it is much less apparent in some individuals than in others : 
but it is always to be seen when it is looked for. 
I The anatomical account of this arrangement is not far to seek. The cardiac 
j valves consist of a loose duplicature of the delicate endocardium, between the folds 
of which is received a thin prolongaiion of fibrous tissue, from the tendinous rings 
surrounding or constituting the several orifices that are furnished with a valvular 
apparatus. In thfe semilunar valves this fibrous substance does not interpose itself 
between the entire space of the folded membrane. It reaches the free edge of each 
valve at three points only ; namely, at the centre, where it forms the corpus aurantii, 
and at the two extremities. Between these points it stops short, and has a definite 
limit and outhne ; a scolloped edge : and so leaves two crescentic portions of the 
valve formed merely by the doubled endocardium. The crescentic margins are thin 
and transparent : the remaining shield-shaped portion of the valve is more or less 
thick, firm, and opaque. 

And the physiological reason of this arrangement is also apparent enough ; though 
I failed to perceive it until it was pointed out to me by Mr. Thurnam. Each valve, 
when opened out, is convex towards the ventricle. The three valves do not merely 
meet by their edges. Their common purpose would be but insecurely provided for 
if such were the case. They meet and bend up, and come broadly into contact 
with each other. Each valve during the diastole has its right and left crescentic por- 
tion applied respectively to the corresponding portion of its right and left fellow valves. 
The thin segments are pressed mutually together, and lie dos-d-dos, as dancers say; 
while their edges look in the direction of the vessel. All this you may convince 
yourselves of by injecting the aorta of an ox with wax, and picking out the wax 
when it is cold. 

Now the curious fact which first led me to remark this natural structure is, that 
the minuter vegetations, which form upon the aortic valves, in acute rheumatic car- 
ditis, most commonly arrange themselves in a row, like a string of beads, along the 
line of union between the scolloped edge of the thicker scutiform portion of the valve, 
and the inner convex margin of the two thinner crescentic portions. Sometimes 
they follow that double festoon very exactly and completely : sometimes the conti- 
nuity of the line is broken, and the excrescences straggle from it a httle ; but still 
the general tendency to adhere to it is evident. No one that I know of has pubhcly 
noticed this fact ; yet that it is a fact, a good many persons, who have been for some 
time about the Middlesex Hospital, are perfectly aware. The truth is, that death 
seldom happens early in these cases ; and perhaps the valves have not always been 
carefully examined when opportunity did offer. My friend. Dr. Latham, had been 
watching, for such a case in vain for some years.J" Recently, however, two of his 
hospital patients died in the first attack of rheumatic carditis ; and he tells me that, 
looking with great interest for the morbid appearances within the heart, he found 
them such as I have been stating. I have chanced to see six or eight such early 
fatal cases. 

The arrangement just described is the most common one, so far as the aortic valves 
are concerned : but sometimes even there, and generally upon the mitral and the 
tricuspid valves, the little wart-like excrescences have a different position ;' jagging 
the free edge of the valve with numerous fine serroe, hke the teeth of a small saw ; 
or being disposed, just within its border, in one continuous line. 

After what has been said, you will readily detect the physical cause of this curi- 
ous distribution of the wart-hke excrescences. The membrane suffers aczf/e inflam- 
mation. Soft lymph exudes from, or is deposited upon it : and as fast as it is formed 
it is pressed aside, by the repeated concourse of the opposed surfaces, from the cre- 
scentic portions of each valve ; and heaped up along the boundary lines of contact ; 

3 H 



686 



RHEUMATIC PERICARDITIS. 



just as a thin layer of butter on a board would be displaced, and heaped up in a 
little curvilinear ridge, by the pressure of one's thumb. The double festoon, and the 
little marginal teeth, are obviously both formed in this way. 

If my verbal description has been insufficient to make all this clear to your appre- 
hension, the drawings before you speak, I hope, in plainer language. 

These, then, are the appearances commonly seen within and without the heart, 
when the patient does not long survive the first attack of rheumatic carditis. When 
death takes place at a later period, you find more than this. You find the conse- 
quences which flow from these primary lesions, operating as mechanical causes of 
further change : hypertrophy and dilatation in their various degrees and combina- 
tions. 

You will please to bear the primary changes in mind : for they satisfactorily 
account for the physical signs of pericarditis and of endocarditis which are displayed 
in these cases, and which I shall describe and explain after I have shortly inquired 
into the general symptoms. 

The symptoms, then, of pericarditis, as set down by authors, and such as I have 
myself frequently noticed, are the following. There is often, very early in the 
disease, a singularity of manner, and peculiar expression of countenance, difficult to 
describe, yet strikingly manifest to the observer ; a strangeness of deportment mixed 
somehow with an aspect of distress. To this are frequently added, palpitation ; a 
sense of oppression at the epigastrium ; a catch in the breathing ; a dry cough ; 
inability or unwilhngness on the part of the patient to lie ojn his left side ; pain in 
the situation of the heart, increased by a full inspiration, Iby pressure upon or be- 
tween the corresponding ribs, and more particularly increased by pressure upwards 
against the diaphragm by means of the fingers thrust beneath the cartilages of the 
false ribs ; stiffness and pain in and about the left shoulder, and extending thence 
down the left arm, and stopping short perhaps at the elbow or wrist. This last cir- 
cumstance, however, the pain shooting down the arm, is more common in chronic 
affections of the heart. And I have yet another symptom to mention, and a very 
important one ; and that is dehriura, sometimes quiet, but often wild and furious de- 
lirium, not dependent upon any disease of the encephaion. 

Of course there are also the febrile symptoms which accompany the acute rheu- 
matism ; or if the pericarditis occur independently of acute rheumatism, there will 
be fever symptomatic of the local inflammation. 

Now each of these symptoms I have repeatedly observed ; but they seldom all con- 
cur in the same case. If they did there would not be much difficulty in the diag- 
nosis : nor would the cardiac disease be so often overlooked as it is. The diagnosis 
of pericarditis has been confessedly uncertain and obscure. Not unfrequently, 
nearly all the symptoms I have been enumerating are wanting ; or so indistinctly 
marked as to attract no attention. It is therefore an important matter to ascertain 
what help we may derive, in these equivocal cases, from auscukation. 

In truth, the help we sometimes get is peculiarly valuable and satisfactory. There 
are certain morbid sounds to be heard when the heart is beginning to labour under 
rheumatic carditis. \ 

The morbid sounds w^hich rmy reach the ear applied in such cases to the surface 
of the chest are two : very distinct the one from the other, and very distinguishable : 
depending upon different causes, and denoting diversities of operation and of site in 
the morbid processes going on within. But they are not both heard in all cases. 

One of these sounds I have been accustomed to call a and fro sound. It 
conveys to the ear the notion"^of the rubbing of two rough surfaces, backwards 
and forwards upon each other. It seems near to the ear ; and therefore near to 
the surface of the patient's body. Like all the other morbid sounds heard within 
the chest, it is capable of much variety in tone and degree. Sometimes it very closely 
resembles the noise made by a saw in cutting through a board. Sometimes it is 
more like that occasioned by the action of a file, or of a rasp, or of a nutmeg-grater. 
But its essential character is that of alternate rubbing; it is a to and fro sound. This 
very pecuhar sound I had noticed and described, and explained, before I was aw^are 
that it had attracted the attention of any other persons. Others, however, had re- 



PERICARDITIS. 



687 



marked it, and had correctly interpreted its meaning. I claim no credit therefore 
for the discovery of what I think a very important symptom : but I claim for the 
symptom itself that additional weight which accrues to it, from its having been 
originally perceived by different observers, independently of each other. The 
physician who, in this country, without my being aware of it, had noted and pub- 
lished some cases in which this phenomenon occurred, is Dr. William Stokes, of 
DubHn. There is a good deal said about it by Bouillaud also ; and he too appears 
■ to have discovered the sound, without any previous knowledge of its having been 
noticed by others. I have heard the to and fro sound now in upwards of a score 
of cases. In a few of these it never ceased except with life. The patients died 
during the primary attack, and the to and fro sound remained as long as the heart 
continued to beat. In all the other cases, the to and fro sound was audible for a 
few days only, and then ceased entirely and for ever : the patients recovering more 
or less completely. 

The other of the two morbid sounds, is the ordinary bellows sound, with which 
you are already familiar. In the cases in question it is a single sound ; a deep-seated 
rush, or whiz, accompanying the systole of the heart. It usually continues long ; 
often for life. 

These two sounds, the superficial to and fro sound and the deep-seated bellows 
sound, may sometimes be heard, by a careful listener, to exist together. Sometimes 
the bellows sound begins to be distinguished when the rubbing sound ceases ; ap- 
pears to supervene upon it, or to take its place; perhaps it then first becomes audible, 
simply because it was previously drowned in the louder superficial sound. Some- 
times there is no to and fro sound, but only the deep blowing noise; or (what in 
many cases is extremely probable, nay, what I may venture to say. is certain) the 
to and fro sound has come and gorie unnoticed — un listened to. 

Now of these sounds, which I repeat are perfectly distinct, and capable of being 
easiljr discriminated the one from the other, the first mentioned, viz., the to and fro 
sound, is always indicative of inflammation of the external membrane ; the other, 
the bellows sound, is always, as I beheve, in these cases, indicative of inflammation 
of the internal membrane'of the heart. You will bear in remembrance, that I am 
speaking of these sounds as they somewhat suddenly occur for the first time, and 
especially as they occur in rheumatic carditis at its first accession. 

Those of you who have seen the thorax opened in an animal whose heart still 
continued to palpitate, may have observed, as I have done, that the pericardium lies 
closely in contact with the heart, but that a considerable extent of slipping motion 
between them goes on at every successive act of systole and diastole. They glide 
over each other evenly and without noise ; but this is only while the surfaces are 
smooth and healthy. When they are already made rough by inflammation and the 
deposition of lymph, which lymph always, as I have shown you, is rough in such 
cases, then the irritation will be no longer noiseless : it will give rise, in the alternate 
movements of the organ, to the harsh and superficial to and fro sound. But why 
does that sound, when once it has occurred, at length cease ; and why, having once 
ceased, does it never by any accident, when the inflammation has been universal, 
recur? Clearty because the pericardium has become adherent to the heart : after 
which there can be no motion of the one membrane over the other, and therefore 
no sound indicative of such motion. 

That this is the true explanation of the occurrence, and of the permanent cessation, 
of the to and fro sound, I am now (March, 1837) convinced, ft was a matter of 
inference with me for some time. A few of the "patients died during the primary 
attack. By much the majority recovered. I do not mean got perfectly well as they 
had been before ; but they regained a great share of their usual health, perhaps 
thought themselves well, and left the hospital Avhere they had been under treatment. 
Now of those who died, the pericardia were non-adherent. The opposite surfaces 
of the membranes were rough, and like tripe : and the to and fro sound never ceased 
in these persons. Such cases are always soon fatal. But, in the others, did adhe- 
sion take place ? I make no doubt of it. Within the last twelve months I have had 
demonstrative proof of it in two instances. One of these occurred in a hospital oatient, 



688 



PERICARDITIS. 



whose case has been published in the Medical Gazette.^ He was a painter, nine 
teen years old ; and he became my patient last May, with acute rheumatism and 
carditis. From the 26th of May to the 13th of June, a to and fro sound was dis- 
tinctly audible, as well as a bellows sound which had preceded it. After that date, 
the bellows sound continued, but the rubbing sound was no longer to be heard. The 
patient improved ; and was about to be discharged from the hospital : when, on the 
29th of June, sixteen days after the sound of friction had finally ceased, he suddenly 
dropped down dead in the garden of the hospital. 

Here 1 had concluded that the pericardium was adherent ; though I had not ex- 
pected to have so soon the opportunity of verifying my opinion. And accordingly, 
except over a small portion of the posterior part of the right ventricle, the union was 
complete at all points. The agglutination was evidently the work of recent disease. 
The medium of adhesion, was of considerable thickness ; and consisted of coagulable 
lymph and coagulated half-organized blood. The pericardium was stripped off, as 
I have seen a poulterer skin a rabbit, and with about the same ease. This was a 
very interesting case to me, for it was the first in which I had had the privilege of 
examining the heart after having witnessed the peculiar succession of phenomena 
that I have been describing. 

But since that time, I have met with another such a case in private practice. The 
particulars of it are sufficiently important to warrant my relating them.t 

In the month of October, 1836, I was taken b}^ Dr. Sweatman to see a patient 
of his ; whom I found sitting up in bed, pale, with sharp features, breathing 
shortly and laboriously. His legs were anasarcous, and his belly was tense and 
fluctuating. 

I learned that he had been for years given up to intemperance in drinking, and to 
indolent and low habits. He told me that the wind troubled him, shooting up through 
the whole of the left side of his chest. On further inquiry I found that he meant 
that he had much pain there. There was loud wheezing over the upper lobes of 
both lungs: both sides of the thorax were dull on percussion at their lower part; 
and on the right side no breathing whatever was audible below. These latter symp- 
toms were indicative of dropsical effusion into the pleura also. The jugular veins 
were swollen and tortuous on both sides of the neck. On applying my ear to the 
pra^cordial region I at once heard a very loud and distinct to and fro sound. This 
was equally manifest when he held his breath. Dr. Sweatman, who was not so 
much accustomed as I have been to hsten to the sounds of the heart in disease, re- 
cognized instantly the peculiar character of this sound. I ventured to express my 
certain conviction, that the patient was labouring under recent and acute pericarditis. 
I added, that he had also hydrothorax ; and that, whatever chronic changes might 
have taken place in his heart previously to his present illness, dilatation of the nght 
cavities constituted at least one of them. 

He had been attacked by his present urgent symptoms three days before I saw 
him, viz., on the 8th of October. On that day, in all probability, the inflammation 
of the pericardium commenced. 

This was his history. In the spring of the year, having, from indolence, kept the 
house for months before, he crossed from the Isle of Man to Liverpool, and was sick, 
and suffered a good deal during the passage. After landing he had a mile or more 
to walk. His companions outstripped him, but were called back to him, and found 
him very pale, breathing with difficulty, and unable for a time to proceed. He 
attributed all his subsequent complaints to that exertion : and he had been ailing, 
though not confined to his room, till the 8th of October. I did not venture, in his 
condition, to open a vein: but leeches were appHed to the praecordia, and he took 
diuretics. 

I did not see him again till the 15th of October, four days after my first visit. The 
rubbing sound was still there, though less loud, less harsh, and less extensive. The 
leeches had given him much relief. His pulse was very small. A blister was now 
apphed. On the 20th I saw him for the third and last lime ahve. The rubbing 



* Vol. xviii. p. 701. 



t Medical Gazette, vol. xxi. p. 544. 



PERICARDITIS. 



689 



sound was quite gone. This Dr. Sweatman also satisfied himself of. There was a 
dull systolic bellows sound in its place. The pulse was scarcely perceptible ; but 
he continued apparently improving, making avast quantity of urine, while the drop- 
sical swellings fast diminished, till the 31st; when, after talking a short time oddly, 
and in a peculiarly loud voice, he sat up to take some medicine, and, having done 
so, reclined his head against the nurse, and expired. Mr. Shaw assisted in the sub- 
sequent examination of the body. I omit giving an account of the condition of the 
lungs and pleura, which was what we had anticipated, and confine myself to the 
state of the heart. That organ was large. The pericardium was adherent univer- 
sally by means of lymph, mottled with blood ; and it was easily separated, so that 
the adhesion must have been recent, as was proved, indeed, by the symptoms. The 
right cavities of the heart were very large, and the aorta was diseased. 

The existence of the to and fro sound in these cases, no one can doubt who has 
once listened for it when present; and the facts respecting it, which have been estab- 
lished beyond the reach of controversy, are these : ■ — 1st. That when it occurs de 
novo, it always surely denotes acute inflammation of the pericardium. I say de 
novo, because (as I stated in the last lecture) a bellows sound may accompany each 
movement of ihe heart, in consequence of internal disease of some standing; and 
this double, sawing, bellows sound, might possibly be confounded with the ahernating 
iloises produced by the attrition of the opposite surfaces of the inflamed pericardium. 
2dly. The to and fro, or rubbing sound, is never of long duration, but soon termi- 
nates in one of two ways. Either the patient dies in' a short time, the sound conti- 
nuing to the last; and then the pericardium is found coated with rough lymph, but 
throughout the far greater part of its extent, or altogether, w?7adherent : or the sound 
ceases, never to return, while the condition of the patient improves ; or he even 
seems, to himself and to others, to recover his perfect health. In these cases, the 
sound ceases from a physical impossibility of its continuance, viz., from adhesion of 
the pericardium over the whole, or the greater part, of the surface of the heart. And 
in this category of apparent but unreal recoveries, I cannot doubt that many of Bouil- 
laud's cases of pericarditis terminating in health''^ ought to be included. 

It follows as a necessary consequence from these facts, that acute pericarditis, so 
far advanced as to occasion the pathognomic rubbina: sound, does not admit of a per- 
fect cure ; and that its best event is the adhesion of the membrane, and the oblitera- 
tion of its cavity. 

AnTl even then, I say, the change is not final. Mere adhesion of the pericardium 
does so embarrass the movements of the heart as to produce at length, sometimes 
rapidly, sometimes slowly, hypertrophy, or other alterations which have already been 
considered. It is held, too, and I beheve justly, though I am not so sure of this as 
of some of the other points I have been dwelling upon, that the inflammation which 
begins in the membrane, sometimes dips into the muscular substance of the heart, 
weakens its elasticity and cohesion, and so leads ultimately to dilata.tion of its 
cavities. 

I need not occupy much of your time in speaking of the other morbid sound that 
is audible in these cases, the bellows sound : which sometimes may be heard before 
the to and fro sound commences ; which I have heard through the to and fro sound ; 
and which often remains after the superficial rubbing sound has ceased. This de- 
pends, no doubt, upon those akerations in the valves of the heart which take place 
from inflammation, at the same time with the, alterations of the pericardium. And 
when it is met with in such cases, it may be set down as very strong evidence of the 
existence of endocarditis. 

I am anxious that you should take an interest in the disease which I have been 
speaking of at so much length this evening, and that you should keep it in mind in 
your future practice ; for I am sure that it is a fertile, but often unsuspected, source 
of chronic disease of the muscular substance of the heart, and of its consequences : 
asthma, dropsy, sudden death. The number of patients that come into the hospitals 
of London affected with acute rheumatism, is annually very large ; and I am sure 
that I do not exaggerate when I say that nearly one-half of them have the heart or 
its membranes implicated. The cardiac affection may easily be overlooked, both by 
44 3h2 



690 



RHEUMATIC CARDITIS. 



the patient and the physician. The recovery may appear to be perfect. But after 
some time, palpitation begins to be occasionaiiy felt ; and, by degrees, other sj^mp- 
toms, marking disease of the heart, declare themselves : but their origin is unsus- 
pected or forgotten. You will be surprised, if you search back into the past history 
of all the patients vv^ho apply to you having disease of the heart, especially among 
the lower classes of society, — you will be surprised to find how many of them will 
tell you that at some time or other of their lives they have been laid up with rheu- 
matic fever. 

It is no part of my purpose .to treat at present of that specific disease of the joints 
to which we give the name of acute rheumatism : but I may as well complete what 
I have to say of carditis as it occurs in connection with that disease; and then I shall 
not need to repeat myself when I come to rheumatism itself. 

In the first place, then, I would say a word more respecting the nervous dis- 
turbance which is apt to supervene in such cases, and to mask the real disease, and 
to mislead the unwary practitioner. Patients labouring under rheumatic carditis 
very frequently become affected with dehrium, or violent mania, or stupor and coma, 
or convulsions, or all of these in succession : and you might suppose that they were 
labouring under inflammation of the brain, or of its membranes. Such cases are in 
fact spoken of as cases of metastasis to the brain. It may sometimes be so, nay, I 
know that it sometimes is so ; but not often. Again and again, when death ha"s 
occurred, and the dehrium had been extreme, no traces of disease have been dis- 
coverable within the skull, while marks of violent and intense inflammation were 
visible in the pericardium. I presume that the acute cardiac affection interferes 
somehow with that regulated supply of blood to the head, which is necessary for the 
due performance of the cerebral functions. But whatever the explanation, recollect 
the fact; and whenever, in acute rheumatism, you find your patient flighty and 
wandering, or more distinctly dehrious, examine carefully the condition of his heart. 

As this is really a point of great importance, and as you will not find much in- 
formation respecting it in books, I shall take leave to quote, here, some part of a 
clinical lecture delivered by myself at the Middlesex Hospital, in the year 1835, and 
printed in the I6th volume of the Medical Gazette. My subsequent experience has 
been quite in conformity with what I then stated. 

"The functions of the brain not unfrequently become disordered in rheumatic 
fever: and disordered in such a manner and degree as would lead, and has led, 
many to believe in the presence oT active inflammation of that organ, or'of its 
enveloping tissues. Yet this affection of the brain is not, I beheve, inflammation, 
but some secondary afiection of the circulation therein ; resulting from disturbance 
at the central organ of the circulation, capable of producing a corresponding derange- 
ment in the cerebral functions. I can best explain what I mean by reciting a few 
examples. 

" The first case of this kind that I ever saw or heard of, occurred in St. Bartholo- 
mew's Hospital, many years ago. I took notes of it at the time, and will read you 
the substance of them. Charlotte Rankin, aged 17, was admitted there on the 12th 
August, 1824, under the care of Dr. Roberts, with acute rheumatism of the joints. 
Her illness had come on suddenly a week before, after unusual exposure to cold and 
wet. The pain and swelling had shifted much from joint to joint. She had been 
bled, on account of pain in her left side, two days before admission. On the 14th, 
she complained of much difficulty of breathing, and of pain when even sHght 
pressure w^as made upon the chest. These symptoms were entirely removed by a 
blister. On the 16th, she was observed to be odd in her manner — peevish, querul- 
ous, restless, without sleep, and desirous of getting out of bed. Her pulse was then 
100. On the 20th the pulse had risen to 120 ; it was quite regular. She said she 
felt no pain, except the soreness occasioned by the blister. She slept very little. On 
the 21st, the pulse was 128. Som.e jactitation of the left arm was now observed, 
which, she said, had never happened before. No sleep. On the 22d, about nine in 
the evening, she became furiously maniacal, and it was necessary to confine her by 
a strait-waistcoat. She continued in that state for upwards of four hours, and then 
died. 



HEAD SYMPTOMS. 691 

' "Twelve hours afterwards the body was examined. The brain was found quite 
I healthy : its vessels seemed, indeed, somewhat fuller of blood than is usual, but there 
I was no effiision, nor any other vestige of inflammation. 

"The pericardium was glued to the heart in several places, by recent adhesions ; 
' and it was universally coated, where not adherent, by a layer of rough, reticulated 
lymph, remarkably harsh to the touch. 

" Now here the most prominent symptoms were such as we are accustomed to 
refer, with tolerable confidence, to inflammation of the membranes of the brain ; 
i whereas, in fact the inflammation was strictly confined to the heart. If no examina- 
ji| tion of the bod}'- had been made, the case might have been quoted, with much show 
J of reason, as a well-marked example of metastasis to the brain. It was so considered 
before the brain was inspected. 

"There had, indeed, been symptoms which indicated, and that not obscurely, the 
cardiac disease. At that time, however, I did not know how frequently carditis is 
combined with acute rheumatism. Auscultation had not yet come much into fashion 
I in this country ; at any rate, I knew little or nothing of its use ; and I had supposed 
(and it had been supposed by others who witnessed the case) that the chest symp- 
toms resulted from rheumatism of the intercostal muscles. 

• "Another instance, in which the course of the symptoms was somewhat different, 
yet equally calculated to mislead, you have lately seen in this hospital. 
; " Wilham Wilkins, a post-boy, 28 years old, was admitted on the 25th of last 
November. 

" He complained of pain in most of the large joints, shifting from one joint to 
' another. There was no visible redness or swelling, but he had much fever. The 
\ pain was greatest at night. He had profuse perspirations, during which the pain 
|: was not mitigated. 

"He had b^en ill eight weeks ; and at first his joints (according to the statements 
j of his friends) were both swelled and red. He appeared to be recovering at one 
I time, but relapsed. For three or four days previously to his admission he had 
I coughed a little, and spoken of pain at the pit of the stomach. He lay more com- 
I fortably on the right than on the left side, but this was habitually the case. He had 
never had acute rheumatism before. 

" He rambled a good deal during the night of the 26th, and on the 2Tth, he began 
tcf refuse to take his medicine, appeared confused and stupid, and answered questions 
tardily and imperfectly. • He was bathed in perspiration, which had the strong acid 
smell so common in cases of acute rheumatism. 

" During the next ten days he remained in a singular state of quiet delirium, re- 
jecting medicine and food, saying he had had enough ; getting out of bed, especially 
in the night, and declaring that he was going home. When questions were put to 
him, his lips moved, and his limbs began to stir and fidget, as though he were about 
to answer; yet he said nothing. He understood what was said to him, and put out 
his tongue when desired so to do ; imperfectly, however, and with slowness and 
apparent difficulty. His bowels were costive, and he passed his stools, when pur- 
gatives acted, in the bed. His pulse was small and frequent ; and when his wrist 
was taken hold of that the artery might be felt, he always resisted, and forcibly con- 
tracted his arm. 

"Then for three or four days he appeared to improve; his countenance became 
more clear and lively ; but he still showed the same restlessness, and maintained 
the same dogged silence when spoken to, and obstinately refused to swallow medi- 
cine. He was somewhat cunning, too, for he would take pills into his mouth, and 

j then, when he thought he was not observed, chew and spit them out again. 

" His pulse became at last very frequent, and his strength diminished rapidly. 

\ He died on the 18th December, and the body was examined on the following day. 

! "The cerebral veins were gorged with dark blood, and there was a considerable 

' quantity of serous fluid beneath the arachnoid and in the lateral ventricles. 

I " The pericardium was free from disease ; but upon the mitral valve, near its edge, 
there was a perfect row of small, slender, bead-like warts. 

I "A few weeks ago I was consulted in a case of a similar nature, which occurred 



I 



692 



RHEUMATIC CARDITIS. 



in the practice of a gentleman who was formerly a pupil here, and who was fully 
aware both of the frequent occurrence of carditis in acute rheumatism, and of the 
anomalous symptoms with which it is sometimes attended. The patient was a young 
man, 24 years of age. 

" On the 22d of December he was seized with pain and swelling of several of the 
larger joints, and with fever. The attack was ascribed to exposure to cold the day 
before ; he had previously enjoyed perfect health. The inflammation shifted rapidly 
from one joint to another. He was confined to bed for six days : then, feeling better, 
he got up, changed his room, and presently underwent a relapse. Mr. Elv/in tells 
me that, after that time, he was never comfortable about this patient ; his countenance 
was pale, and his aspect unpromising; his pulse frequent; and more than once he 
complained of shght pain in the epigastrium, increased by a full inspiration. This 
was removed by a mustard-poultice. No morbid sound was detected upon a careful 
examination of the praecordial region by the ear. He rem.ained low-spirited, but 
slowdy mendings till the 3d of January, when in the evening, without any notice or 
obvious cause, he began to be restless and delirious. 

" On visiting him the next morning, Mr. Elwin found him with an anxious coun- 
tenance ; a frequent and irregular pulse, which occasionally intermitted ; his mind 
wandering; the action of his heart strong, and attended towards the sternum with a 
loud bellows sound. The next day his breathing was difficult, and 'catching;' the 
pulse 120, hard and wiry. At that time I had the opportunity of seeing him. He 
was lying in a sort of stupor, yet not unconscious, for he put out his tongue at my 
request, and answered pertinently one or two questions, after they had been frequently 
repeated. He had the air of a person obstinately determined to say as hltle as pos- 
sible. He became more distinctly delirious towards evening; and the next day his 
pulse and breathing were both so frequent (148, and 78, in the minute respectively), 
that he was thought to be dying. A distinct bellows sound was audible, near the 
left mamma. This state continued, with slight fluctuations, till the 8th, when his 
condition appeared somewhat more hopeful. He was calm, had no dyspncea, and 
conversed more readily, — saying sometimes that he felt as if he were ' dead ;' some- 
times that he was ' burnt up.' He complained, for the first time, of pain in the right 
temple ; his gums were slightly under the influence of mercury ; his pulse scarcely 
exceeded 100 ; the bellows-sound was very manifest. 

"On the 9th he again became, first restless, then violently and wildly delirious, 
screaming out, refusing to take medicine, or to open his n:-outh when it was offered ; 
)^et he evidently knew what was said to him. During the night general convulsions 
came on in occasional spasms, of a tetanic character : in the intervals between them 
he la}'- in a state of coma. He survived in this condition till the 12th. 

" 1 was present at the inspection of the body ten hours after death. Some of his 
family insisted on being in the room with us ; but we were able to make an accurate 
examination of the head, and of the heart. 

"The veins of the brain seemed somewhat fuller of blood than is common. The 
arachnoid was shghtly elevated by a clear serous fluid collected in the pia mater. 
There was but a small quantity of a similar fluid in the lateral ventricles. The lungs 
appeared quite healthy. 

" There was no fluid in the pericardium. Its surface was everywhere exceed- 
ingly vascular, but it presented no appearance of lymph, except where it adhered to 
the posterior side of the heart, bver a space about two inches and a half in length, 
and upwards of an inch in breadth. The lymph which formed the medium of con- 
nection was firm, but evidently of recent formation; and a very slight degree of 
force sufficed to separate the adhering membranes. The heart was rather small, 
and the left ventricle had a singular wrinkled appearance externally. Towards the 
edge of the mitral valve there was a profuse crop of httle wart-like vegetations, of 
the size of millet-seeds ; and numerous red lines converged towards them from the 
base of the valve. The aortic valves all presented curious festoons of similar ex- 
crescences, larger, however, and more prominent, than those upon the mitral valve. 

" In the beginning of the year 1882, a girl nineteen years old, Frances Kirk by 
name, was a patient of mine in the hospital, with acute rheumatism of the joints, 



HEAD SYMPTOMS. > 



693 



and carditis, manifested by many of the most usual symptoms — by pain in the situa- 
tion of the heart, dyspnoea, great frequency of pulse, and a distinct bellows sound. 
She lived two montihs from the commencement of the cardiac disease. During that 
period she was at times wildly dehrious — at times stupid, taciturn, and almost idiotic 
— and at times quiet and rational. The brain in that case was found perfectly iiealthy, 
except a slight serous effusion beneath the arachnoid. The pericardium was every- 
where adherent to the heart. By some mismanagement the opportunity of inspect- 
ing the inner membrane of the heart was lost. 

"In each of the three last-mentioned cases there v/as more or less serous fluid 
found in the meshes of the pia mater, and in the lateral ventricles. You may ask, 
perhaps, whether this effusion was not good evidence of previous inflammation there ? 
whether it did not show that the metastasis, which I have spoken of as seldom hap- 
pening, really did happen in these very cases ? 

"I apprehend not; and for the following reasons: — In one only of these cases 
was the amount of the serous accumulation at all considerable. There was no othe^' 
trace of inflammatory action in any of them ; no redness, nor pus, nor lymph ; none 
of the unequivocal products of inflammation. What quantity of serous efTusion be- 
neath the arachnoid, or in the ventricles of the brain, is requisite to establish its 
morbid origin — within what hmits such effusion may be considered natural — whether 
it may not be ascribed wholly, or in part, to mechanical transudation after death ; 
these are questions which have not yet been definitely settled among pathologists. 
For my own part, whenever I" see the veins of the pia mater full of blood, I expect 
to find serum between that membrane and the arachnoid. How much of it may 
have been poured out before death, and how much afterwards, it would be difficult 
to estimate. In each of the cases before us there was evidence, not to be mistaken, 
of cardiac inflammation. Now that acute inflammation, fixing itself upon some 
portion of the heart, should embarrass its action, and modify the condition of the 
circulation through the cerebral blood-vessels, is not only conceivable, but highly 
probable. Any retardation of the venous circulation in the head — any engorgement 
or congestion of that system of vessels — would be hkely, if we may reason from the 
analogy of other parts, to produce effusion. I have seen, in the brain of a criminal 
who had been hanged while in a state of perfect heaUh, as much serum collected in 
the same parts as we found in the patients whose cases I have been relating. It is 
possible that, in them, the disorder of the sensorial functions depended upon simple 
disturbance of the cerebral circulation ; it is possible that the same disorder depended 
upon the serous effusion ; and it is possible, and (I think) probable, that it depended 
in part upon both these causes. It is very certain that similar symptoms have 
occurred in similar cases, when there was no appreciable effusion ; and, apparently, 
from mere derangement of the natural circulation of the blood in its vessels. On 
the other hand, we know that an equal, or a greater amount of effusion, has often 
been observed, when no such cerebral symptoms had manifested themselves. I 
conceive, therefore, that the symptoms referable to the brain, and the quantity of 
serum found effused there (whether these bear to each other the relation of cause 
and consequence, or not), are both to be regarded as secondary effects of the cardiac 
disease ; that they denoted no inflammatory condition of the brain, or of its mem- 
branes, but were the common !"esult of that inflammation of the heart, concerning 
the existence of which the inspection of the bodies left us no room to doubt. 

"That this view of the matter is correct, is the more probable because (as I just 
now stated) the same symptoms have been known to accompany carditis, although 
no serous effusion was met with in the head. There was none in the case of the 
girl Rankin ; none in a case related by Dr. Davis ; none in a remarkable case de- 
tailed by Dr. Latham ; none in a striking example of a similar kind which fell under 
the observation of that accurate and most accomplished pathologist, Andral. I shall 
take the liberty of citing these two instances. 

" ' One of the children of Christ's Hospital,' says Dr. Latham, ' had, in the opinion 
of all who saw him, the severest inflammation of the brain. The attack was sudden, 
with great heat and frequency of pulse. He had delirium and convulsions, and 
point( d to his forehead as the seat of his pain. In three days he died, and, upon 



694 



RHEUMATIC CARDITIS. 



dissection, not a vestige of disease was found within the cranium ; but the heart was 
exclusively the seat of the disease, and no other part of the body discovered the 
slightest morbid appearance. The disease of the heart was not confined to its mvest- 
ing membrane. It was the most intense inflammation pervading the pericardium 
and the muscular substance.' 

"Andral's case, which is referred to by Dr. Latham, occurs in his Clinique Me- 
dicale. 

"A woman, twenty-six years old, was brought to La Charite, in a state of delirium, 
and no account could be obtained of her previous condition. The delirium was re- 
markable for the obstinate taciturnity which attended it. When questioned, the 
patient turned a fixed gaze upon the person who spoke to her, but made no reply. 
Her face was pale ; her pulse small and frequent. During the two following days 
the head was frequently drawn backwards, the trunk was shaken at intervals by 
convulsive movements, and she had subsultus tendinum ; but she now spoke, and 
appeared to comprehend what was said to her, but talked incoherently. The pulse 
was very frequent, and intermitting. On the fourth day the dehrium ceased ; she 
com.plained of nothing but great debility. The muscles of the face were almost 
continually agitated by convulsive twitchings, and the arms from time to time pre- 
sented a sort of tetanic stiffness. On the fifth day the delirium returned ; the patient 
then fell into a state of coma, and died the next morning. 

"Neither the brain, nor the spinal marrow, nor their membranes, presented any 
appreciable morbid appearances. The pericardium was lined by coagulable lymph, 
and its opposite surfaces were connected, in some places, by recent bands of adhe- 
sion. It contained also some ounces of a greenish flaky serum. No other trace of 
disease was discoverable. 

" Now if you are not made aware beforehand of this strange course of the syrap- 
tom.s arising, sometimes, out of rheumatic carditis, you will be apt to overlook the 
cardiac affection, and to direct your remedial measures wide of the mark. In a se- 
cond instance mentioned in Dr. Latham's essay, 'the whole force of the treatment 
was directed to the head, from a belief that the brain was inflamed. Upon dissection 
the brain and its coverings were found in a perfectly healthy and natural state ; and 
the pericardium, towards which during hfe there was no symptom to direct the 
shghtest suspicion of disease, discovered the unequivocal marks of recent and acute 
inflammation.' Dr. Davis, also, in reference to a case published by him so early as 
1808, has the following remark : — 'The restlessness in the case of Miss H. C. was also 
attended with dehrium, a symptom not previously noticed as belonging to pericarditis 
by any writer whom I have consulted. It was so prominent a feature of the disease 
under which this young lady laboured, as to divert the attention of her medical at- 
tendants from its actual seat.' 

" This occurrence, in the course of rheumatic carditis, of cerebral symptoms calcu- 
lated to perplex and obscure the true nature of the disease, is probably not so rare as 
has been supposed. In less than three years three instances of it have fallen under 
my own notice ; and I have been informed by a medical man residing in the neigh- 
bourhood, that a friend of his, who has a very large general practice among the 
middle and lower classes, attended within the last year or two not less than twenty 
cases of acute rheumatism, in which a metastasis, oi**an extension of the inflamma- 
tion, appeared to take place to the brain. 

" In all the detailed cases of this kind that I have met with, and in those which I 
have myself watched, there were certain general points of similarity, which you will 
do well to bear in mind. In all of them the pulse was extremely rapid ; the deli- 
rium, though violent and active at intervals, was characterized for the most part by a 
singular, and, as it seem.ed, perverse taciturnity : even when the patient was evi- 
dently able to speak, and understood the questions that were put to him, he main- 
tained a sullen silence. In most of these patients, also, not long before the fatal 
event, a brief interval of amendment took place, and encouraged some hope of 
recovery. In many of them various convulsive movements were observed ; and in 
two of the cases the head symptoms, and probably the heart disease also, supervened 
after a relapse of the rheumatism of the joints." 



HEAD SYMPTOMS. 



695 



It is a curious circumstance that rheumatic carditis is sometimes the first step in 
the whole disease ; the cardiac symptoms will sometimes, I mean, precede those of 
the joints ; even by two or three days. For example. A lad was brought to the 
hospital with acute articular rheumatism, and with unequivocal symptoms, which I 
need not detail, of carditis. He gave the following distinct history of his illness : — 
He had been on a visit into the country several days before, and there, after having 
felt poorly for nearly a week, with a sensation of "sinking within him," he ate 
largely of oysters, and drank more porter than he was accustomed to. On the same 
day he was seized with pain in the left side of the chest, and violent beating of the 
heart. The attack was probably a severe one, for he applied to a medical man, 
who immediately bled him. In the course of the ensuing night he began, for the 
first time in his life, to feel some stiffness beneath and about his knees, but he was 
able to walk about the next day. On the evening of the second day the joints 
became so painful and swollen, that he could not leave his bed, and then the pain of 
the side and the palpitation diminished. This boy has several times since returned 
to the hospital with acute rheumatism, and on each occasion presented manifest in- 
dications of some permanent affection of the heart, — slight, probably, in amount, but 
aggravated upon every return of inflammation of the joints. 

I have met with one or two other instances in which the cardiac disease appeared 
to have preceded the arthritic; but none so well made out as that I have just related. 
Dr. Duncan, in the Edinburgh Medical and Surgical Journal for 1816, gives a 
case of " inflammation of the heart" which began with symptoms oi pectoral inflam- 
mation. Succeeded the next day by rheumatic affections of the joints. 

One law respecting the connection between the cardiac and the arthritic symp- 
toms may be stated with confidence, namely, that the younger the patient is who 
suffers acute rheumatism (and I have seen it so early as the third or fourth year) the 
more hkely will he be to have rheumatic carditis. The chance of the combination 
appears to diminish, after puberty, as life advances. I have known only two persons 
pass through acute rheumatism with an untouched heart prior to the age of puberty; 
and in these two I am by no means certain that the articular disease was genuine 
rheumatism. In each of them, the large joints became painful, and swelled, for a 
day or two' only, tow^ards the close of scarlet fever: — a circumstance not, I believe, 
unusual. I was dreadfully apprehensive of carditis, but it did not occur. 

I have observed, also, that when a patient has come under my care who has had 
repeated attacks of acute rheumatism, in him I have generahy found reason to believe 
that some organic affection of the heart was present. Probably the disposition to 
such repetitions of the disease, so remarkable in some individuals, may be kept up 
by the cardiac complication. 

With respect to the period of the actual attack, and the circumstances under 
which the extension of the disease to the heart occurs, no fixed law has been ob- 
served. Sometimes the cardiac affection declares itself as the inflammation of the 
joints declines. Quite as often, however, they proceed together, and are aggravated 
or mitigated simultaneously. On this point my own experience nearly agrees with 
that of Dr. Latham, who says : — "It (the cardiac affection) is incident to all the de- 
grees and all the stages, and all the forms (?) of acute rheumatism. It is not more to 
be looked for when the disease is severe than when it is mild; more at its beginning 
than during its progress and decline ; more when it is shifting and inconstant in its 
seat, than when it is fixed and abiding." 

There are some other symptoms that I must not omit to mention as occurring in 
some cases of pericarditis. In one of the fatal instances which fell under my own 
notice, there was a very strong purring tremor felt by the hand placed upon the 
region of the heart. This is not a constant, nor even a frequent, symptom ; but it 
has a certain degree of corroborative value when it does occur. 

When the fluid products of the inflammation predominate, when there is much 
serum poured out, the symptoms, as well as the danger, will be different from those 
nvhich are remarked when there is not so much serous liquid. If the pericardium 
be distended, percussion will furnish a dull sound over an unusually large space; 
much beyond the natural limits of the precordial region: and you may often mea- 



696 



RHEUMATIC CARDITIS, 



sure the amount of the effusion, and its daily increase or decrease, very accurately 
in this manner. But the general symptoms will vary also. The pulse will be 
feebler, and more disposed to falter and to become irregular, in proportion as the 
liquid effusion is large ; and at the same time the patient will frequently be fixed in 
one position, and unwilling or afraid to change it, lest that small exertion should fur- 
ther excite the action of his heart, and hurry his respiration. He will lie, perhaps, 
always upon one side ; or he will remain immovable on his back, with his head ele- 
vated ; or he will sit up continuall}-, with his body leaning forwards ; and he will 
not dare to alter his posture. But when the solid products of the inflammation pre- 
dominate ; when there is coagulable lymph, and but little serum ; when the peri- 
cardium, instead of being distended, becomes attached to the heart ; then the pulse 
will retain that force and regularity with which the disease commenced, the dull 
sound yielded to percussion will not transgress the precordial limits, and the patient 
wih not in general experience any absolute necessity of accommodating his body to 
one constrained position. 

Of a merel}'' adherent pericardium there are no diagnostic signs to which, so far 
as I know, we can trust, either ausculatory or general. None, I mean, presented by 
the body at the time. If we are accurately acquainted indeed with the history of 
the patient's disease, and if we know that, at any time, a to and fro sound existed, 
which to and fro sound soon ceased, and has never recurred ; then our conclusion 
that the pericardium is adherent will scarcely be open to any source of fallacy. 

When the opposite surfaces of the membrane have been once united, they never 
separate again ; the adhesion remains for life. But the lymph interposed' between 
them, if the inflammation be not renewed, becomes less and less thick ; until at length, 
in some cases, a mere layer of firm, but thin, areolar tissue is left, through which the 
heart is visible. 

But when inflammation has stiffened the valves of the heart, or studded them with 
little wart-like masses of fibrin, how far do these morbid states admit of perfect re- 
covery ? It is not so easy to say. I am not aware of any facts, which would forbid 
altogether the hope that here, as in iritis, the re-absorption or removal of the lymph 
may be total, and the restoration of the parts complete. On the contrary, the com- 
parative infrequency of wart-hke excrescences in the slowly fatal cases of rheumatic 
carditis leads to the opinion that such deposits may disappear as readily and entirely 
from the valves of the heart as from the iris. 

Since I lectured upon this subject last year, two examples of rheumatic carditis 
have occurred among my hospital patients, differing in some remarkable points from 
any that I had ever seen. A brief description of them will complete my personal 
experience of this terrible disease. 

The histories of the two cases are curiously similar. The patients were young 
women ; their ages respectively twenty-one and twent3"-two. They were admitted 
during the same week ; one a day after the other. Both were suffering under a first 
attack of rheumatic fever ; both had also acute pleurisy, with effusion into the chest ; 
and both died ; one of them three weeks, and the other a month, after her admission. 
In both cases there were symptoms referable to the heart ; pain, and unnatural sounds; 
but in neither case was there any friction-sound ; nor were any traces of pericarditis 
discovered after death. But the inflammation had fallen, partially, upon the aortic 
valves ; whence it had extended (so I imagine) to the muscular substance. I show 
you the morbid appearances represented in these drawings, made by Mr. Lonsdale 
at the time : and, better stiU, I show you the parts themselves, which are preserved 
in our museum. 

The whole of one of the aortic valves was, in each case, a mass of ragged ulcera- 
tion ; and the adjacent portions of the two other valves were, in a slighter degree, 
implicated in the mischief. What remained of the tattered valve was covered with 
rough irregular shreds of lymph, or vegetations. In one of the cases, the ulcerating 
process had penetrated through ihe valve, and into the muscular substance beyond, 
and had eaten a hole completely through the septum. A portion of tymph protruded 
just below the valve of the pulmonary artery through the channel of communication 
thus formed between the left and right sides of the heart. In the other case, an 



\ 

ACUTE PERICARDITIS. 697 

; abscess as large as a hazel-nut was found in the muscular substance of the septum, 
I immediately opposite the disorganized valve. 

I TiJJ I met with these cases, I was not aware that this destructive incrustation of 
the cardiac valves with wart-Hke excrescences was ever the result of acule inflamma- 
tion. Chronic changes of that kind are not uncommon. Suppuration in the heart 
is very rare. In these two instances the cardiac affection was comphcated with acute 
pleurisy. I should have mentioned before, that the pleura very often participates in 

j the inflammation when pericarditis occurs. You will not wonder at this if you 

I consider the close vicinity, and the similarity in texture, of these two serous mem- 

j branes. 

! I must defer what I have to say respecting the treatment of acute pericarditis and 
i endocarditis, to the next lecture. 

i ' ' 



LECTURE LXII. 

! 

' Treatment of Acute Pericarditis, and Endocarditis : blood-letting ; mercury; 

blisters. Chronic and partial Inflammation of the Pericardium. Disease of 
i the Aorta. Thoracic Aneurisms ; their various situations, and symptoms; 
j plan of treatment. 

I TRUST that I made distinctly apparent, in the last lecture, the great danger which 
; belongs to ever}^ case of acute inflammation of the pericardium. First, there is the 
j danger of speedy death. If the inflammation goes to the extent of effusion, and the 
I collection of serous fluid be large, and the pericardium be distended by it, the action 
I of the heart is so much oppressed by the liquid surrounding it, that it falters and 
I flutters, and at length stops, and goes on no more. Secondly, there is the danger 
that (the pericardium having become adherent) other structural changes will, soon 
or slowly, develop themselves ; and first render hfe burdensome and full of suffering, 
, and then consign the patient to an earher grave than might else have awaited him. 

Now what can we do to prevent, or to diminish, these evils ? I once thought that 
I if we caught the inflammation at ils very commencement, we might calculate upon 
I a perfect cure, by first bleeding the patient freely, and by, secondly, putting him as 
speedily as possible under the specific influence of mercury. I am sorry to be 
obliged to say, that the more I see of this formidable malady, the more reason I find 
for fearing that it is seldom within the possibility of thorough repair. Bring the in- 
j flammation to a stop, you perhaps may ; or nature will do it for you ; and you may 
greatly assist the natural powers in effecting this. But that alone can be called a 
cure, which either leaves the structure of the part affected in its original integrity; 
or, at any rate, leaves no spring or source of further changes for the worse : and such 
complete recovery as this I seldom dare to hope for in cases of acute and general 
j pericarditis. 

j There can be no use in deceiving ourselves in this matter; but we may very easily 
deceive ourselves. In a large proportion of cases, whether they be treated well, or ill, 
or not treated at all, the patients wiU seem to recover. But I say that the recovery 
is so far unreal, that it involves the germ of future destruction. If any of you have 
read Bouillaud's heavy, yet instructive work on diseases of the heart, you will know 
that he boasts of the success of his treatment in acute pericarditis. He declares that 
by the bold use of the lancet he extinguishes the inflammation; jugulates (as he 
calls it) or slaughters the disease at its birth ; and restores the patient to the fufl con- 
dition of health, or to the state in which he was before the disease came on. You 
must hereafter judge of this question for yourselves ; but it is my duty to caution you 
against crediting these statements. Not that I would insinuate a doubt of M. Bouil- 
^ud's veracity ; but I beheve that he has been deceived by false recoveries ; and I 



698 ACUTE PERICARDITIS. 

would not have you beguiled, by his representations, into the indiscriminate adoption 
of that "enlightened hardiness" which he endeavours to inculcate. 

But if we look closely at his statements, we do not find, after all, any such won- 
derful success. Of 18 patients, 6 died ; a very large proportion, 1, viz. in 3. To be 
sure, with some ingenuity he makes the proportion to be 1 in 7. For three of the 
fatal cases occurred, he says, before he took to his heroic plan of blood-letting ; and 
excluding these 3, he has 15 cases, and only 3 deaths ; or 1 in 5. But one of these 
three proved fatal from the supervention of tetanus ; therefore setting that also aside, 
there will be 14 cases of the disease and 3 deaths. Now, I have not, hitherto, been 
able to look through ray case-books in reference to this point, but I am quite certain 
that the mortahty in the Middlesex Hospital has been nothing like so great as that — 
the immediate mortality, of course, I mean — either among my patients, or among 
those of my colleagues ; and I know that, until within the last twelve months, Dr. 
Latham had not lost a single case of rheumatic pericarditis in the course of the first 
attack of that disease for several preceding years. 

But what I most doubt about, is the true recovery of Bouillaud's surviving patients. 
I say such patients do apparently get w^ell. In some of them, indeed, a bellows 
sound remains, sufficiently indicative of (he damage that the organ has sustained: 
and I have already told you that any amount of change, however small, which alters 
the healthy proportion of the cavities and their outlets, or which interferes with the 
natural play of the heart, is a seed from which further changes will at length be 
found to grow. But patients will get so far well that you can detect nothing wrong 
about them. Follow them, however, in their subsequent hves ; and you will learn that 
many of them very soon begin to find that they are incapable of doing or enduring 
all that they could do or endure before their illness : and if this does not soon happen, 
it does at last. The disease of the heart (if the patient be not cut off by some other 
malady) becomes at length obvious ; and when he dies, the source of the ultimate 
changes is commonly to be detected. There is an adherent pericardium ; or there 
is disease of the valves; of which no other account can be given than that it had 
continued to exist since the primary symptoms of carditis ceased ; and that it had 
caused all the rest — the hypertrophy, to wit, and the dilatation. 

The remarks that I have now been making bear upon the question, to what amount 
blood-letting should be carried in acute pericarditis. If the general symptoms teach 
you that it exists, and yet no sound of attrition is heard, you may, in that case, if in 
any, hope to arrest the inflammation, and to achieve a complete cure, by early and 
copious bleeding. But if the to and fro sound has been audible, I do not think the 
consequences of the inflammation can be so abolished. I beheve that the best event 
which can then happen is adhesion. "We must, however, in many cases, take blood 
by the lancet from the arm, or by leeches from the precordial region ; yet not in the 
lavish manner recommended by Bouillaud. I know that his treatment has been fairly 
tried in this country, and has failed. And I think (but this I only offer as an opinion) 
that there is a peculiar risk in frequently bleeding to syncope in this affection. There 
is, almost always, endocarditis (in rheumatic cases at least) coincident with the peri- 
carditis ; and there is a readiness or tendency towards a deposition of the fibrin of 
the blood, in the shape of minute vegetations, upon the inflamed valves : and it is 
probable that this tendency may be favoured by a retarded movement of the blood 
over them ; and still more so by its temporary stagnation. In the experiments on 
the ass, referred to before, the circulation (kept up by artificial breathing) became 
languid and sluggish, and vegetations were deposited upon those valves which had 
been irritated by the wire. Hence there is, I think, a danger in bleeding to such an 
extent in these cases, as to bring the heart's action to a pause in deliquium. Bleed, 
therefore, (if you deem it requisite to bleed at all,) till some effect upon the pulse has 
been accomphshed, and then stop : and renew the venesection, or refrain from it, 
according to circumstances. But you may freely cup the precordial region, or cover 
it repeatedly with leeches : and to this mode of abstracting blood, from the neighbour- 
hood of the inflamed part, my own experience would assign the preference. In fact, 
I seldom open a vein in such cases. 

At the same time, you will endeavour to get the gums tender wath mercury. And 



ACUTE PERICARDITIS. 



699 



' it is most unfortunate that, in this disease, the system frequently resists, with great 
\ obstinacy, the influence of that mineral. Sometimes, do what you will, you fail to 
I attain your object. A knowledge of this fact may render you less scrupulous than 
j you would otherwise be in the use of the remedy. Not only should calomel be given 
in frequently-repeated doses, guarded, if need be, by opium : but mercurial inunc- 
tion should also be had recourse to, in these perilous cases, from the first. When 
the gums do begin to rise, there will always be, according to my experience, a 
manifest subsidence of the distress, and mitigation of the symptoms. There wiH be 
less pain, less palpitation, less dyspnoea. The mouth should be kept sore for some 
time together : for supposing the membranes to adhere, it does not follow that the 
inflammatory process should thereupon cease. 

When you learn, from symptoms and signs already described, that the pericardium 
is distended by liquid effusion, I would advise you to lay a large blister over the 
precordia. The diminution, or complete disappearance of the liquid, under this 
treatment, is often rapid and striking. 

Even when all the symptoms have vanished, previous disappointments have taught 
me not to be sanguine as to the permanency of the recovery. I believe that months, 
and years even, may elapse before the secondary effects of the mischief left behind 
by the inflammation begin to be palpable. But in many instances, they shovi^ them- 
selves very early. Others have noticed all this : especially Dr. Latham, who truly 
remarks, that " in acute pericarditis there is no medium between complete cure and 
certain death." H§ deemed, at the time when the lectures from which I quote were 
given, that the early and vigorous use of mercury would be equal to the complete 
cure. 1 think I may venture to say that he has since seen reason to doubt on that 
point. I have several times already expressed my own behef, that where the to 
and fro sound has manifested itself, that is, where the inflammation has gone so far 
as the effiision of coagulable lymph, if the patient does not die outright, he survives 
at the expense of an adherent pericardium ; and he survives only for a time. Haeret 
lateri lethalis arundo. But I am also of opinion, that by the cautious employment 
of the lancet and of leeches, and by the early and unshrinking use of mercury, the 
mischief may be greatly hmited, and the consecutive changes staved off' to a distant 
period. The final catastrophe arrives much more slowly where there is mere adhe- 
sion of the pericardium, than where that condition is complicated with permanent 
disease of the valves within the heart. I need scarcely say that other, minor expe- 
dients are to be put in force ; strict abstinence I mean, perfect quiet, and an occa- 
sional purgative to clear out the ahrnentary canal. 

When the pericardium has once become adherent, if (as is very likely) the patient 
again suffers acute rheumatism, he may again have heart symptoms. Not, of course, 
the to and fro sound ; but pain, palpitation, and dyspnoea. Now it is of some prac- 
tical importance to be aware that this renewal of morbid action does not require that 
active treatment which the primary inflammation demanded. The effect of such 
renewal will be to augment the existing mischief ; but the morbid process is much 
less vigorous, and much more easily subdued. It will generally yield to the repeated 
application of leeches, or of blisters, over the situation of the heart, and to the mode- 
rate exhibition of mercury. 

Akhough acute inflammation in this, as in other serous membranes, shows gene- 
rally a strong disposition to spread all over the affected surface ; yet does the peri- 
cardium seem readily susceptible of slight and partial inflammation. You will very 
frequently indeed see, upon laying the bag open, a white spot, as big as the finger- 
nail, upon the surface of the heart. I have examined these spots very often ; and 1 
believe they almost always consist of a thin flake of lymph lying sometimes beneath, 
but ofiener upon, the membrane. They may, in fact, be peeled off' sometimes, and 
the subjacent membrane left smooth and sound. On one occasion, I met with a long 
riband of lymph passing from the centre of one of these white spots, to connect 
itself with the loose bag of the pericardium. I conclude, therefore, that these spots 
are really the resuk of a very limited inflammatory process : but under what condi- 
tions they arise, or whether during their formation they furnish any symptoms, I do 
not know. 



700 



ACUTE PERICARDITIS. 



Such is the view which I had long taken, and taught, of these white spots upon 
the surface of the heart ; and I am glad to have it confirmed by the observation of 
Mr. Paget, who has recently adduced (in the tAventy-third volume of the Medico- 
C/iirurgical Transactions) conclusive evidence, both of their frequency, and of 
their inflammatory origin. 

So much then for the heart itself, and its membranes. There still remain to be 
considered the morbid conditions of the great vessels that spring from it, and lie in 
the thorax, and especially of the aorta : those morbid conditions I mean, which 
declare themselves by symptoms, and which become the object of medical treat- 
ment. 

The aorta is very frequently indeed found diseased, and its disease, as I have 
already explained, is a common cause of organic changes in the left ventricle of the 
heart. You will find that its inner membrane, instead of being smooth, and of a 
uniform yellowish-white colour, is rendered very uneven by a great number of yel- 
low opaque projections, of cartilaginous consistence, lying immediately beneath the 
membrane. And in a more advanced stage of the same diseased condition, you may 
perceive that some of these projecting Httle masses consist of irregular scales of bone, 
having sharp edges ; and sometimes these plates of ossific matter are quite bare ; the 
inner membrane is gone, and the exposed bone is washed by the current of blood. 
Now the necessary effect of these changes is to diminish and destroy the natural 
elasticity of the vessel ; and as ihere is a perpetually recurring strain upon it, by the 
blood sent out from the heart, the vessel dilates, becomes larger than it should be. 
This, if you please, you may call aneurism ; but a simpler namS is dilatation. In 
other cases, the enlargement is not general, but partial. A pouch is formed on one 
side of the artery, and this pouch may be very small or very large. It appears to 
result from the giving way, the rupture in short, or the ulceration, of the inner and 
middle coats of the artery, and then the blood, passing through the broken part, 
presses against the cellular coat of the vessel, and distends it into a sort of bag. 
There have been curious discussions as to what should be called true aneurism, and 
what should be called false aneurism ; discussions upon which I have neither time 
nor taste for entering. It is enough for all practical purposes to state, that the artery 
sometimes dilates only, sometimes throws out a pouch. I know that you have re- 
ceived, or will receive, from my colleague, Mr. Arnott, all the information that is 
requisite concerning the modes in which aneurism may arise. These are matters 
of the highest interest in surgery, for surgery can cure an aneurism ; an achieve- 
ment which is but seldom within the skill of physic. 

I have known two cases in which the diseased artery all at once cracked across — 
its inner and middle coats, I mean — and death very rapidly ensued. In one of these 
instances, the crack extended round a considerable part of the circumference of the 
aorta. It looked exactly like a clean cut made by a sharp knife. The blood, in this 
example, dissected its way (if I may so say) between the middle and external coat 
of the aorta, and got at last into the pericardium, and coagulated round the heart in 
a uniform layer : so that a bag of coagulated blood was enclosed in the bag of the 
pericardium. Of course, nothing can be done for such cases as these. 

Most commonly the aneurisraal tumour goes on enlarging ; and often it becomes 
lined, and sometimes it is nearly filled up, by layers of coagulated blood, which form 
in its interior. At length the tumour bursts, and the patient perishes. 

Aneurisms of the thoracic aorta are met with chiefly in the earlier portions of that 
vessel, in its ascending part, and in its arch. There seem to be two reasons for this. 
One is, that the diseased state of the coats of the artery (to which the rupture and 
subsequent aneurismal pouch, or the dilatation, as the case may be, are owing) is 
more common, and more advanced generally in that part of the aorta ; and another 
reason is, that the momentum of the blood, as it is forcibly propelled from the left 
ventricle, is sustained chiefly by the same part. 

Mere disease or dilatation of the commencing aorta, affords, as I formerly endea- 
voured to explain, a physical impediment to the due emptying of the left ventricle. 
It is a common cause, therefore, of hypertrophy and dilatation of that ventricle ; 
and consequently, the signs of hypertrophy and dilatation of the left ventricle of 



THORACIC ANEURISBIS. 



701 



' the heart will at length result from disease and enlargement of the aorta near it& 
I mouth. 

When aneurismal pouches form, as they often do, at the very entrance of the 
aorta, or in the coronary arteries, they often defy detection. I, at least, know of no 
sign of their existence upon which a physician can rely, or which can lead him 
j even to suspect such a state of matters. But all at once the patient drops down 
I dead : and upon searching for the cause of this sudden extinction of life, you find 
j the pericardium distended with blood, and the source of that blood you find to be 
the ruptured aneurismal pouch, so near the root of the aorta, as to project within the 
I pericardium. In the preparation which I hold in my hand, an unbroken aneurism 
' actually bulges into the right ventricle of the heart. 

! When the aneurismal tumour occupies a portion of the ascending aorta a Httle 
I more distant from the heart, or is formed at the arch itself, it sometimes attains a 
\ large size, and the evidence of its existence is derived from the effects its enlarge- 
! ment produces on the surrounding textures; and these effects are apt, for a while, 
I to be obscure and equivocal, until an external pulsating swelling makes its appear- 

ance, or a sudden gush of arterial blood through the mouth discloses the true nature 

of the rjialady. 

In these cases we infer the existence of aneurism sometimes from peculiar symp- 
|| toms. Aneurism at the arch of the aorta may come to press upon the trachea, and 
[; impede the breathing ; or by its effect upon the recurrent nerves, it may cause a 
very accurate mimickry of laryngitis. The operation of tracheotomy, as I told you 
jl before, has more than once been performed, to relieve the supposed inflamed condi- 
I' tion of the larynx, while the sole disease was aneurism at the arch of the aorta. 
! Such mistakes are always discreditable; and the lesson they furnish should not be 
1 lost upon us. Whenever we find that a wheezing dyspncea has gradually arisen, 
which no apparent affection of the air-passages satisfactorily accounts for, and the 
patient has a sense of pulsation within the thorax, we may suspect that an aneurism 
is at the bottom of these symptoms. 

The effect of aneurismal enlargements of the artery in causing absorption of the 
I neighbouring tissues, upon which the tumour presses, is very curious. You know 
that even the solid bone is removed, worn away as it were, before an advancing 
aneurism. Hence it not unfrequently happens that the trachea, or some of the 
larger bronchi, are at first flattened, and then give way ; the aneurism breaks into 
the air-passages ; and the patient, overwhelmed by a torrent of blood into and from 
his lungs, perishes in a few seconds. Or the tumour may contract adhesions with 
the pulmonary tissue, and destroy it to a certain extent, and so cause mortal hasmop- 
tysis. But such cases are not always fatal at once. 

Again, according to its situation and extent, an aneurism of the thoracic aorta may 
press upon the oesophagus, and cause the ordinary symptoms of stricture of that 
! tube. Hence cardiac disease, and pulsation within the chest, accompanied at length 
j by the signs of a constricted oesophagus, form strong presumptive indications of the 
I existence of an aneurism ; and in such cases, the oesophagus may at last ulcerate 
! through, and then copious and fatal hemorrhage ensues. Hasmatemesis it may be 
called, though the blood is vomited not from the stomach, but from the gullet. A 
patient in the Middlesex Hospital, with symptoms of stricture of the oesophagus, 
one day brought up from the throat a red mass, which, at the moment, was sup- 
posed to be a bit of meat that he had been trying to swallow. It really was part of 
j the clot from an aneurism ; and it was speedily followed by a stream of red blood, 
and by death. 

j Again, aneurism of the thoracic aorta does frequently obstruct, by its juxtaposition 
and pressure, the vena cava superior ; nay, it may even obliterate that vessel, of 
I which I have seen two instances. To one of these cases I alluded before, as a most 
i curious example of dropsy. It illustrated exceedingly well the effect of venous ob- 
I struction in causing serous effusion. The man was a patient of Dr. Hawkins. He 
presented a most extraordinary spectacle. His face, neck, and arms, were tumid 
and anasarcous to an enormous degree ; while there was not the least trace of swell- 
I ing or oedema anywhere below the ribs. He looked as if his upper half had been 

3i3 



702 



THORACIC ANEURISMS. 



stuffed ; and except that it was distressing, his appearance was extremely comical. 
His countenance was livid ; his eyes seemed starting from their sockets ; and even 
the areolar tissue beneath the conjunctiva was osdematous. The integuments of his 
neck" and chest were quite brawny; and his arms were so swollen that they projected 
from his sides. The surface of the thorax in front was embossed by numerous veins, 
which were turgid with blood ; and here and there patches of ecchymosis were 
visible. You may form some notion of the degree of mechanical congestion that 
existed, when I tell you that, upon the scarificator being applied, after a cupping- 
glass was taken off, upwards of twenty ounces of blood escaped in two minutes. 
The epigastric veins were visible and tortuous, and a free communication by anas- 
tomosis existed between these veins ascending from the inguinal region, and the 
mammary veins. There was a bellows sound, which increased in loudness and 
harshness, from the root of the aorta to the top of the sternum. The patient soon 
died ; and a large aneurism of the aorta was laid open by lifting up the sternum, 
to which the arterj^ had adhered, and into which, indeed, it had eaten a little. Not 
far above the right auricle, the vena cava was totally impervious ; its sides having 
been gradually pressed together, as the tumour grew. The other case, of the same 
kind, which occurred in one of my own patients, I shall have occasion t(^ refer to 
hereafter. 

But aneurism of the thoracic aorta may exercise its pressure in another quarter, 
and wear awa}^ the bones of the vertebrse, and cause pain in the back, and ukimately 
palsy of the parts below that portion of the spinal cord ; so that pain in the back, 
with pulsation, may justly awaken suspicion of aneurism making its way backwards. 
I remember hearing Dr. Farre describe a case of this kind, to inculcate the necessity 
of paying attention to the sensations of a patient. A man came to him for advice, 
having been told by another physician that there was nothing the matter with him — 
that he was fanciful. But when an adult person makes constant complaint of certain 
morbid feelings in a part, the probabihty is that he has something the matter, and 
we must investigate the case with what helps we can get. In the instance in ques- 
tion, there were two signs of disease, and two only ; a white tongue, and pain in the 
back. The whiteness of the tongue soon disappeared under the use of some medi- 
cine addressed to the digestive organs. The pain in the back remained. Dr. Farre 
interrogated the patient minutely every time he visited him, till at last the man got 
vexed and tired, and said, pettishly, "I know that if you split me down the middle, 
I am sound on my right side, and diseased on my left." Very soon after, he was 
found dead in his bed. What he had said was perfectly true : there was aij aneu- 
rism pressing on the left side of the dorsal vertebrae. 

Another consequence of an enlarging thoracic aneurism, sometimes observed, is 
pressure upon the thoracic duct, causing engorgement of the absorbent vessels and 
glands, and inanition. In short, whatever parts the aneurism may reach, and subject 
to its pressure, may have their function thereby suspended or disturbed, or their 
structure spoiled. 

One sign, which I have myself frequently verified, of aneurism of the arch of the 
aorta, is a difference in the force of the pulse in the two radial arteries. The pulse 
in the one wrist will be extremely feeble, or even disappear. This happens when 
the state and position of the arteria innominata, or of the left subclavian artery, be- 
come altered in consequence of the enlargement of the aorta ; and sometimes the 
one or the other of these arteries is completely closed up. But inasmuch as a similar 
difference of the pulses may arise from other causes, we can only look upon this 
symptom as one which may help to solve an ambiguous case. To give you an 
example of a difference in the beating of the arteries in the two wrists from other 
causes, T ma};^ mention a case in which the subclavian artery was thrown forwards, 
and compressed by an exostosis on the first rib. The case is mentioned in Mr. Mayo's 
Pathology. It occurred in a patient of mine, the husband of a nurse in my family. 
I had a girl for some time in the hospital, in one of whose arms no artery could be 
found to pulsate. Why, we none of us could make out. 

Very lately, a surgeon from the country came to my house, desirous (he said) to 
consult me about a sense of discomfort in his head; and particularly about the state 



THORACIC ANEURISMS. 



703 



of his vision. When erect, he saw things obscurely. At three yards' distance he 
could see my face, but could not distinguish the separate features. What he 
thought very strange was that he could see perfectly well when in the horizontal 
posture. 

On my proceeding to feel his pulse, he said, in a careless manner, "By-the-by, 
that is another thing wrong with me ; I have no pulse." Nor could 1 detect any, in 
either arm. He then told me that, four or five years previously, a medical friend, 
intending to feel his pulse in the left wrist, could find none. He was confident pulsa- 
tion had existed a short time before that. After a while, the movement of the radial 
artery returned, in a very slight degree ; and then finally ceased. Within nine or 
ten months of this discovery, the right pulse, after growing less and less distinct by 
degrees, had vanished also. Though somewhat weak, and subject to faintness, this 
gentleman had not wasted ; nor had the muscles of his arms lost either bulk or vigour. 
Their veins were full enough of blood. His hands were often cold ; and he felt alto- 
gether worse during cold weather. 

Failing to detect any pulsation in the brachial and subclavian arteries, I next felt 
for the carotids : but I could perceive no beating in the track of their course. I had 
placed my finger, for a few seconds only, in front of the left sterno-mastoid muscle — 
when I saw that his head drooped, his cheeks became white, and he was on the 
brink of fainting. But h^ recovered immediately. Then I made similar pressure, 
for a moment, on the right side of the neck, and the same phenomena were instantly 
repeated, with the addition of convulsive jerking movements of the head and arms. 
He ralUed again directly upon my removing my finger, and was scarcely aware of 
what had happened. For a second or two he had been unconscious. His femoral 
arteries throbbed as usual. 

I next examined his chest. There was no external irregularity or want of sym- 
metry. Percussion gave a clear resonant sound everywhere in front. The heart 
was heard, beating with frequency, but without any bruit, over the greater part of 
the thorax. Its impulse in the precordial region, below the nipple, was feeble : but 
a strong jarring impulse was communicated to the ear when the stethoscope was 
applied to the upper part of the sternum. 

The patient complained of pains affecting his shoulders, clavicles, and the back of 
his neck ; and of slight difficulty of swallowing. 

From the intelligent physician who had attended this gentleman in the country I 
learned the instructive fact that, twenty months before, a loud rasping bruit had beer 
audible, without impulse, at that part of the sternum where he, as well as 1, now 
found no bruit at all, and a very considerable impulse. 

I cannot doubt that in this painfully interesting case there *is aneurismal disease 
of the aorta, interfering Avith and lessening, but not absolutely excluding, the stream 
of blood through the arteries which spring from its arch. 

In the numerous specimens upon the table, you will find ample evidence and 
illustration of almost every one of the effects which I have described as apt to result 
from the pressure of thoracic aneurisms of the aorta. But similar effects would ensue 
from the same degree of pressure, however caused; and other morbid tumours, 
cancerous tumours in particular, are not uncommon within the thorax. Hence these 
same effects, considered as symptoms, are in themselves, of equivocal import. If 
they occur in conjunction with signs of disordered circulation, or of a diseased heart, 
we may reasonably conjecture that they are produced by an aneurism. But we can 
seldom be quite sure of this, until the advancing aneurism comes near the surface, 
and causes an external prominence or tumour which pulsates visibly, or of which 
the pulsations are perceptible by the touch. And even then it may require some 
I care and tact, to avoid mistaking an enlarged gland, or a malignant growth, lying 
j over a sound artery, and receiving an impulse from it, or communicating to it some 
1 unnatural sound, from the diseased vessel itself. 

I The pulsating tumour, if the aneurism has formed in the ascending aorta, makes 
its appearance, usually, on the right side of the sternum. If the aneurism is situated 
I in the forepart of the arch, it produces a bulging at the sternal extremities of the 
I upper rii)s on that side. When it springs from the summit of the arch, the tumour 



704 



THORACIC ANEURISMS. 



rises abovo the sternum, and the sternal ends of the clavicles ; and when the disease 
occupies the descending portion of the thoracic aorta, it will sometimes destroy the 
ribs and the bodies of the vertebra, and push forward the lower part of the left sca- 
pula: or it may show itself in front, beneath the left clavicle. 

When such a tumour presents itself, and is attended with a steady^ heaving pulsa- 
tion, synchronous with the systole of the heart, the doubt and obscurity which may 
have previously hung over the nature of the patient's disorder is cleared away. A 
liule attention to all the circumstances of the case, will generally suffice to deter- 
mine its true character. 

There are, however, some errors prevalent respecting these pulsating tumours, 
which errors I shall glance at in passing. In the first place, the pulsation of the 
tumour is frequently, most frequently, attended with a rough bellows sound ; and 
some persons rely upon this as distinctive of the nature of the pulsating tumour. 
They hold that this harsh bellows sound is always discernible in an aneurismal 
tumour; and that when such a sound cannot be heard, the tumour is not an aneur- 
ism. But this is a mistake. There have been in the Middlesex Hospital within the 
last six months (1887), two instances of pulsating tumours in the fore part of the 
thorax, unattended with any bellows sound; yet they were both ascertained, after 
death, to be aneurismal tumours. One of the aneurisms is before you. In the case 
of the country surgeon, a bellows sound was present at ft certain period of the dis- 
ease, and absent at a more advanced period. I may say the same of the purring 
thrill. It is a common, but by no means a necessary attendant upon thoracic aneur- 
isms. Again, much stress was laid by Laennec, upon the circumstance of the 
aneurismal pulsation being single, being unattended by any second sound. But this 
is not a true rule if taken universally. In the instance which furnished this very 
preparation, the sounds were double, just like those of the heart. The second 
sound heard is, no doubt, the second sound of the heart, conveyed from the place of 
the aortic valves, where it originates, along the course of the vessel, to the aneurism ; 
which often indeed lies in contact with the heart, and could scarcely fail to have the 
diastolic sound propagated through it. It is a fact not so easily explained, 3^et it cer- 
tainly is a fact, that a double sound may be audible in aneurisms very distant from 
the heart. Dr. Davies states, that he never heard a second sound in abdominal 
aneurisms ; yet I presume that, under favourable circumstances, the sound of the 
closing of the floodgates at the root of the aorta, may be heard far along its channel. 
I can account in no other way for the second sound, heard by myself and by many 
others, in a popliteal aneurism, I mentioned before, a patient whom I saw in St. 
Bartholomew's Hospital, and in whom an exceedingly loud diastolic sound, like the 
sharp whining note of a dog, was audible by the ear placed upon his arm, over the 
brachial, and even over the radial arteries. 

There are some very judicious remarks made by Dr. Hope upon the sounds that 
are apt to be heard in these pulsating aneurismal tumours to the right of the ster- 
num ; showing how they may be distinguished from the natural sounds of the heart 
itself, conveyed to that spot through some dense conducting medium. He observes 
(and all that I have seen has been consonant with this observation), that the first of 
the aneurismal sounds, when there are two, the sound that coincides with the pulse 
is always louder than the natural systolic sound of the heart, and generally louder 
than any of the morbid systohc sounds ; and that instead of increasing in intensity, 
as the stethoscope is moved gradually towards the precordial region (as it ought to 
do, if it were the conducted sound of the heart itself), it diminishes in loudness, 
until it is gradually lost in the actual systole of the heart. Whereas the second 
sound heard over the tumour does augment as we get nearer the heart, for it is, in 
truth, the diastohc sound of the heart, and therefore is more audible as we approach 
the point where it is generated. The sounds of aneurisms of the aorta are usually 
audible in the back also ; and if a very loud bellows sound be heard there, where 
the natural sounds, if heard at all, are always much abated, that circumstance fur- 
nishes a strong additional ground for suspecting the presence of an aneurism, or ol 
some great change in the aorta. 

To give you some notion of the course which aneurism of the thoracic aoria 



THORACIC ANEURISMS. 



705 



may run, I will describe another instance of that disease which occurred under 
my own observation. The subject of it supplied the preparation to which I last 
referred. 

He was a stout, healthy-looking man, forty years old, a private coachman. He 
became my patient in the hospital on the 8th of September, 1836. He complained 
of pain and tenderness around and above the right mamma. The pain was increased 
by a full inspiration ; and when lying on the opposite side, he felt as though he was 
tied in the painful part. 

He had been ill a month only. His illness commenced with severe rigors, 
and fever, and sudden pain in the side, for which he was bled three times with 
much relief. He attributed the attack to having lain, upon his right side, in a damp 
bed. 

There was scarcely any projection at the spot where the pain and tenderness were 
experienced. By careful examination several times repeated, I satisfied myself upon 
the following points. 

On the right side of the thorax no vesicular breathing could be heard ; and thp. 
whole was dull on percussion. On the left side percussion gave a hollow sound, and 
the respiratory murmur was clear and strong. In the tender spot, an inch and half 
above the mamma on the right side, a strong pulsation could be felt, and two sounds 
were distinctly audible, the first of them keeping time with the pulse at the wrist. 
But there was no bellows sound. M. Sanson, the celebrated French surgeon, was 
then in London, and went round with me one day, and examined this patient; and 
he expressed his opinion that it was not a case of aneurism, because there was no 
whiz or bellows sound to be heard. Of course his examination was a cursory one, 
and I mention this circumstance merely to show yon what importance is attributed 
to the presence or absence of a bruit de soitfflet in such cases. M. Sanson suggested 
that the heart might be displaced, and pushed over to the right side. However, it 
was clear to me that this could not be the case, because the breathing was deficient, 
not on the left, but on the right side ; and, above all, because the apex of the heart 
could be both seen and felt beating in its proper situation, in the precordial region on 
the left side. Also on the left side, percussion made on the edge of the ribs gave a 
tympanitic sound, indicating the place of the stomach ; on the right a dull sound, 
pointing out the situation of the Hver ; so that it was not a case of transposition of 
the viscera, such as had been found, not long before, in one of my patients. In the 
course of the disease, a slight bellows sound did become perceptible over the right 
mamma, when the patient sat up ; but even then the natural sounds of the heart, 
without any morbid quahty, could be heard in the natural position of that organ. 
(Egophony was audible at the back part of the right side of the chest. 

This patient had repeated attacks of pain, dyspnosa, restlessness, and inability 
to lie down ; and these attacks were, always most sensibly mitigated by the appli- 
cation of leeches to the diseased part. By the 11th of October he was so com- 
fortable that he wished to go out ; and he went to his master's in Connaught 
Place. 

Two days afterwards, he sent to beg that I would go and see him there. He 
had brought up, on the preceding evening, during a paroxysm of coughing, about 
a pint of bright red blood ; and he had continued to cough, and to expectorate small 
quantities of blood. I had him again brought to the hospital on the 14th of Octo- 
ber, where he remained, apparently much the same as before he went out. But on 
the 19th he suddenly expired. The whole duration of his illness had been nine or 
ten weeks. 

We found the heart natural in size and in appearance ; the pericardium healthy, 
and containing no more than the usual quantity of serum. All the cavities were 
natural in their dimensions, and in the thickness of their walls ; and all the valves 
healthy, excepting one white spot on the mitral valve, which could not have inter- 
fered with its motions. 

The aorta at its origin was also natural in size ; but it began to dilate just befoio 
it escaped from the pericardium, and the dilatation continued to the giving off of th« 
left subclavian, where the vessel resumed its proper capacity. The arteries arisinji; 
45 



706 



THORACIC ANEURISMS. 



from the aorta did not partake of the dilatation ; but the sac overlapped and adhered 
to the external surface of the innominata, for about a quarter of an inch from its 
origin. This explained a symptom I omitted to mention, viz. : that the right radial 
artery beat much more feebly than the left. 

The pouch formed by the aneurism adhered in front, for the space of two inches, 
to the inner surface of the third rib ; and close to the edge of this adhesion there 
was a small irregular aperture about two lines in diameter, by which the interior of 
the pouch communicated with the right pleural cavity. Nearly a pint of loosely 
coagulated blood was found in that cavity, together with a greater quantity of serous 
fluid than could have belonged to the coagulum. Just above the adhesion to the rib, 
the pouch adhered to the substance of the lung, over a space about an inch square ; 
and here the parietes of the artery seemed wholly wanting. This, doubtless, had 
been the channel of the copious hsemoptysis a week before his death : and it is inte- 
resting to observe that the opening of the aneurism into the lung was not imme- 
diately fatal. The artery was much diseased, in the usual manner. The right lung 
was nearly all of it "carnified" by the compression it had undergone. 

If this case had not terminated as it did, no doubt the aneurism would have made 
its way outwards through the ribs, as happened in the very remarkable specimen 
before you ; in which you see that the sternum and five of the ribs have disappeared 
before the pressure of an aneurism in the ascending portion of the aorta. Some- 
times, the tumours that form in this manner, project and attain the size of the head 
of a full grown foetus before they burst. 

What can we do in these melancholy cases ? Not much. Certain points of prac- 
tice are so obvious that it is almost superfluous to mention them. I mean the ob- 
servance of quiet, and the religious avoidance of every thing hkely to excite or 
quicken the circulation: bodily exertion, therefore ; straining of all kinds; mental 
emotion ; stimulating food and drink. These are not only likely to aggravate the 
existing mischief, but prove often the immediate cause of the rupture of the aneu- 
rism, and of sudden death. 

I mentioned, in describing the morbid anatomy of aneurism, that when the diseased 
vessel began sensibly to dilate, and more especially when it was protruded into a 
sack or pouch, the blood began to coagulate upon the diseased membrane. And it 
continues to do so, from time to time, in successive layers, so that upon dividing the 
aneurismal sac, you will see concentric laminae of firmly coagulated blood. This is 
clearly a strengthening of the weak place— a reparatory and compensating process 
analogous to others which we have already had occasion to notice. And our object, 
here as in other cases, must be, not to interfere with the natural attempts towards 
repair, but to assist and promote them, if we can. 

This principle has long been distinctly recognized in the treatment of anuerisms 
that are incapable of relief by surgical means. 

But it is much to be doubted whether the principle, so sound in itself, has been 
judiciously followed out. You have probably heard, or will hear, a good deal of 
Valsalva's and Albertini's mode of treating aneurisms. It was simply that of bleed- 
ing the patient repeatedly, and keeping him upon as low a diet as was barely 
enough to prevent his perishing of inanition. The object of this plan of treatment 
was to facilitate the coagulation of the blood by diminishing its force and velocity, in 
the hope that at length such a solid barrier might be built up and organized, as might, 
in some sort, furnish a new wall to the artery in the dilapidated part. When this 
object had had the best chance of being accomplished ; when the patient had been 
so reduced as to be scarcely able from weakness to raise his hand from the bed, to 
which he was strictly confined ; then Valsalva increased his quantity of nourishment 
by degrees, until the necessary strength was restored. 

Now I quite agree with Dr. Copeland in thinking that this practice may be car- 
ried, and has been carried, to a hurtful extent. He says that he has seen cases " in 
which aneurismal tumours had existed for some time witlTout any increase, «o long 
as the patient avoided any marked vascular excitement, and continued his accus- 
tomed diet ; but wh^n repeated depletions, and vegetable or low diet were adopted, 
great augmentaiion of the tumour, and fatal results, soon followed." 



DISEASES OF THE VEINS. 707 

In truth, we shall perceive reason to expect that this would be the case, when we 
consider, first, that the starving system, and the frequent abstraction of blood, diminish 
the quantity of fibrin in that fluid, rendering it more watery, and less disposed to 
coagulate ; and, secondly, that what is called reaction — or a violent palpitating action 
of the heart — is very apt to follow repeated losses of blood ; and this forcible action 
of the heart must tend rather to sweep away the existing coagula, than to cause an 
additional deposit. 

A more reasonable and hopeful plan of management, therefore, would, in my 
opinion, be one which should keep the action of the heart gentle and moderate, and 
the motion of the blood as slow and languid as possible, without impoverishing that 
vital fluid. We should husband the materials of repair, and promote the deposit of 
them where they are wanted. A nutritious but unstimulating diet ; perfect repose 
of mind and body ; and a due regulation of the natural functions ; with the abstrac- 
tion of so much blood only as may be necessary to alleviate pain, or to subdue exces- 
sive arterial action, or to unload vessels which are manifestly oppressed by their 
contents ; — these, I humbly conceive, constitute the most rational means of furthering 
the endeavours of nature towards a cure. Few cures, indeed, can be hoped for in 
any way. Yet hfe may be prolonged in these cases, by great care ; and the exten- 
sion of existence even for a month or two, or a week, or a day, may sometimes be 
an acquisition of the greatest moment. 

I have little to say concerning particular drugs. Digitalis may, perhaps, be some- 
times of use ; and the acetate of lead is well spoken of by those who have tried it. 
I have not had sufficient experience of either of these remedies in the treatment of 
aneurism, to enable me to state any thing to you, confidently, in respect to their 
value. 



LECTURE LXIII. 

Diseases of the Vems. Phlebitis; adhesive, and suppurative: consecutive scat- 
tered Jibscesses. Treatment of Inflammation of Veins. Effects of the gradual 
obstruction of large Venous Trunks. 

Yesterday I concluded what I had to say, as a physician, respecting diseases of 
the arteries : and this seems as fitting a time as any for taking a final notice of some 
of the morbid conditions of the veins — -especially of their inflammation. Already, 
more than once, brief reference has been made to this important subject : important, 
whether we consider the large amount of mortal disease which it comprehends, or 
its wide and intimate relation with general pathology. I should have done better if 
I had given you, in the earher part of the course, a more complete and connected 
account of phlebitis, and its consequences. It is this malady which gives to many 
fatal injuries, and to many, nay to most, of the fatal operations of surgery, their 
mortal character: it is of surpassing importance, therefore, to the surgeon. The 
same malady lies at the bottom of the deadliest cases of puerperal fever : it is con- 
sequently of the deepest interest to the accoucher. It occurs also, not seldom, in the 
practice of the physician, appalhng him by its insidious, its rapid, and too frequently 
its resistless course. Moreover, its pathology, which has been successfully investi- 
gated only within these few years, furnishes a key to that of other morbid conditions 
of great moment. 

The first effect of inflamraadon of a vein is to impede, or arrest, the passing blood, 
which, coagulating upon the ]nflamed surface, adheres to it. In some instances the 
inflamed coat of the vessel is merely (as Mr. Hunter said) furred over: in others its 
channel is completely dammed up. The obhteration of a small vein in this manner 
can seldom have any serious consequence ; but much suflering, and distress, and 
even death itself, may result from the sudden and continued obstruction of one of the 
large venous conduits. For example, the painful disorder, called phlegmasia dolens 



708 



DISEASES OF THE VEINS. 



is caused by a stoppage of the blood in the Jemoml vein. A similar arrest of its 
current in the sinuses of the brain, is a mortal change. 

This adhesive form of phlebitis is a local disease. Whatever ill effects it may- 
produce are purely mechanical; and depend upon the closure of the canal. If the 
organ mechanically affected by it be not a vital organ ; — if the system can await the 
development of a collateral venous circulation ; — all, at length, may end well. Some- 
times, indeed, as the inflammation gradually subsides, the coagulum is softened and 
partly reabsorbed, the blood drills for itself a fresh passage through the centre of the 
plug, and the restoration is restored to its accustomed channels. 

I'his is, fortunately, the commoner form of phlebitis : but sometimes the inflam- 
mation advances beyond the adhesive, and into the suppurative stage. Even then 
the disease may remain a local* one. The adhesive process may bound and isolate 
the suppurative in both directions : and an abscess in the part is then the usual 
result. 

But if the suppurating surface of the vein be not so shut off", and pus mingle and 
circulate with the blood, the disorder is no longer merely local. The contaminated 
blood is conveyed to distant parts, and the whole system tainted. The malady has 
become general, and of the most formidable character. 

It had long been noticed, as a matter of fact, that collections of pus were not 
uncommon in various parts of the body, when death had followed mechanical inju- 
ries, or great surgical operations. Abscesses in the liver, in particular, were known 
to be associated with mortal fractures of the skull. Very fanciful rc-asons were 
assigned for this coincidence. By degrees it was ascertained that these scattered 
collections of matter — occurring most commonly in the lungs and liver, but not un- 
frequently in or near the joints also, in the serous cavities, among the muscles, in the 
brain, in the eye, and elsewhere — were connected with the introduction of some 
vitiating secretion, and especially of pus, into the current of the venous blood. 

And this step having been gained, fresh speculations arose, concerning the manner 
in which the internal collections of pus were formed. In the viscera they were 
usually small, well-defined, surrounded by the healthy tissue of the organ, and 
several in number. Some maintained, that the pus, in substance, was carried to the 
parts in w^hich it was found, and there simply deposited. Others were of opinion 
that the tainted blood created in the system a general tendency to inflammation, 
v^^hich was developed in many places simultaneously. Neither of these suppositions 
was quite true, neither of them quite false. The pus discovered in the serous cavi- 
ties was accompanied by unequivocal traces of inflammation in those parts. This 
alone rendered it probable that the smaller purulent collections were not merely 
dropped there by the blood in its course, (a thing very difficult to conceive,) but 
were the products of actual inflammation, excited somehow in those very spots. And 
it is now believed that these abscesses of, as well as in, a part, proceed from suppu- 
rative inflammation, provoked by the presence of particles of pus, brought thither 
with the circulating blood. 

I told you before, that foreign substances, entering the blood, and failing to pass 
out of it again through the natural emunctories of the body, are liable to be stopped 
when they arrive at the first network of capillary vessels that He in their course. 
Now the blood, circulating in the veins, reaches (much of it at least) in each of its 
circuits, two such great networks, the hepatic and pulmonary. Through the pul- 
monary network all the blood must pass, through the hepatic some of it ; and it is 
there, in the capillary tissue of these organs, that particles of pus, and other material 
substances, foreign to the blood, and incapable of elimination with the customary 
excretions, are apt to stick, or to be entangled, and to excite inflammation. Some 
of them, however, in general, pass on, and arriving at the left side of the heart, are 
transmitted, with the arterial blood, to various parts of the body, there to exercise a 
similar deleterious influence. 

Such was, and is, the theory : and it has been tested and confirmed by direct ex- 
periment. Inasmuch as the conveyance of the pus cannot be traced by the eye, 
nor the manner of its being collected into an abscess demonstrated, except by in- 
ference, Cruveilhier introduced quicksilver into the veins of animals ; a metal which 



PHLEBITIS. 



709 



IS liquid, and divisible into very minute particles, and which exerts no chemical 
agency upon the vital fluid. When the mercury was inserted into the veins which 
concur to form the vena portEe, the whole, or the greater part of it, was arrested in 
the liver. In that organ, the animal being killed a certain time after the introduction 
of the metal, small, roundish, red spots were always discoverable, which passed 
gradually into little abscesses surrounded by a halo of inflammatory redness ; and in 
the centre of each red spot, and of each abscess, lay a minute globule of mercury. 
A few similar points of suppuration were usually to be seen in the lungs also. But 
when the quicksilver was put into the blood in its direct course towards the vena 
cava, then it was in the lungs that these points were either exclusively detected, or 
at any rate most numerous. 

You must, I think, perceive how strictly these experiments bear upon the rational 
humoralism acknowledged at the present day. If pus, and mercury, may thus be 
distributed to particular organs, and thus excite circumscribed inflammation, so 
doubtless may other extraneous impurities — introduce^ by the poison of what is 
called good living, by the respiration of foul air, and in various other ways — reach 
and settle in different parts of the body (the liver, the lungs, the kidneys, the joints), 
and there produce, if not inflammation and pus, yet such changes at least as spoil the 
texture of the organ, and pervert its healthy office. That cancer is propagated in 
this way we have heretofore seen reason to believe. In all probability the deposi- 
tion and increase of tubercles fall under the same law. There is, however, this 
remarkable difference between tubercles and phlebitic abscesses, that the former 
occupy chiefly the upper portions of the lungs, while the latter are generally most 
numerous in their lower lobes. 

Suppurative phlebitis — with all its horrible effects — is liable to arise, not only 
after severe but also after slight injuries; from the trivial as well as the grand ex- 
ploits of surgery; nay, spontaneously, as it were, without any local hurt, under the 
agency of natural causes, such as exposure to cold. And the part in which the 
phlebitis occurs has some influence, as you will now understand, in determining the 
principal seat of these scattered abscesses. When they succeed amputation of a 
limb, or fracture of* the skull, or the interlerence of surgery with varicose veins, or 
(as they may) even the simple operation of phlebotomy, the}'- are likely to be most 
numerous in the lungs. But they are more conspicuous to hasty observation in the 
liver than in the lungs; and that is why hepatic abscess was supposed to have some 
special connection with injuries of the head. Morgagni, however, long ago pointed 
out the fact, that other parts also were affected in those cases. Again, we may ex- 
pect to find these disseminated abscesses chiefly in the liver, when suppurative 
phlebitis occurs in any of the tributary veins of the vena portse: when it supervenes, 
therefore, upon operations on the bladder or on the intestines- — operations for the 
removal of stone, for the release of hernia, for healing fistula in ano, for the cure of 
piles. 

It is, hov/ever, very common for the poison to pervade the whole body, and for 
abscesses to form in various other situations, as well as in the lungs and liver. I 
once saw a young woman die, in the Middlesex Hospital, from phlebitis, with large 
abscesses in many parts, and especially in the joints, after the simple excision, with 
scissors, of some small spongy irritable growths about the orifice of her urethra. 

Two or three instances of suppurative phlebitis, unconnected with any known 
hurt, and originating apparently in exposure to cold, have fallen under my own ob- 
servation: but I prefer giving you the following short case, with the details of which 
I have been favoured by Dr. Maiden, of Worcester. 

Miss , a teacher in a Ladies' School, was attacked, after exposure to wet 

and cold, with acute pain, heat, and redness, in the front of the left forearm. Mr. 
Cole, an eminent surgeon, of Bewdley, by whom she was at first attended, discovered 
inflammation following the course of the cutaneous veins. Upon its subsidence the 
veins were left like hard cords. Soon after the right arm was afl^ected in a similar 
way: and next, both the lower extremities, which became anasarcous. All this was 
attended with paroxysms, simulating those of tertian ague ; exhausting sweats, diar- 
rhoea, and a frequent feeble pulse. At the end of a month, deep-seated fluctuation 

3k 



710 



DISEASES OF THE VEINS. 



was detected in the right thigh, three inches below Poupart's hgament. The abscess 
gradually approached the surface, and was opened, and more than three pints of 
very fetid pus were discharged. The wound never closed, and she sank, exhausted, 
a month after it was made. 

There was no pain, premonitory or attendant, connected with this formation of 
matter. 

The abscess was traced, after death, upwards, behind the muscles of the pelvis, as 
far as the sacro-iliac symphysis, where the bones were extensively carious. 

Many of the superficial veins, both of the upper and lower extremities, were 
found to be completely obliterated by adhesive inflammation, or sealed up by coa- 
gula of blood. 

This spreading and morbiferous inflammation of veins is som.etimes so remarkably 
prevalent, as to partake of the character of an epidemic disorder : and this, its occa- 
sional prevalence, appears to be owing to some pecuhar condition of the atmosphere 
— or rather to some predisposition of the human body, engendered by the operation 
of influences which are prooably atmospheric. During such periods prudent men 
refrain, if they can, from the performance of surgical operations. 

The view which I have now set before you of suppurative phlebitis, and of its 
distant effects, involves some apparent difficulties, and some curious questions. A 
short consideration of these may serve to throw a clearer hght upon the main subject. 

First, then, how^ is it — if indeed the disseminated abscesses result from the intro- 
duction of pus into the blood — how is it that we do not meet with them oftener ? Pus 
is absorbed, in numberless instances, without the occurrence of any such formidable 
consequences. We see great abscesses disappear spontaneously, and yet no other 
smaller scattered abscesses ensue. Does not this fact invalidate the theory of the 
cause and formation of such distant points of suppuration ? No. It seems, that for 
their production, pus as such, pus in substance, pus in the mass, must be received 
into the veins, and circuia:e with the blood. The pus which is taken up by ordinary 
absorption, is altered, probably, by that process, before it reaches the blood : at any 
rate it has not the same miscliievous and fatal effect. 

You may here inquire in what manner pus gets into the ckculation, in conse- 
quence of an amputation ? Is it not absorbed from the suppurating stump ? I con- 
ceive not. Supposing the amputating knife to cross and sink into an existing abscess, 
and to divide a vein — then, indeed, pus might be sucked into the vein, and the usual 
consequences follow. But the veins that lead to, or rather from, a stump, become 
blocked up, and impervious, from adhesive inflammation, or from mere coagulation 
and adhesion of the blood in them, before the stump has had time to suppurate. 
How then does the pus ever find admission? No doubt it is a product, in this case 
also, of phlebitis. The interior of a vein inflames, and goes on to suppuration ; and 
the pus which it pours forth mingles, as pus, with the circulating stream. 

Indeed these scattered abscesses appear to originate alwaj-s in phlebitis. Such is 
the opinion of my colleague, Mr. Arnott, who has contributed a valuable paper on 
this subject to the jMedico-Chirur gical Transactions. Such is also the opinion of 
M. Cruveilhier. It has been objected that, in some fatal cases of this kind, no 
phlebitis could be detected: that the principal veins have been dihgently traced, 5'et 
no vestige of suppuration, nor even of adhesive inflammation, has been visible. To 
make this objection valid, all the veins throughout the body should be scrutinized ; 
and that has seldom, I fancy, been done. I have known several instances, in which 
most of the larger trunks were searched in vain, till at length a short tract of one of 
them, an inch or two perhaps, was found, bearing marks of having been inflamed. 
You must not conclude therefore against the antecedent existence of phlebitis, until 
vou have examined every vein in the soft parts of the body : no, nor even then. 
You must go deeper than the more obvious veins. There is good reason for believ- 
ing that the bones and their veins are often the seat of the primary mischief, the 
fountain from which the pus, which thus renders the blood a poison, first proceeds : 
the veins, for example, of the diploe of the skull, when scattered abscesses ensue 
upon injuries of the head ; the veins of the bones of the extremities after unsuccess- 
ful operations. There is yet another explanatory supposition applicable to some 



PHLEBITIS. 



711 



cases. All local traces of the primary inflammation may vanish before death, while 
the vital powers are being undermined, and about to sink under its secondary effects. 

Cruveilhier repeatedly performed the following experiment, and always with simi- 
lar results. He introduced crude mercury within the hollow shaft of the thigh bone 
of a living dog. "When the quantity was considerable, death occurred in a few days, 
and the metal was found strewed thickly through the lungs, each globule occupying 
a capillary branch of the pulmonary artery, and surrounded by a small sphere of 
inflammatory redness. When the quantity was minute, the animals hved lon(?er, 
and little abscesses, enclosing each a particle of mercury, were then discovered in 
the same organs. The mercury he supposes to have found a direct entrance into the 
blood, in these cases, from the cancellous portion of the bone: and through the same 
channel it seems to be that pus often enters the circulation. You may remember 
my relating some fearful examples of scattered abscesses, supervening upon chronic 
disease of the bones of the ear. Cruveilhier states that having been present at the 
examination of the body of one who had sunk after amputation of the leg, and whose 
lungs were full of httle abscesses, he sought, without success, for some inflamed vein: 
but upon dividing the tibia and fibula, he found the spongy extremities of these bones 
infiltered with pus. Here, beyond question, had been the source of the visceral 
mischief. 

The local phenomena, when a superficial vein of some magnitude is inflamed, are 
pain and tenderness in the course of the vessel, which, in the adhesive variety of the 
complaint, is soon converted into a tangible, hard, and sensitive cord. Whether the 
vein be near the surface or deeply seated, there is usually more or less oedema of the 
areolar tissue of the part. Phlebitis of this kind has been sometimes confounded, I 
believe, with inflammation of the lymphatic absorbent vessels. You distinguish the 
latter by the sienderness of the painful cord; by its position, which is still more 
superficial than that of a subcutaneous vein ; by the number of little knots which 
diversify its course ; and by the streaks and patches of bright inflaramator3'- redness 
which appear along the same track. Dr. Graves remarks {Clinical Medicine, p. 
454), that inflammation of the lymphatics "is seldom continuous, but is developed 
at certain insulated points." 

In the suppurative form of phlebitis the general symptoms take the lead. The 
formation of pus in separate and often distant parts is rapid, and frequently unan- 
nounced by any local pain. When, however, the joints, or parts near the joints, are 
the seat of suppuration, much soreness is complained of, and the malady is liable to 
be mistaken for rheumatism; and when the serous cavities are ij;nplicated, the pain 
is sometimes severe. Suppurative phlebitis is commonly attended in its progress 
with repeated shiverings, and with profuse sweats, and occasionally with copious and 
very unnatural discharges from the bowels. These last have been noticed in ani- 
mals soon after the introduction of pus, or of putrid matters, into their veins. Nature 
seems to attempt to eliminate the poison in this way: and where the quantity of pus 
so introduced has been small, the attempt is now and then successful. But in gene- 
ral there is a continual supply of the noxious substance, and the system is irrecover- 
ably infected. Typhoid symptoms occur in most cases, but not in all. Very con- 
stantly there is great agitation, and a m.arked disturbance of the nervous system. 

I have called this purulent infection of the blood a formidable disorder : in truth 
it is almost always a fatal disorder. Yet that it is not inevitably mortal I know by a 
case which has recendy occurred in Mr. Arnott's practice at the Hospital, and which 
be permits me to mention. He had occasion to amputate the forearm of a man 
whose hand had been crushed by machinery. Two or three days after the operation, 
the patient's pulse quickened, and he had a severe rigor. These two circumstances 
led Mr. Arnott to apprehend the supervention of phlebitis; and accordingly one of 
the large, superficial, visible veins of the forearm became swollen, hard, and tender. 
Leeches v/ere apphed along its course ; and the parts were kept covered with the 
water dressing. In no long time an abscess formed in the other arm ; next, a large 
one in the back, from which twenty ounces of pus were evacuated; then one beneath 
the glutei muscles of the buttock, on both sides — each of these two contained about 
sixteen ounces. In short, datmg between the beginning of October and the middle 



712 



DISEASES OF THE VEINS. 



of December, no less than seven collections of matter presented themselves in various 
places. The last of them was in a very unusual part, beneath the man's tongue, in 
the ordinary situation of ranula, for which, indeed, it was at first mistaken. In every 
instance the pus was let out as soon as possible, and the main feature in the general 
treatment was the administration of opiates, and of wine, with a liberal allowance 
of good beef-tea in the earlier stages, and of meat afterwards. This man recovered ; 
and was seen in the month of May followmg, in perfect health. The case is ex- 
tremely interesting. It shows, 1 say, that suppurative phlebitis, even when it dissemi- 
nates consecutive inflammation and suppuration throughout the body, is not absolutely 
and hopelessly fatal. Whether abscesses, from this cause, distributed in the lungs 
or hver, are capable of repair, I cannot tell you. Under the treatment employed, the 
inflammation of the vein in the arm gradually subsided. All outward evidence at 
least of its existence, all induration even, disappeared ; and presumptively all inward 
evidence too. So that had this patient sunk, late in the course of his disorder, under 
the multiplied secondary abscesses, his venous system might probably have been 
searched in vain for any remaining traces of phlebitis : and yet we know that at one 
time he had phlebitis, more severe and extensive than belongs to the natural and 
kindly healing of every stump. 

The treatment found most suitable in phlebitis has just been briefly indicated ; 
local depletion when the inflamed vein is accessible ; regulation of the bowels ; strong 
animal broths and wine to* support the strength. Our object is in the first place to 
subdue and resolve the inflammation ; or at any rate to prevent its passing beyond 
the adhesive stage. To this end, the vein, being obvious and superficial, we apply 
leeches, cold lotions, or fomentations. 

[In cases of phlebitis from venesection, the late Dr. Physick recommended the application 
of a blister over the orifice in the arm, as soon as the inflammation commences, the orifice 
itself being first defended by a plaster of simple cerate spread on linen. He fomid this to 
be invariably beneficial in causing the arrest of the inflammation. Dr. Dorsey also found a 
blister thus applied to produce always a good effect; and in a case related by Dr. Evans, 
(Transac. College of Physicians of Philadelphia^ vol. ii., p. 106,) the good effect of blisters in a 
case of spontaneous phlebitis, w^as strikingly evinced. — C] 

During the progress of the malady, especially when suppurative phlebitis is pre- 
valent, it would be unsafe to cut into a large vein, lest by that shght violence we 
establish a fresh local phlebitis. Indeed, after the suppurative form has once been 
set up, general blood-letiing does no good; but, on the contrary, impairs the power 
of the system at large to struggle against the disease. 

The obliteration of a large vein, whether by adhesive phlebitis or in any othej 
way, is perilous in proportion to its magnitude, and to the rapidity with which its 
complete occlusion has been effected. The gradual stoppage of even the largest — 
the primary venous trunks, the veuEe cavjE — admits of some degree of compensa- 
tion. In one instance of this kind, which I briefly described yesterday, and which 
I myself witnessed, the superior cava w^as flattened, and its channel completely 
effaced, by the pressure of an aneurismal tumour: in another, which I mentioned 
formerly, on Mr. Kiernan's authority, an immense varix of the superficial veins of 
the abdomen supplied to the returning blood the passage denied to it, in its natural 
course, by the partial obliteration of the inferior cava. To impress upon your recol- 
lection the ordinary phenomena that result from these grave derangements in the 
hydraulic machinery of the body, I will state here, from my hospital case-book, the 
outlines of two additional examples of a similar character. 

James Buck, aged thirty-three, was admitted on the 6th of March, 1838. The 
appearance of this man was very remarkable. His countenance was swollen and 
hvid ; his eyeballs projected ; his hps, the end of his nose, and the rims of his ears, 
were of a deep purple colour. It was manifest that the blood did not freely descend 
from the head. Further evidence of this became apparent when the trunk of his 
body was uncovered. The throat Vv^as very full and' tumid, like that of a goitrous 
person, yet the swelling was not owing to enlargement of the thyreoid gland, nor to 
oedema ; but fek firm and fleshy. The jugulars were distended ; and the whole sur- 



PHLEBITIS. 



713 



face of the thorax in front, with that of the shoulders, and of part of the abdomen, 
was thickly overspread with a network of prominent veins. The external mammary- 
veins were seen to communicate freely with veins proceeding from the neck on each 
side, with the veins of both the upper extremities, and with the epigastric veins from 
beneath. Here and there were patches of minute purple varicose branches, crowded 
closely together. 

He told us that whenever he stooped down, to tie his shoe-strings, for instance, he 
became giddy, his head swelled, and his face and ears grew black : that he was very 
nervous, easily flurried, and dreamed much, thinking he was flying in the air, falling 
down precipices, and the like. He had not noticed any swelling of the face or throat 
until three weeks previously ; and he had never, he said, had a day's illness before. 
He knew of no cause for the complaint ; had been making no extraordinary bodily 
effort ; had never suffered rheumatic fever. Fie professed, also, temperate habits, 
but he had been a soldier, and afterwards a pugilist, and his wife informed me that 
he had led an irregular life. 

The evidence I say was strong, of some obstructioii to the return of the blood 
through the superior cava. Now such obstruction is most commonly produced by 
intrathoracic tumours — sometimes by carcinomatous ; much oftener by aneurismal 
tumours. There were no circumstances to make it likely that the malignant growths 
existed ; but there were circumstances which corroborated my first suspicion, that 
the symptoms were dependent upon aneurism of the aorta, or of one of its primary 
branches. 

There was indeed no external prominence, no pulsative or other swelling, no 
aneurismal whiz, to guide us to this diagnosis. Upon careful and repeated auscul- 
tation of the chest, the murmur of respiration was found to be in some parts feeble 
and unequal. This might consist with the presence of any kind of tumour. The 
heart's action was heard, and feh, strong and heaving, in the proper place, beneath 
the left nipple. To the right of the sternum also, and near the middle of its upper 
portion, one's ear was distinctly jarred at each systole of the heart, though with less 
force than in the precordial region. But in the space intermediate between these 
two spots, no such jarring sensation was perceptible, although the heart could be 
heard, beating with a slight bellows sound. Moreover, the right radial artery was 
considerably weaker and smaller than the left. This showed that the innominata 
was interested in the disease. The symptoms, taken together, left no doubt on my 
mind than there was an aneurismal pouch beneath the sternum, where the jar was 
experienced. I have gone somewhat into particulars to show you how confidently 
sometimes, by close observation, you may pronounce upon the condition of parts 
which you can neither see nor touch. 

All that could reasonably be hoped for from medicine, was postponement of the 
evil day. To relieve the oppressed blood-vessels by taking away part of their con- 
tents, by freely purging the patient, and by setting his kidneys to work — this was 
what was to be attempted; and this was done. He was repeatedly cupped, and 
always with most sensible relief to his feelings, the blood flowing copiously. Pur- 
gatives and diuretics also acted well ; and so much was the man benefitted by these 
measures, that twice he left the ward, and became an out-patient. 

About the middle of June a new symptom arose — severe pain extending from the 
right collar-bone across the shoulder. He died on the 10th of July. Three or four 
days before his death, he had rigors and extreme dyspnoea, complained of pain over 
the whole thorax, and declared that his "heart seemed on fire." These symptoms 
were caused by the supervention of pericarditis, which proved speedily fatal. A thin 
layer of recent, reticulated lymph was found covering a considerable extent of the 
surface of the heart. 

The body was examined by Mr. Shaw, after injection of the veins, and of the tho- 
racic duct. 

There was a large aneurism of the arteria innominata; of which I omit all. parti- 
cular description, my present object being to draw your attention to the state of the 
veins. The two great trunks that, coming from either side, unite to form the vena 
cava superior, were completeh'- closed up, as well as the corresponding portion of the 

3k2 



714 



DISEASES OF THE VEINS. 



cava itself, which was lost and confounded in the walls of tne aneurismal sac. The 
subclavian veins were pervious up to the point w^here they joined the internal jugu- 
lars, but no further. The preparation of these parts, which is before you, and the 
rough diagrams which I here exhibit, will aid your comprehension of the mode 
whereby the blood descending from the head, found its way at iength, through many 
circuitous channels, to the heart. The larger deep-seated compensating veins were 
not greatly magnified, but the number of the smaller branches was much augmented. 
The vena azygos, for example, was very little above its usual size ; yet it was appa- 
rently provided with a greater number of considerable branches than are commonly 
observed under natural circumstances. 




A, Obstructed veins. 

B, Seat of the right auricle. 

C, Tiioracic, pectoral and mannmary veins convey- 

ing the blood in a contrary course to its usual 
direction, and anastomosing with the inter- 
costal and epigastric veins. 

As the veins into which the trunks of the absorbent vessels discharge their con- 
tents were obhterated, it became interesting to examine the state of these vessels, and 
of the lymphatic glands. Bat the condensation and confusion of all the parts 
around the tumour rendered it difficult to trace the thoracic ducts. The glands 
were remarkably large, of a purple colour, and gorged with bloody serum. The 
fulness of the neck, noticed during hfe, was occasioned by this turgescence of the 
glandular concatenate. Large glands were seen studding the walls of the aneurism, 
and adhering to the great vessels connected with it : i. e., in situations where, under 
ordinary circumstances, such glands, from their minuteness, can scarcely be detected 
at all. 

With this case, contrast the following : — 

Harriet Baldwin, thirty-three years old, was admitted December 29, 1840, anasar- 
cous as high as the hips, and with an enlarged abdomen. The swelhng had begun, 
she said, a fortnight before. 

She complained of cough, and of expectoration, which was sometimes tinged with 
blood. She could not he down in bed for dyspnoea. Her urine was scanty and 
dark-coloured. 

She told us she had dropsy, quite as bad, five years ago, of which she was cured 
in St. Bartholomew's Hospital. 

All this we learned in the admission-room. The next day, when she was in bed, 
we learned a good deal more. 

The large abdomen did not owe much, if any, of its bulk to ascites. It contained 



OBLITERATION OF VEINS. 



715 



a palpable tumour, filling the right hypochondrium, and extending thence far beyond 
the umbilicus to the left, and into the . right groin. This tumour, from its situation, 
and from the continuous dullness ehcited by percussion from the right mamma down- 
wards over its whole extent, was evidently formed by the liver, much enlarged, and 
out of its place. 

But besides the tumour, the abdomen presented on its surface a very singular ap- 
pearance. Two zig-zag lines of large, varicose veins ran up its middle, near the 
right edge of the linea alba. These, which were evidently the epigastric veins, 
inosculated above with the mammary. Large, but straighter veins, wandered over 
the front of the thorax on both sides. 

The swollen legs of this woman were quite purple from innumerable clusters of 
small varicose veins. 

Other symptoms also there were, but I pass them by as irrelevant to my present 
subject. It was plain that the current of the blood 
along the vena cava inferior was suffering impedi- 
ment. That vessel was presumably compressed, 
perhaps rendered totally impervious, by the superja- 
cent tumour. The existence of the tumour ; the 
great cedema of the legs, compared with the shght 
amount of hquid in the cavity of the belly ; the va- 
ricose state of the cutaneous vems of the legs ; and, 
above all, the remarkable condition of the superficial 
veins of the abdomen : — these were the evidences. 
The blood from the lower extremities passed mainly 
by the way of the intercostal and subclavian veins, 
to the heart. Death took place on the 19th of Janu- 
ary, 1841. A part of the liver appeared perfectly 
healthy ; another part contained a prodigious quan- 
tity of hydatids. When removed from the cyst 
which had contained them, they filled a large wash- 
hand basin. The sides of the inferior cava were 
pressed together by the tumour, and its channel was thus completely closed up for 
the space of three inches. 

In each of these two cases, the closure of the great venous trunk was gradually 
effected, as the compressing tumour augmented ; and time was afforded for the deve- 
lopment of collateral supplementary channels. In both cases, the superficial veins 
of the thorax and abdomen contributed largely to supply the growing needs of the 
system ; but the stream of returning blood ran oppositely in the two cases : from 
above downvv^ards in the first, from below upwards in the second. The direction in 
which the blood in the veins is moving can, of course, be always readily ascertained ; 
and this might furnish a test, w^ere other tokens wanting, whereby to determine whe- 
ther the obstruction lay in the superior or in the inferior cava. And there is another 
circumstance worthy of remark, and of which the same use might be made. In the 
first case, the dilated veins of the thorax were tortuous, those of the abdomen direct. 
In the second, this was reversed ; the epigastric veins were singularly sinuous, the 
mammary veins were straight. In other words, those veins were, in each instance, 
contorted and winding, in which the actual course of the blood was retrograde. The 
vessels were bent and twisted as the current forced its backward way against the 
opposing but ineffectual barrier of the valves. 

It is impossible, I think, to find more clear evidence than these interesting cases 
exhibit, of the power inherent in the animal body of rectifying, to a certain extent, 
its own accidental derangements. You cannot, under such circumstances, overlook 
the existence, or mistake the tendency a vis medicairix naturse. 




716 



ASTHMA. 



LECTURE LXIV. 

Asthma : its nature ; complications ; exciting causes ; and treatment. Diseases 
of the (Esophagus : Inflammation; Stricture; Spasm; Dilatation. 

I MUST not leave the subject of thoracic disease without saying a word or two 
respecting asthma; a complaint which might have been properly arranged among 
the nervous spasmodic diseases, in a former part of the course. But 1 purposely 
deferred speaking of it, because, though in many instances purely spasmodic, and 
independent of any discoverable faulty structure, it is still more often connected with 
organic diseases of the heart, or of the lungs ; which diseases had not then been 
described. 

I scarcely need caution you against the vulgar error of calling all kinds of diffi- 
cult breathing by the name of asthma. You will be constantly meeting with per- 
sons who, labouring under some permanent embarrassment of the respiration, tell 
you they are asthmatic. They conceive that asthma is simply an inconvenient, and 
not at all a dangerous affection : and they please themselves with the notion — con- 
sumptive patients and their friends do this continually— that they are merely asthmatic. 
Asthma is dyspnoea, but dyspnoea is not necessarily asthma. 

Asthma may be defined as being — great difficulty of breathing : occurring in 
paroxysms; accompanied by a loud wheezing sound of respiration ; going off, after 
some hours, with more or less mucous expectoration ; and unattended with fever. 
And these paroxysms of dyspnoea are beheved to depend upon a spasmodic constric- 
tion of the bronchial tubes. 

To go rather more into detail : the phenomena which constitute and characterize 
a fit of asthma, are somewhat as follows : — The patient, if he have previously suf- 
fered under the disease, has usually some well-understood warnings that an attack 
is hanging over him. Loss of appetite ; frequently much flatulence and eructation : 
languor, irritabihty, drowsiness, oppression, cTiilliness ; and he goes to bed ill and 
uncomfortable. The dyspnoea comes on generally after midnight, about two or three 
o'clock in the morning ; often during sleep ; and the patient wakes with a sense of 
tightness and constriction about the chest, and an inabihty, as it seems to him, freely 
to expand it. He is obliged at once to rise up ; and he sits, leaning forwards, with ' ; 
his knees drawn up, his elbows on his knees, and his head supported by his hands, ! 
labouring for his breath, and making such a loud wheezing noise as to be audible at i 
a considerable distance. He experiences a strong desire or necessity for fresh air : \ 
opens the door of his room and goes out upon the stair-case, or flies to an open win- i 
dow, even in very cold weather : and remains there, with his head out, sometimes I 
for hours. That he can do so with impunity is a strong presumptive proof that it i 
is the nervous system which is principally affected in these cases. His extremities ] 
at the same time are usually cold, and his countenance is distressed and haggard : j 
while the trunk of his body may be wet with perspiration. Sometimes the face is a 
httle flushed and turgid : but more commonly, it is somewhat pale, and shrunk. The 
pulse is often small, feeble, and even irregular; and in many instances there is { 
much palpitation of the heart. At other times the pulse remains undisturbed. If | 
urine be passed, as it frequently is, at the beginning of a fit of asthma, it is copious 
and water}^ pale, and without smell, like the urine of hysterical women. The 
bowels are also sometimes relaxed, with " something (as Dr. Forbes observes) of the 
impatient hurry and imperfection of spasmodic action." There may be some i 
propensity to coughing, but the patient can hardly achieve a cough ; and is so occu- 
pied with his breathing, that he can speak in an interrupted manner only, with 
difficulty and uneasiness. He has not, however, in general, any misgivings about 
the event of the attack, but looks forward with hope to the expected termination of ' 
the paroxysm. ,. 

" These symptoms often continue for many hours together ; and particularly from f 
midniffht till morning is far advanced. Then, commonly, a remission takes place i 



i: 



ASTHMA. 717 

j by degrees. The breathing becomes less laborious, and more full ; so that the per- 
' son can speak or cough with more ease. And if, as is usually the case, the cough 

brings up some mucus, the remission becomes immediately more considerable, and 

he falls into a much-wished-for sleep." 
I Paroxysms of this kind will often continue to recur for many nights in succession : 

remitting at length in their severity ; and ceasing, for a period, altogether. 
I During the intervals between these paroxysms, in the day-time, the patient may 
j| be perfectly well ; but he seldom is so ; though so great is the difference between 
I his condition during the remissions, and in the paroxysms, that he declares, and per- 
! haps fancies, that he is quite well. You will mostly find, however, that he is short- 
j winded ; that he does not utter many words of a sentence before he pauses to take 
I breath ; that slight bodily exertion hurries his respiration ; and that he is not easy in 
j a horizontal posture, with his head low. 

j Although the dyspnosa is thus intermittent, or remittent, you are not to suppose 
that the paroxysms recur with the regularity of those of ague. The interval is of 
I uncertain duration; and the circumstances of the paroxysm differ in different in- 
|l stances. I may remark also, that when the paroxysm ceases with Uttle or no expec- 
I toration, the case is said to be one of dry asthma ; when expectoration is copious, it 
is humid, or humoral asthma. 

Now this, I say, is looked upon as being essentially a spasmodic affection. Upon 
! what grounds ? 

Why, in the first place, the patients have a sensation of constriction in the chest. 
I An old gentleman whom I saw lately, and who is subject to fits of asthma, made 
[ use of the term cramp when he described what he felt about the thorax ; and his 
attacks were always accompanied or succeeded by actual cramp of the muscles of 
the calves of his legs. This is no uncommon circumstance, this co-existence of 
decided spasm in other parts ; and it throws some light upon the nature of the dis- 
order. Again, the rapidity with which the dyspnoea comes on, and the suddenness 
with which it often abates, resemble the caprice of spasm. The supervention of 
extreme, sometimes enormous flatulence, and the secretion of hysterical urine, mark 
I also the nervous character of the symptoms. So likewise do the juvaniia and the 
Ixdentia, as I shall presently explain further ; the affection being suddenly produced 
by certain causes of irritation, and even by mental feehngs — suddenly relieved, some- 
times, by medicines which are reckoned antispasmodic. If we add to these consi- 
derations the fact that patients dead of asthma have often, on being examined, pre- 
sented no vestige whatever of disease, either in the lungs or in the heart, we obtain 
very strong presumptive evidence, that the phenomena attending a fit of asthma are 
often the result of pure spasm. 

But if this be so, what are the muscles thus fixed in spasmodic contraction ? 
You are doubtless aware that the air-tubes are encircled with a series of little 
fibres, or bundles of fibres. I have more than once shown you these, exaggerated 
by hypertrophy, in the larger bronchi. They have been traced, by Reissessen, in 
tubes of a very small diameter. Laennec states that he had distinguished them in 
bronchial ramifications less than one line across. Now, supposing these circular 
fibres to be muscular, it becomes at once, and a priori, hkely that they, no less than 
other muscles, should be liable to spasm. And the phenomena of asthma prove, to 
my mind, that they are so. Analogy would say that the fibres, thus disposed, are 
slender muscles, similar to those which surround the 'intestines and the urinary 
bladder: and the microscope, scrutinizing their minute texture and appearance, 
! asserts that they are actually muscles, of the unstriped kind ; Hke other involuntary 
I muscles subserving the organic life. This fact — which I know has been doubted — 
j I state upon the authority of Professor Todd and Mr. Bowman ; both known to you 
I all as faithful and expert observers. But a test, less fallible than the microscope, 
I has practically settled the question. Dr. Williams has recently demonstrated, by a 
I set of ingenious and satisfactory experiments, that the lungs and air-tubes are actually 
j contractile to a very considerable degree, under electrical, chemical, and mechanical 
j stimuh. The contractions take place steadily and deliberately ; and are followed, 
as soon as the stimulus is withdrawn, by an equally gradual relaxation. This is 



718 



ASTHMA. 



very like tonic spasm. The contractions were rendered apparent by means of a 
bent glass tube, containing coloured liquid, and adapted to the windpipe of an animal 
just deprived of life. The column of liquid in the glass tube would of course be 
readily movable by any contraction of the lungs and air-tubes, causing pressure of 
the included air against it. In one of the experiments, "on passing a galvanic 
current from the margin of the lungs to the insertion of the tube in the trachea, the 
fluid rose quickly, but gradually, nearly two inches ; sunk speedily on breaking the 
contact ; again rose upon completing it ; but fell slowly when the current was con- 
tinued for some seconds ;" i. e., when the irritability of the tissues was temporarily 
exhausted. Temporarily, I say, for on waiting two or three minutes between each 
application of the galvanism, the liquid was raised again and again for upwards of 
an hour; till, in fact, the organic hfe was extinct. Is not all this exceedingly like 
the behaviour of parts acknowledged to be muscular, under similar influences? 

The phenomena were not occasioned by any general shrinking of all the pulmo- 
nary tissues. For when the lungs were cut across by sharp scissors, at right angles 
to the air-tubes, and the open sections of these tubes were galvanized, they were 
seen to contract to one-half of their former diameter ; and even to become smaller 
than that. The contraction was the most distinct in the middle-sized tubes, being 
about the bigness of a straw : but it was sensible enough in the trachea, which was 
sometimes so far reduced in dimensions, that the ends of its cartilaginous rings came 
together. 

A foreign experimenter, M.. Valentin, carries us a step nearer to the full solution 
of this interesting question. He found that the rings of the trachea could be made 
visibly and distinctly to contract, by irritating the par vagum. 

Upon the whole, we may safely conclude that asthma is one of the spasmodic 
disorders of the excito-motory system of nerves. I believe, moreover, that, as in 
most other disorders of the same class, the spasm may be of centric, or of eccentric 
origin. In the eccentric form, the par vagum is doubtless the afferent nerve; and 
the impression it conveys to the medulla oblongata is reflected, through associated 
motor nerves, upon the bronchial muscles. The centric variety results from a similar 
impression originating in the nervous centres : which respond, mysteriously, to cer- 
tain feehngs of the mind. 

I have never had a favourable opportunity, since I became aware of the value of 
auscultation, of listening to the sounds of the breathing during a paroxysm of pure 
spasmodic asthma. But they who have enjoyed such opportunities declare that no 
respiratory murmur, or very little indeed, can be heard. And an attentive inspec- 
tion of the outside of the chest shows, that amidst all the tugging and heaving for 
breath, the expansion of the thorax is very limited. The patient cannot open his 
lungs as it were : and w^hat air does get in, has a difficult and narrow passage, as 
the wheezing noise demonstrates. Laennec affirms, that if the patient, after holding 
his breath nearly as long as he can, attempts a quiet and gentle inspiration, the 
spasm may often be overcome as if by surprise ; and, for a few seconds, the entrance 
of the air into the cell may be heard in a clear and even puerile sound. If this be 
true, it is a strong additional proof that the obstruction to the admission of air was 
really owing to a tonic contraction of the little muscular fibres of the bronchi and 
their ramifications. 

The hereditary nature of asthma is perfectly consistent with the same theory. 
It is one of the maladies which are distinctly transmitted — the disposition to them, 
I mean — from parents to children. And like other spasmodic disorders, it facili- 
tates its own return. When it has once occurred, it seldom fails to happen again 
and again. 

But though I believe, for the reasons I have now mentioned, that asthma, in the 
restricted sense of that term, is purely a spasmodic affection, yet I know also that it 
is very frequently indeed combined with organic alterations within the thorax. These 
changes of structure are to be regarded as so many strongly predisposing causes. 
They induce a readiness to take on spasmodic action : and some of them are perhaps 
aggravated, or even produced, by the fits of asthma, upon which they afterwards 



ASTHMA. 



719 



react injuriously. Judging from my own experience, I should say that genuine 
uncomplicated spasmodic asthma was rare. 

The organic diseases with which spasmodic asthma is often found connected, are 
principally emphysema of the lungs, and structural changes in the heart and great 
blood-vessels. It is extremely probable that the first step towards the production of 
the spasm, consists in some altered condition of the circulation through the lungs. 
The chilliness of the surface, and the sensation of want of air, make it hkely that 
the blood accumulates in the lungs at those times : that there is congestion of the 
membrane, as well as spasm of the circular fibres. And it would seem that, in the 
humoral asthma, the congestion is relieved by a copious secretion of mucus ; and 
that, with the congestion, the spasm also subsides and disappears. You will observe 
that very generally the paroxysms come on during the first sleep : at which time, as 
Dr. Alison has suggested, " the blood is perhaps in fullest quantity, its movements 
-slow, and its congestion in internal parts easiest, because it is least solicited to the 
organs of sense or locomotion." But there seems to be another reason for this re- 
markable circumstance. Respiration is mainly an automatic act; yet it also obeys 
the will. During sleep this moderating influence of the will is suspended. Those 
changes of posture, and those voluntary alterations in the rate of breathing, which 
are wanted to balance and correct the commencing derangement of the pulmonary 
circulation, and which are prompted at once during the waking state, do not occur: 
until at length the derangement reaches that pitch at which it provokes spasmodic 
contraction, and rouses the sufferer. 

This same congestion, leading to spasm, sometimes passes into a slight form of 
inflammation; and we have symptoms of bronchitis. And ..these symptoms may 
remain manifest even during the intervals of the paroxysms. It appears probable 
also that the vesicular emphysema of the lungs, which so often accompanies asthma, 
is increased by the paroxysms, even if it be not, in all instances, originally induced 
by them. In either case, there will be some abiding dyspnoea between the fits. 

Many of these asthmatic patients have just healthy lung enough to breathe with, 
in tolerable ease and comfort, under ordinary circumstances ; and dyspncea is brought 
on whenever even a shght additional demand upon the respiration anyhow arises. 
Hence, as I stated before, flatulent distension of the intestines, undue repletion of the 
stomach by an excessive meal, the recumbent posture, all of which cause pressure 
against the under surface of the diaphragm, may suffice to bring on the fit. Hence, 
also, probably, in part, its frequent occurrence in the night-time. 

In like manner, any extraordinary task imposed upon a heart which is barely 
equal to its functions v^^hile the body is in repose, may induce a paroxysm of asth- 
matic dyspnoea. 

Asthma is a disorder Vv^hich is incident to both sexes, but it is much more common 
in men than in women. It is incident to all ages also ; but it belongs more to adoles- 
cence, and to the middle portion of life, than to its. extremes. It is not, I think, a 
common disease prior to the age of puberty : yet instances of it do occur at an earlier 
period than that. I have lately seen a boy of eight or nine, who has had several 
well-marked attacks of pure asthma. Nor does it often begin to show itself in old 
age. Sometimes, after plaguing the subject of it for several years, it leaves him alto- 
gether. The chronic dyspnoea, with occasional irregular exacerbations, which is so 
frequent a disorder among old people, and which always depends upon organic dis- 
ease, is not to be confounded with true asthma. It is said that asthmatic persons are 
exempt from phthisis : and I understand that one physician in this town, who an- 
nounces that consumption is, curable, maintains the doctrine of the incompatibility 
of phthisis and asthma ; and endeavours to bring about the latter, that he may protect 
his clients from the former. It may be that persons affected with genuine asthma 
seldom become the victims of pulmonary consumption : but I am sure the rule is not 
universal. One of my earliest friends had from time to time, while we were school- 
fellows, and long afterwards, the most exquisite fits of spasmodic asthma. At length, 
when he was between thirty and forty years old, they wholly ceased : whereupon 
he greatly congratulated himself. But they only yielded before a worse disease. 
He began, in a few months, to spit blood : and in a few months more he died of well- 



720 ASTHMA. j 

marked phthisis. Our lamented principal, the late Mr. Rose, afforded another sad ! 

example of the same sequence. And I have known two or three famihes in which [ 
one individual was subject to asthma, while others were scrofulous and phthisical. 

The exciting causes of the asthmatic paroxysm are manifold ; and some of them j 

curious. They seem to be reducible to two classes. 1. Particular states of the ' 

atmosphere, which irritate or offend the mucous surface of the air-passages ; or ' 

rather, some of the fibrils of the par vagum. 2. Certain subtle influences which ' 

affect in a peculiar manner the nervous system. All the known exciting causes of | 

catarrh are therefore likely to bring on attacks of asthma in the predisposed. But I 

there is a singular caprice in asthmatic patients in this respect. Some persons, sub- , 

ject to the disorder, are unable to breathe in the thick smoky air of London ; require ' 

a high and clear situation ; and respire easiest in " the difficult air of the keen i 

mountain-top." Others can nowhere breathe so comfortably as in low moist places : ! 

in some of the streets by the water-side in the city, for instance. The friend to I 

whom I lately alluded lived at Newmarket ; a most exposed and bleak spot. But j 

if he left it, and attempted to sleep in a strange place, he never was certain that he i 

should not be assailed in the night by his well-known enemy. So that there were j 

towns in which, after experiencing the effects of their atmosphere, he dared not i 

sleep ; and there were others in which he knew he might go to bed in security. It | 

would have been difficult, I believe, to point out any essential difference between j 
some of those localities. His lungs, however, formed an infaUible eudiometer. 

Another college acquaintance of mine, much tormented by asthma, is equally sensible ' 

to these inscrutable influences. Two inns in Cambridge are named respectively the j 

Red Lion, and the Eagle. He can sleep in one of them, and not in the other. Nay, ' 

he is thus variously affected within much narrower Hmits. He assures me that, \ 
when in Paris, he never escapes a fit of asthma if he attempts to sleep in the back 
part of Meurice's Hotel, and never suffers if he sleeps in a front room. Dover 

Street suits him ; Clarges Street does not. He cannot rest in Manchester Square. [ 
This he attributes to its being built upon piles. Whether it really has such a 
foundation I do not know. And agencies still more shght and subtle are enough to 
set the springs of these seizures in motion. The mere absence of light, for instance. 

Laennec speaks of a man who invariably was roused from his sleep by a paroxysm , 

of asthma, if his lamp was extinguished ; or if his chamber-door was shut. The ' 
consciousness that the customary preventive remedy was not at hand, has, appa- 
rently, brought on a fit. 

There are many persons who never fail to become asthmatic if they inhale cer- 
tain effluvia. Particles of ipecacuan floating in the atmosphere, or (what is perhaps ' 
the same thing) its mere odour, are insupportable to many. They are thrown into ! 
a paroxysm of dyspnoea if they enter an apartment where that drug is under prepa- ! 
ration. I think I mentioned before a certain laboratory-man at St. Bartholomew's j 
Hospital who possessed this peculiar and inopportune susceptibility : he was obHged 
to fly the place whenever ipecacuan was about. Most persons, probably, who have j 
had much experience in druggists' shops, are acquainted with similar examples : so . ] 
that the influence of ipecacuan in exciting fits of difficult breathing, resembling i 
asthma, is undoubted, and common to many constitutions. We might as well speak 
of ipecacuan asthma, as of hay asthma, which is a precisely analogous affection. 
Dr. Marshall Hall calls attention to the familiar but interesting fact, that the same | 
drug, ipecacuan, acting upon the gastric branches of the par vagum., excites the ! 
reflex spasmodic act of vomiting. \ 

I have said, that the relief afforded by antispasmodic -remedies affords presumptive , 

evidence of the spasmodic nature of these attacks. If asthma supervene upon mani- ' 

fest bronchitis, or if there be any signs of congestion about the head, it may be pru- ' 
dent to abstract blood : but this measure will not in general be requisite, and when 
not requisite it should be avoided : for whatever tends to debilitate the patient, or to 

lower his vital powers, tends, at the same time, to augment his susceptibility to the , 

exciting causes of the disease. The dyspnoea may frequently be moderated or alto- ) 

gether assuaged by some form of narcotic. Now opium is the narcotic to which 'i 

we most trust for the mitigation of spasm in general : and opium is of vast service ' 



i 



ASTHMA. 



721 



in paroxysms of asthma. But there is also another of the vegetable narcotic sub- 
stances which has obtained an especial repute for its effect in quieting the difficult 
breathing in these cases ; and that is stramonium. This herb, the datura stramo- 
nium, and another species of the same genus, the datura ferox, had long been em- 
ployed in India as a remedy for asthma. And when it was introduced into this 
country, about the beginning of the present century, it was cried up as a specific ; 
and every body who called himself asthmatic began to smoke stramonium : for that 
is the way in which it has been chiefly employed. The leaves and stalks are cut 
and put into a pipe, and smoked hke tobacco. The smoke descends, of course, into 
the lungs : and when the saliva is swallowed, the remedy is introduced into the 
system in that w^ay also. 

Stramonium thus used, sometimes fails altogether : sometimes calms the paroxysm 
like a charm. The late Dr. Babington told me of a patient of his who had been 
grievously harassed for a series of years, by asthma, but who declared to him, after 
he had made a fair trial of stramonium, that he no longer " cared a fig" for his 
asthma ; which he could always stop in a moment. So a Mr. Sills, in a collection 
of communications relative to the datura stramonium, pubHshed in London in 1811, 
states, that he had been a great sufferer from asthma: that the fits usually continued, 
with short interruptions, from thirty-six hours to three days and nights successively ; 
during which time, he had often, in the seeming agonies of death, given himself 
over, and even wished for that termination of his miseries. But having at length 
discovered the virtues of stramonium, he uses this strong language : — "In truth, the 
asthma is destroyed. I never experienced any ill effects whatever from the use of 
the remedy; and T would rather be without life than without stramonium." 

This, then, is an expedient which it will always be well to suggest, for reheving 
the urgent distress of the paroxysm of asthma. But most patients subject to that 
complaint try it of their own accord. We have still to learn why it is so efficacious 
in some cases, and so entirel}^ useless, or even hurtful, in others. This probably 
depends something on the presence or absence of organic disease in the lungs 
or heart : but more accurate observations are wanted on this point. 

Some of the animals upon whose lungs Dr. Wilhams performed his experiments 
had been killed by poison. In two instances stramonium was the poison employed; 
and it is interesting to know that scarcely any contraction of the air-tubes could be 
produced by the galvanic apparatus. The trachea, at the same time, was lax. It is 
requisite to notice the condition of the wind-pipe in these experiments ; for the same 
want of contractility would be apparent, supposing the parts to be already in a state 
of tonic spasm, from the operation of the poison. This seems to have been the case 
when conium was used : the fluid in the glass tube indicated scarcely any com- 
pression of the air contained in the lungs ; but then the wind-pipe was so far con- 
tracted, that the extremities of its rings met. There was but little contractility, and 
a lax trachea, after death by belladonna; and after death by the meconate of mor- 
phia. The contractility was slight when Hfe had been destroyed by strychnia ; but 
the condition of the trachea is not reported. 

Experiments of this kind appear to be well worthy of careful repetition. 

I have found a mixture of opium and sulphuric aether of great service in tranquil- 
izing the breathing in asthma. And in one case, which was under my care for some 
time, I made comparative observations respecting opium and stramonium. Both 
gave much relief; but stramonium the most, and the most certainly, if it were 
applied in time. This patient was in the habit of being roused from sleep by the 
supervention of the paroxysm: and if he had the means of lighting his pipe in- 
stantly, he could stave the fit off. But when once it had attained its full intensity, 
he was unable to smoke. Under such circumstances, he would swallow the mor- 
phia and aether ; and the effect of this depended also in a great measure upon the 
period at which it was taken. It would stop a commencing paroxysm; but had 
little influence over one that was fully formed. 

It has been suggested, as one clue towards determining the particular kind of case 
to which the stramonium is applicable, that it succeeds if it produces expectoration ; 
and not otherwise. But I doubt about this. The relief is sometimes too sudden to 
46 3l 



722 



DISEASES OF THE CESOPHAGUS. 



admit of its being so explained. Dr. Forbes quotes the following passage of a letter 
from an old and intelligent asthmatic to himself. " Smoking tobacco or stramonium 
is sure to give relief, if it produces expectoration ; and it will generally do so if, the 
moment I awake (i.e., in the incipient paroxysm), I begin to smoke, and continue to 
do so for three or four hours. Smoking, I am able to say, after fifteen years' prac- 
tice, and suffering as much as mortal can suffer and not die, is the best remedy for 
asthma, if it can he relieved by expectoration. I have been in the hands of all the 
doctors of the place for fifteen years ; and still I say, smoke.^^ 

The lobelia inflata has been of late much lauded for its beneficial operation upon 
dyspnosa of all kinds, and upon asthma in particular. I beheve its virtues have been 
overrated. It sometimes, like stramonium, has an almost magical effect ; but fre- 
quently it fails to do the smahest good ; and I know that sober practitioners who have 
employed it more than I have, have thought that it may occasion dangerous symptoms. 
Of my own knowledge, I have nothing worth communicating to you of this drug. 

Strong coffee is a common domestic remedy for asthma. The friend and school- 
fellow already mentioned used to take it in considerable quantities, and, as he assured 
me, with very great benefit. It is a safe, and simple, and grateful remedy, and has 
numerous testimonies from medical practitioners in its favour. But it is much less 
sure than the stronger narcotics. 

Ipecacuanha, which is so frequently the cause, has also been recommended for the 
cure of asthma ; and a host of drugs besides, with which I have no intention to 
weary you. Among the rest, the application of galvanism was once in great vogue. 
In the only patient who ever tried it under my own eye, — -and he insisted upon 
being galvanized when his fits were quite absent, — the galvanism brought one on 
immediately. 

If we can shorten or mitigate the paroxysms, we do our patient a most essential 
service, and spare him a great deal of suffering. And during the intervals between 
the fits, we must endeavour to prevent their recurrence. 

For this purpose, I can only just hint at the principle upon which we should go. 
In the simple form of the complaint, when it is apparently uncomplicated with 
any organic disease, we must caution the patient against whatever has a tendency to 
disturb the general health. He must be temperate in all things ; he must pay atten- 
tion to the regulation of his digestive organs ; he must discover what kind of situa- 
tion suits him best ; and avoid those which experience has shown to disagree with 
him. And if any one remedial measure be hkely to fortify him against his malady, j 
I believe that measure will oftenest be found in the shower-bath, employed in the | 
way which I formerly recommended. i 

If the asthma occurs in connection with any obvious pulmonary or cardiac disease, j 
we must, in addition to the means I have now been adverting to, apply ourselves to j 
the mitigation of such superadded disease. And in respect to this I have nothing j 
more to offer. i 

I go next to the morbid conditions of the oesophagus, so far as they concern the j 

physician ; and these morbid conditions are not many. The oesophagus hes partly , 

in "the chest, and partly in the beUy, and therefore may very properly close the sub- | 

ject of thoracic diseases, and introduce those of the abdomen. j 

The ossophagus is less hable to disease than any other part perhaps of the ali- i 
mentary canal. It differs in structure somewhat (as you know) from ah other parts. 

Its mucous membrane is provided with a thick epithelium, which extends a little '. 

beyond the cardiac orifice of the stomach. Beneath hes a dense web of areolar j 
tissue, and two layers of muscular fibres ; the one layer being disposed circularly 

around the tube — the other longitudinally, in the direction of its axis. In some cases j 

there are pouches found in the sides of the oesophagus, formed apparently by a kindi | 

of hernia of the mucous membrane, between the separated fibres of the muscular j 

coat. These are not common, however, and scarcely worth mentioning, except that ;, 

their existence has been supposed to have a possible connection with a curious phe- ■ 

nomenon, peculiar to some persons ; the power, viz., of ruminating ; the power of f 
bringing into the mouth again, by a voluntary effort, food which has been for some < 



\ 



DISEASES OF THE (ESOPHAGUS. 723 

time swallowed, as cows, and the rest of the ruminantia do. There are but few 
individuals of the human species who possess this faculty ; there are but few who 
have appendices to their oesophagus. Whether the phenomena in question belongs 
to these last few has never been determined ; but as the possible connection of the 
two circumstances has been suggested, it is well for you to be aw^are of it, that you 
may refute or verify the notion, in case you ever have the fortune to examine the dead 
body of a person who had the power of ruminating. 

The covering of cuticle protects the cesophagus from the injurious influence of 
matters passing over it, which might otherwise be hurtful. The morbid state for 
which we are most often consulted is stricture, actual or spasmodic. I believe that 
the cesophagus is very little subject^ to inflammation, except from mechanical violence 
or chemical injury. I have seen a few cases, however, in which I inferred a spon- 
taneous inflammatory condition of the tube, from the symptoms complained of; 
which were a sense of heat and pricking exactly in the course of the (Esophagus, 
and felt between the shoulders, and precisely in the part (the patients said) where a 
potato, swallowed too hot, gives pain while it is descending into the stomach. With 
these symptoms there was some degree of dysphagia, not explained by anything 
visible in the throat or pharynx :,. and some degree of fever. In all the instances of 
this kind that I have met with, the symptoms have yielded in a few days to absti- 
nence, purgatives, and the apphcation of leeches along the track of the oesophagus. 

This part of the alimentary canal often suffers severe injury from the deglutition 
of certain poisons, especially the corrosive poisons ; the strong mineral acids, for ex- 
ample, or the caustic alkahes. We have, in the museum of the college, some very 
interesting specimens of the effects of these destructive substances. Sometimes, 
when the quantity of the poison has been small, and its transit rapid, the cuticular 
lining alone of the gullet is destroyed. It is shrivelled up, broken into fragments, 
abraded. At other times, the subjacent textures are affected, and ulceration takes 
place, which at length heals, and leaves a permanent, and generally a progressive 
constriction of the oesophagus ; and sometimes the whole of the internal membranes 
slough away, and are discharged in one continuous tube, from the mouth ; and yet 
the patient survives for some time. My colleague. Dr. Wilson, had a case of that 
kind. The patient, a young woman, swallowed about a tablespoonful of oil of vitriol. 
A week afterwards, she brought up, during a paroxysm of choking cough, a com- 
plete cast of the gullet, with ragged ends ; or, rather, the gullet itself. Some of the 
muscular fibres of the esophagus were plainly visible on the outside of this tubular 
slough, in its recent state. She lived eleven months afterwards, swallowing all that 
time with difficulty and pain, and subsisting on slops and soft food. Yet at one pe- 
riod she certainly gained flesh. After her death, the channel, as it remained after 
the injury, was taken out and examined. They are both before you — the original 
slough, and the ultimate gullet. The latter was formed by a surface which consisted 
of an irregular cicatrix. The tube was contracted considerably in the lower two- 
thirds of its course. 

When patients have suffered inflammation and ulceration of the oesophagus from 
these causes, and do not perish at the time, they are very hable indeed to have their 
existence abridged by the occurrence of stricture of the gullet, which goes on slowly 
increasing until no food can pass it, and then, of course, the patient dies of starvation. 
I show you here an oesophagus taken from a man whose case I had opportunities of 
observing from the beginning. He was under the care of Dr. Macmichael, in the 
Middlesex Hospital. He was brought there in Novernber, 1830, having swallowed, 
half an hour before, a solution of the impure carbonate of potass, which had beeri 
made for the purpose of cleaning paint, and which he had mistaken for beer. Not 
more than a tablespoonful passed the fauces, and probably none of the poison reached 
the stomach. He suffered severely, and was in considerable peril for several days, 
in consequence of inflammation of the fauces and epiglottis ; but this gradually sub- 
sided, and he went out apparently well. From what I knew of the resuh of such 
cases, I ventured, however, to predict that this man would, sooner or later, come back 
with stricture of the cesophagus. He had always pointed out a spot about half-way 



724 



DISEASES OF THE OESOPHAGUS. 



down the sternum, where he said the oil of tartar had caused him extreme pain at 
the very first, and below which he had not felt it. 

Accordingly, I was not surprised to see the poor fellow at the hospital in February, 
1834, attending as an out-patient. He came there, he told me, because in eating 
some soup he had accidentally swallowed, without chewing it, a piece of carrot, 
which lodged in its way dovA'n, and which it became necessary to push onwards into 
the stomach by means of a probang. Morsels of food had stuck in the same spot 
before ; and it was the very spot where he felt the effects of the caustic at the time 
of the accident. He looked tolerably stout and healthy ; but said that, since swal- 
lowing the potass, he had never been the man he was before. 

He continued to make his appearance, from time to time, at the hospital, with 
similar symptoms, till the 5th of last December (f536), when he was brought there 
insensible, and evidently dying. We could obtain no satisfactory account of his 
recent symptoms. He had the mark of a blister, however, on his left side ; and 
upon closely examining him, it was plain that that side Avas full of fluid. It was 
perfectly motionless in respiration; it was palpably larger than the right side; it 
yielded everywhere a dull sound on percussion ; and no vesicular breathing what- 
ever could be heard there by the ear. The respiration on the right side was puerile ; 
and the beating of his heart, with a systolic beliov/s sound, was audible on the right 
of the sternum. 

Although I was certain that the left pleura was full of hquid of some kind, I did 
not have the thorax punctured ; because, in the first place, he was manifestly in 
articido mortis, and I thought that his death, which was certain, might be attributed 
to the operation ; and secondly, because he was not dying of suffocation. His 
breathing was not laborious or much distressed ; but he was dying of coma, and his 
extremities were already cold, and his pulse was fluttering. I conjectured that an 
ulcer of the oesophagus had made its way into the pleura, and caused inflammation 
there. But my conjecture was wrong. 

I will mention the main particulars of the examination of the dead body, because 
the case was, in several respects, an interesting one. 

There was a considerable quantity of serous fluid in the meshes of the pia mater, 
beneath the arachnoid ; and there was some liquid of the same kind in the lateral 
ventricles. No other diseased condition could be detected in the brain. The effu- 
sion was sufiicient, supposing it to have come on suddenly, to explain the com.a. 

I had the ribs sawn away on the right side, leaving their cartilages attached to the 
sternunn ; and then we saw plainly that the heart and mediastinum were thrust over, 
about four inches by measurement, beyond the mesial line on the right side. The 
body was on its back. It was easy to perceive how a pleura thus full of fluid must 
oppress the lung of the other side, especially w^hen assisted by the force of gravity. 
The left cavity was distended by a grayish-coloured and most offensive fluid, of the 
consistence of gruel; the pleura pulmonahs was covered by a layer of coagulable 
lymph; and the lung was flattened against the vertebral column. We could not 
discover any communication between the cavity of the pleura and the cesophagus or 
air-tubes. 

About the middle part of the cesophagus there was a distinct stricture, occupying 
about half an inch of the tube. Through this portion it was impossible to push 
one's little finger, which elsewhere found a loose and ready passage. 

In this case, the man did not die of the stricture ; but he would have done so, had 
not another disease carried him off". I do not know why the constriction, after it has 
once taken place, should go on continually increasing; yet it seems to be so. In 
his Surgical Observations, Sir Charles Bell mentions three cases like that just de- 
scribed. In one of them, where soap-lees had been the substance swallowed, death 
took place by starvation from stricture of the gullet, twenty years afterwards ; and 
Sir C. Bell had no doubt that the stricture originated in the chemical injury inflicted 
by the soap-lees. 

When the symptoms of stricture come on in these cases, physic can do almost 
nothing. Surgeons pass bougies into the gullet, and attempt to dilate the strictured 



DISEASES OF THE CESOPHAGUS. 



725 



portion, or to prevent any further narrowing. But this expedient is usually of tem- 
porary benefit only, and the patient dies at last of inanition. His miserable existence 
may perhaps be protracted a little by injecting nutritive enemata into the rectum. 
Sometimes the oesophagus ulcerates through, and a communication is formed between 
it and the neighbouring parts. 

But the oesophagus, like the urethra, and Hke the bronchial tubes, — like every 
canal, indeed, in the living body, that is surrounded by circular muscular fibres, — is 
liable to temporary constriction and closure, by the spasmodic action of its own mus- 
cles ; and this affection is, of course, a far less formidable one than the last. 

Patients who are subject to spasmodic stricture of the oesophagus experience occa- 
sionally, in some point or other of that tube, a sensation as if there were a knot ; or 
sometimes a feelino- as if some solid substance was ascending from the stomach 
towards the pharynx. If they happen to be then engaged in eating, the morsels of 
food, after mastication, readily pass the pharynx ; but, at a certain distance down the 
gullet, they stop, and occasion pain which is felt between the shoulders, or distinctly 
in the passage itself. Great anxiety and distress accompany this stoppage, and the 
food is often rejected by a reversed action of the oesophagus. 

The symptoms, in fact, are identical vi^ith those which result from permanent stric- 
ture of the gullet, except that they are not permanent. When the stricture is or- 
ganic and abiding, the symptoms occur during or after every meal. When it is 
simply spasmodic, they come and go, capriciously, we often cannot conjecture why 
or wherefore ; after the fashion of other spasmodic ailments. 

Spasmodic stricture may be independent of any disease of structure in any part 
of the body ; but it is of some importance to be aware that it may also be symp- 
tomatic of very serious organic changes. Mr. Mayo relates the case of a young 
man " who had difficulty of swallowing ; he could get dowm liquid food only ; and 
that not without an effort. A bougie being introduced, some resistance was found at 
the upper opening of the oesophagus, but it yielded : the resistance was spasmodic, 
and depended upon neighbouring irritation caused by ulceration in the interior of 
the -larynx. The use of the bougie for a few days, with appropriate remedies to the 
larynx, removed the dysphagia." 

The purely spasmodic cases occur principally in persons of a movable constitu- 
tion : in young women whose uterine functions are deranged, and who are liable to 
hysteria. The remedies for hysteria will prove remedies for the spasm of the oeso- 
phagus also. And whatever is calculated to excite ordinary hysterical symptoms, 
whatever tends to render the system weak and irritable, will tend to aggravate the 
oesophageal stricture. I alluded to such cases in a former lecture. I give you ano- 
ther, related by Sir Benjamin Brodie. A lady consulted him, unable to swallow the 
smallest morsel of sohd food ; and swallowing liquids not without great difficulty. 
The symptoms had been coming on upwards of three years. A full-sized oesopha- 
gus bougie being introduced, entered the stomach without meeting the shghtest 
impediment. This lady's face was pale and bleached : her feet were edematous. 
She had long laboured under internal piles, from which repeated discharges of blood 
had taken place. Under the use of remedies which relieved the piles and the bleed- 
ing, the difficulty of swallowing went away. 

It is a singular, and it might, if more frequent, be a puzzling circumstance, that 
very nearly the same symptoms which occur when the oesophagus is permanently or 
temporarily constricted, happen also sometimes under a totally opposite condition of 
that tube ; I mean its dilatation into a large, inelastic, inert bag. One remarkable 
example of this I witnessed in a woman whom I attended in conjunction with Mr. 
Mayo, some years ago, in the Middlesex tiospital. The case has been fully de- 
scribed by Mr. Mayo, in the third volume of the Medical Gazette ; and more briefly 
in his Outlines of Pathology. She was thirty-three years old. She was brought 
to the Hospital in a state of extreme feebleness and emaciation. They who brought 
her said that for the preceding month she appeared to keep dowm nothing. What 
she took as food seemed to her to stop in the gullet; and, after a few minutes, it 
returned. A large oesophagus bougie passed readily into the stomach. She could 
swallow liquids more easily than solid food. When she took a small quantity, it did 



726 DISEASES OF THE GESOPHAGUS. 

not feel to her as if it reached the stomach ; and in three or four minutes it was inva- 
riably rejected. The vomiting was not preceded by nausea, although in its progress 
it had the appearance of ordinary retching. She craved for food and drink, and 
seemed hterally starving. The complaint had begun ten years before, during her 
pregnancy, and had gradually got worse. The belly w^as so shrunk that the umbi- 
licus was not more than an inch distant from the spine. There was no enlargement 
nor hardness about the stomach ; no particular tenderness on pressure of the epi- 
gastrium ; nor any uneasiness there. She died, utterly extenuated, sixteen days after 
her admission. 

The stom.ach was found small, and contracted at its middle to the breadth of an 
inch and a half. The upper part of the duodenum was but half the ordinary size 
of the ileum. The oesophagus I show you, turned inside out. 

It is enlarged to an extraordinary degree of dilatation, as you perceive. It was 
healthy, and of its natural size, at and near each extremity. Intermediately the lining 
tunic was thickened and opaque, with numerous depressions in it. The muscular 
fibres, which appeared to have multiphed with the expansion of the canal, were of 
their natural colour and thickness. 

Here is another preparation : a dilated oesophagus w^ith cancerous degeneration of 
the cardiac orifice of the stomach. I do not know its histor}' ; but the mechanism 
of such dilatation is intelligible enough. The food, unable to pass out of the gullet 
into the stomach — or passing slowly and uncertainl}^ — the tube behind it is habitually 
distended, and loses at length its proper contractility. I saw last summer, in con- 
sukaiion with Mr. Mayo, an old gentleman, of seventy, who, for two years, had 
experienced difficulty in getting food into his stomach. He would eat a few mouth- 
fuls very well ; and then, of a sudden, the next mouthful, after passing the pharynx, 
w^ould stop just short of the stomach ; and a sensation of swelling would arise in the 
low^er and middle part of the cesophagus ; and presently up the mouthful would come 
again. Sometimes, by waiting quietly a little while, the morsel would go on ; some- 
times he could wash it forwards by a gulp or tu^o of drink : but if once the food got 
fairly into the stomach he had no further trouble with it. This gentleman had no 
discoverable disease of the heart or lungs. He gradually grew worse. At last he 
began to vomit grumous matters, resembling coffee-grounds, and soon died. He was 
at some httle distance from London at the time, and the body was not (I beheve) 
examined. J have no doubt that he had mahgnant disease of the cardia; and I 
think it probable that his oesophagus was dilated. I had a female patient about two 
years ago in the hospital with very similar symptoms ; and her stomach was found 
to be full of cancerous disorganization. The state of her gullet is not recorded. 
We are apt, in such cases, to satisfy ourselves with ascertaining the gastric disease, 
without carefull}' examining that part of the alimentary canal which hes above. 

For maladies like these medicine has no cure. Opiates may give comfort, and 
promote the euthanasia : and that is all. 

[During the period of infancy, the mucous membrane of the (Esophagus is not unfrequently 
the seat of inflammation, of a diphtheritic, follicular, or erythematic character. The disease, 
however, is not very often detected during the life-time of the patient, in consequence of the 
symptoms by which it is accompanied being those which are common to many of the affec- 
tions of the earlier months of existence. In fact, almost the only symptom in many cases 
of oesophagitis in the infant is frequent vomiting; — immediately after the deglutition of 
drinks, or of aliments of any kind, these are discharged by vomiting, without having under- 
gone any change. The infant usually refuses the breast and fluids generally, evidently from 
the pain excited by the act of deglutition; occasionally, however, he will swallow, without 
much difliculty, half solid aliment when given in small quantities at a time. If the stomach 
be aflected with inflammation at the same time with the oesophagus, the undigested food and 
drinks discharged by vomiting will be, occasionally, mixed with the morbid secretions of 
that organ. The disease is seldom attended by any degree of febrile excitement — The 
infant is, usually, fretful and restless, and becomes rapidly emaciated. Whenever an infant 
rejects the breast, or any species of fluid aliment, vomits frequently, and discharges what- 
ever he swallows in the same state nearly as when it Avas taken, it is the duty of the prac- 
titioner to institute a minute examination, in order that he may detect the inflammation of the 
oesophagus if it exists. It is probable that pressure along the whole track of the cesophagus 
will excite the cries of the child, when we can have no hesitation as to the diagnosis. If 



DISEASES OF THE ABDOMEN. 



727 



this doea not happen, we may nevertheless be tolerably certain as to the existence of the 
inflammation, if the infant be labouring at the time, or has very recently been labouring, 
under one or other of the forms of stomatitis. If the inflammation is confined entirely to 
tlie mucous membrane of the gullet, and is not aggravated by improper food or drinks, it 
will often subside, after a few days, spontaneously; but when it is connected, as is very 
generally the case, with inflammation of the stomach or intestines, it is an affection difBcult 
to control, and usually fatal. In perhaps the majority of cases, oesophagitis in the infant is 
preceded by erythematic, diphtheritic, or follicular stomatitis. 

The frequency with which inflammation attacks the mucous membrane of the oesophagus 
in the infant, is evidently due to the predisposition which exists, at this period, to disease of 
all the mucous surfaces from their constant state of hypersemia; it is liable to be excited by 
too much or improper food, or that which is too hot or stimulating. In infants confined to 
the breast, it may be occasioned by the bad quality of the mother's milk, or by some tempo- 
rary morbid change occurring in the latter — and which may be produced by a variety of 
causes. CEsophagitis has been known to result from the reprehensible nursery practice of 
administering to infants infusions of spices, or even gin and water, for the purpose of expel- 
ling v/ind, or to relieve the colicky pains with which they are so frequently affected. — In 
common with all the affections of the mucous membrane in early life, inflammation of the 
oesophagus occurs most frequently, and is the most difficult to manage in infants exposed to 
the baneful influence of personal and domestic filth, and a confined and impure air. Accord- 
ing to Billard, the atlection of the gullet is almost invariably preceded by stomatitis — parti- 
cularly, we may add, of a diphtheritic or follicular character. 

The pathological changes detected after death in cases of cEsophagitis, are stated by Bil- 
lard to be vivid redness, with destruction of the epithelium, of some portion of the mucous 
membrane of the oisophagus, especially of its upper portion; in some cases, a curdlike ex- 
udation, more or less extensively diffused, is present; in others follicular ulcerations; a sepa- 
ration of portions of the epithelium, often in large shreds, is occasionally met with ; nume- 
rous red or dark-coloured striae occurring where the epithelium is not destroyed ; large, 
irregular eschars of a black colour, with intervals of deep, bright-red excoriations, are occa- 
sionally met with, and, in some cases, gelatinous softening of nearly the entire thickness of 
the oesophagus. 

V/hen an infant is affected with CEsophagitis, there should not be given to it any stimulat- 
ing or hot drinks — it will be proper, however, to supply it, at short intervals, with a small 
quantity of some perfectly bland mucilaginous fluid, as gum water, or an infusion of the pith 
of sassafras, or of the inner bark of the slippery elm, given cold ; the throat should be co- 
vered externally with a soft, emollient poultice, especially when the inflammation of the 
oesophagus has succeeded to- stomatitis ; a few grains of calomel may also be administered, 
and followed by injections of milk with the addition of sugar. If it be found necessary, the 
strength of the infant may be supported by injections of milk and broth, or milk with rice 
flour, tapioca or arrow root. We have derived advantage in cases presenting the symptoms 
of oesophagitis, from a. few leeches applied along the sides of the neck, and internally a tea- 
spoonful, every three hours, of a. solution of four grains of the acetate of lead in one ounce 
of water, with the addition of a few drops of strong vinegar. — C] 



LECTURE LXV. 

Diseases of the AbdoYaen: sometimes difficult to identify. Method of investigating 
these diseases ; by the eye, the hand, the ear. Inflammation of the Peritoneum: 
its symptoms; and causes. Puerperal Peritonitis. Peritonitis from Perfo- 
rdtion. 

I AM about to consider the diseases of the abdomen. The organs contained in 
this cavity of the body are not vital organs in the same sense in which the brain, the 
the heart, and the lungs, are vital. That is to say, the functions of the abdominal 
viscera will bear to be suspended for some considerable time, without the exting-uish- 
menl of life. But these parts are subject to numerous diseases, some of which are 
apt to be quickly fatal, and others carry with them a vast amount, and very severe 
kinds, of suffering. 

The parietes of the fore part of the belly being soft and flexible, you might natu- 
rally suppose that the physical morbid conditions of the organs they cover would 
submit themselves to an easy diagnosis ; that the sense of touch, exercised through 



728 



DISEASES OF THE ABDOMEN. 



these yielding walls, would detect alterations of bulk, of form, or of place, in the ; 
subjacent viscera, with much facility and exactness. But the truth is, that since the | 
discovery of the method of auscultation, the diseases of the abdomen are much more j 
hard to discriminate than the diseases of tlie thorax. The reason of this is to be | 
found in the number and complexity of the parts contained in the abdomen ; the | 
loose manner in which some of thern are packed ; and the consequent readiness with i 
which they pass out of their proper and natural situations. It is necessary that I 
should say a few words, but I shall not detain you long, respecting the mode of ex- j 
amining the abdomen, with the purpose of investigating its diseases. 

In the description of symptoms, we are often obliged to speak of particular por- | 
tions of the abdomen: and it will be of future convenience to us if we make ourselves 
acquainted, at starting, with such a superficial map, marking out the topography of | 
the belly, as I exhibited to you sometime since, in reference to the chest. Draw a i 
horizontal hne round the body, touching the extremity of the ensiform cartilage; and ; 
this will form the superior boundary of the abdomen, thus roughly defined for prac- I 
tical purposes. Draw another such line round the body, horizontally, touching the j 
lower edge of the last false ribs : and a third touching the crest of each ilium. We j 
then have three horizontal zones formed. These must be further divided by vertical I 
lines: one on each side from the anterior spinous process of the ilium perpendicu- | 
larly upwards. Each zone will thus be subdivided into three regions. The middle I 
region of the upper zone is the epigastric region ; on either side are the hypochon- \ 
dria. The middle region of the middle zone is the umbilical region ; the iliac 
regions or the f.anks lie to the right and left of it. The hypogastric region is the : 
middle region of the lou^ermost zone ; and the inguinal regions are contiguous to it. 
This is all the division which is necessary. 

Now independently of the general signs of diseases that have their seat in the 
abdomen, we are greatly assisted in many cases by the physical signs. I shall take | 
a very brief survey of the modes by which these physical signs are collected. They 
are derived from the exercise of the three senses of sight, of touch, and of hearing. 

The sense of sight supplies, occasionally, very valuable information ; and in all 
serious and equivocal cases we must not dispense with its use. We are not, indeed, 
to make an ocular inspection of the nahed abdomen imnecessarily : and I hold it | 
superfluous to admonish you that when we do avail ourselves of that mode of in- ) 
vestigation, especially in the case of females, we are bound to do so with the most 
careful attention not to offend the patient's delicacy. We may sometimes ascertain 
all that is required concerning the rnoveinents, size, and shape of the abdomen, 
without removing the under garments. i 

This rule applies, indeed, to all parts of the body that are ordinarily covered by i 
the dress. j 

I was lately consulted by a lady, who told me she had, on the rear of her person, | 
a painful boil. She thought any physician ought to be competent to prescribe for a j 
boil, without wanting to see it. But she seemed very ill, and her sister told me that 
the boil had lasted a fortnight, and was a very large one ; so that I was obliged to 
press for an inspection. And I found — a boil sure enough, but of that gigantic and , 
formidable species which we call carbuncle. 

M. Rostan relates a case still more in point. Going round the wards of his hos- | 
pital, he came to an old woman, who was complaining of severe pain in the abdo- | 
men, towards the left iliac region. Her face was flushed, her skin hot, her pulse ^| 
strong and frequent, her tongue dry ; and she was very thirsty. The abdominal ' 
pain was exasperated by pressure, and by the movements of the patient. Upon 1 
these data Rostan founded his diagnosis. He concluded that the case was one of | 
acute abdominal inflammation ; and he prescribed accordingly ; and with befitting I 
energy. One of the pupils, however, lingered behind him : and having removed | 
the woman's chemise, in order to examine the seat of the pain, he discovered that all ! 
the symptoms proceeded in reality from a very harmless, though troublesome, disor- 
der, herpes zoster ; what is vulgarly called the shingles. 

Vestis -adempta est 
Qua posita, nuclo patuit cum corpore crimen. 



PERITONITIS. 



729 



In the second place, we gather very important intelligence by the sense of touch. 
We learn the existence and the size of tumours; we approximate to a knowledge of 
their nature, whether it be solid or fluid ; we determine whether they are movable 
or fixed, painful or indolent, hard or soft, smooth or uneven, pulsating or not. We 
ascertain whether the surface be hot or cold. In order to make palpation most 
effectual, the patient should be placed in the most favourable posture for its perform- 
ance; i. e., he should lie on his back, with his head a little raised, and his knees up. 
In this position, the abdominal muscles are relaxed and unstrung : and the patient is 
to be cautioned not to do anything which may make them tense. Sometimes, in 
spite of this caution, and in spite, probably, of the patient's endeavours to obey it, 
the recti muscles remain so tightly contracted as to prevent any satisfactory examina- 
tion of the parts beneath them. The very occurrence of this instinctive striving 
against the pressure of our hand may be taken as a ground of suspicion that those 
parts are not in a healthy state. We must take care, when the muscles are thus 
obstinately rigid, not to mistake the swelling central portions of the recti, or their 
well-defined edges, for tumours, or for indications of an enlarged stomach or liver. 
By a pecuHar management of the palpation, we often satisfy ourselves at once of 
the presence of liquid in the cavity of the peritoneum, or in a cyst : we obtain that 
sensation which we call fluctuation. 

The exploration by the sense of touch is very much aided — often confirmed, some- 
times corrected — by that which addresses itself to the sense of hearing. Sometimes 
we hsten to the natural sounds through a stethoscope ; and we may thus decide the 
important question, whether a pulsating tumour be or be not an aneurism ; or the 
question, sometimes scarcely less important, whether a different kind of tumour en- 
closes another living being or not. But, for the most part, our information respect- 
ing the maladies of the abdomen, collected by the sense of hearing, is obtained by 
listening to sounds which we ourselves produce; in one word, bj percussion : and 
mediate percussion, percussion performed through the finger as a ready pleximeter, 
is particularly apphcable to the disorders of the abdomen. By this expedient ',ve 
can tell whereabouts the intestines he ; whether the parts beneath the place per- 
cussed be hollow and filled with air, or solid ; or, though naturally hollow, distended 
with liquid. By making the patient change his posture, we are enabled often, 
through the aid of percussion, to trace fluid effusions hither and thither, when they 
have changed their relative situation, by reason of the force of gravity ; and then we 
know that they occupy the cavity of the peritoneum. All these points I pass over 
cursorily, because I must advert to them again when speaking of particular diseases. 
And I shall proceed, on that account, without further delay, to the consideration of 
those special diseases. 

Consulting your convenience, and m}^ own, rather than any scientific order, I 
shall take, in succession, the several parts and organs contained in the cavity of the 
belly, and inquire separately into their diseases ; inflammatory, organic, and func- 
tional. And I begin with the peritoneum ; the great serous sac which lines and 
constitutes the cavity of the abdomen, and in which most of its viscera are wholly or 
partially folded. 

Like the serous membranes in general, the peritoneum is very ready to take on 
inflammation, upon the operation of certain exciting causes. Acute inflammation, 
beginning in one spot, is almost sure to transfer itself to any other spot that happens 
to he in contact with the first ; and is very apt to extend itself rapidly to the whole 
membrane. The inflammation tends to the efl^usion of serum, and of coagulable 
lymph ; it is of the adhesive kind : and its effects are those of distending the peri- 
toneal cavity with fluid — or of gluing its opposite surfaces together so as to obliterate 
that cavity — or of forming partial attachments. In all these respects, the analogy 
between inflammation of the peritoneum and inflammation of the serous membranes 
of the thorax — the pleura, and the pericardium — is perfect : and therefore these are 
points which I shah not dwell upon, except where specific differences arise, from 
original diversities of structure or function in the parts affected. 1 may observe at 
once, that the morbid conditions which are apt to remain after peritonitis, are some- 
times, hke those which follow pericarditis, inceptive of further disease; sometimes, 



730 DISEASES OF THE ABDOMEN. | 

like those of the pleurse, final, and limited to their immediate influence upon the ^ 
health and comfort of the individual : or even protective against some worse evil, ; 

Acute inflammation of the peritoneum is characterized by pain in the abdomen, [ 
increased on pressure, and attended with fever. But as these symptoms are common t 
to almost all the inflammatory conditions of the parts contained in the abdomen, we f 
must look for more distinctive circumstances. Cullen defines the disease in this i 
manner: "Pyrexia: dolor abdominis, corpore erecto auctus, absque propriis aharum • 
phlegmasiarum abdominahum signis." He concludes that it is the peritoneum j 
simply that is inflamed, when the specific symptoms that indicate inflammation of 
particular organs are wanting. It is not inflammation of the liver, for there is no | 
pain of the right hypochondrium in particular, increased by lying on either side, no \ 
pain of shoulder, no jaundice, no vomiting, perhaps : neither us it inflammation of the j 
bowels or stomach, for there is no disturbed function of the alimentary canal to i 
denote such inflammation. ' 

The pain, Cullen says, is increased if the patient sits up. He might have added, ' 
that it is increased also by drawing a long breath, by coughing, sneezing, or strain- 
ing, and by pressure made with the hand upon the belly. All these circumstances 
resolve themselves into the same obvious principle ; viz., that of pressure aggravating 
the pain of an inflamed membrane. The erect posture throws the weight of the 
viscera upon the peritoneum, and tends to stretch parts of it. The pain occasioned ' 
by pressure is often excessive ; the patient cannot even bear the weight of the bed- i 
clothes. Though the pain is, at first, sometimes confined to particular spors, yet it 
generally soon extends over the whole abdomen ; and this is a circumstance of some I 
importance as respects the diagnosis. But before ihe inflammation has become uni- ' 
versal, while it is yet restricted to particular spots, the pain is often much increased 
by pressure made on other parts of the abdomen. In truth, in a shut sac of that 
kind you cannot compress any one part without exercising pressure indirectly upon i 
every other part. The patient cannot sit up, nor, usually, lie on his side ; but 
remains always upon his back: in which position you will perceive that the pres- 
sure made by the viscera upon the peritoneum is a minimum ; is the least possible. 
He draws up bi-s legs too. And he lies still ; for movements cause pressure, and 
therefore pain. The descent of the diaphragm in inspiration presses also upon the 
membrane; and the patient not only complains of the pain thus produced, but in | 
order to avoid it gets into a way of breathing by means of his ribs only. So that j 
upon inspection of the abdomen, it is perceived that, instead of rising and sinking j 
alternately in respiration, it remains motionless. The phenomena oi thoracic respi-, j 
ration is a symptom of peritonitis. The breathing is necessarily shallow in these i 
cases, and less air being admitted at each movement of respiration, the number of 
those movements therefore is increased : the breathing is quick as well as shallow : 
there are perhaps forty, or even sixty respirations executed in a minute, instead of 
eighteen or twenty. When we find a person lying only on his back, with his knees i 
up, breathing in this manner, and complaining of tenderness of the belly on pressure, | 
and feverish withal, we may be tolerably sure (unless that person be an hysterical 
girl) that the peritoneum is inflamed, whatever else may be the matter. 

The pain in peritonitis is generally sharp, cutting, or pricking in its character. 
And independently of any pressure made from without, or caused by any change 
of posture, this pain is apt to be much aggravated at intervals. This, when the 
inflammation is general, is sometimes owing to the passage of flatus along the bowel, 
partially distending it, and stretching the inflamed membrane; so that here also, it 
is TGdWy assure which augments the pain. 

When you explore the abdomen by pressure, take care not to make the examina- 
tion unnecessarily a source of pain. Press first gently, Y»dlh the open flat hand ; 
and keep your eyes on the patient's face at the same time. You will perceive by 
the expression of his features, whether you are hurting him ; even before he takes to 
verbal complaining. 

Acute peritonitis generally sets in with well-marked symptoms : sharp rigors, and 
high fever, with a hard and strong pulse, which very soon becomes frequent, and 
often becomes feeble, and is sometimes small from the very first. After the disease 



PERITONITIS. 



731 



has continued for a certain time, it is attended with tension and swelling of the belly. 
The tension and swelling are tympanitic in the earlier stages. You learn this with 
certainty by mediate percussion. As the disease advances, the enlargement is some- 
times occasioned, in part at least, by the effusion of serum : of the presence of which 
infalhble indications may be obtained by the joint employment of the finger and the 
ear; by palpation and auscultation ; and by noticing the difference, as to the results 
I of percussion, caused by alterations of posture. 

I When the disease is advancing towards a fatal termination, the abdomen often be- 
I comes greatly distended ; the pulse is exceedingly frequent and feeble ; the counte- 
j nance (which in all the stages of the disorder is expressive of anxiety) becomes 
pinched and ghastly ; cold sweats ensue ; and the patient dies at length by asthenia : 
' death beginning at the heart. The mind is often clear to the very last. 
I Such is the ordinary course of peritonitis. But other symptoms, which I have not 
j mentioned, do sometimes accompany it ; arising out of the pecuhar circumstances of 
■ different cases. Thus sickness and vomiting occur very frequently : and these 
I symptoms are supposed to denote that the peritoneal covering of the stomach is 
I especially implicated : but I question whether this is always a correct inference. 
I When strangury happens, which is not uncommon, that part of the membrane 
' which is reflected over a portion of the bladder is probably involved in the mischief. 
Inflammation of that part of the peritoneum which lies, in the immediate vicinity of 
the kidneys, may cause. Dr. Abercrombie thinks, suppression of urine. 

Peritonitis is apt to arise under the influence of cold, dike other internal inflamma- 
tions : especially when cold combined with moisture is apphed, under certain condi- 
tions, to the surface of the body. It is occasionally produced by mechanical inju- 
ries inflicted upon the abdomen. It often prevails epidemically, and produces 
great mortality, among parturient women : and there is ground for believing that 
this form of the disorder is propagable, and often propagated, by contagion. Be- 
sides this, a very terrible kind of peritonitis is a frequent result of the extravasation 
of the contents of the ahmentary canal, or of urine, or of bile, into the cavity of the 
membrane ; through apertures that are sometimes made by external violence, but 
more often are the consequences of the progress of previously-existing disease. 

I shall make a few observations in respect to one or two of these points, and but 
a few. 

That awful disorder, puerperal fever, is more frequently accompanied with inflam.- 
mallon of the peritoneum, than with any other inflammation. This variety of peri- 
tonitis necessarily engages the attention of the accoucheur; and it doubtless is more 
fully considered in the lectures of the Professor of Midwifery than I propose to 
consider it. Indeed, if you would understand puerperal fever as a whole : its shifting 
aspects, its single source, and its appropriate management ; you must study Dr. Fer- 
guson's masterly and conclusive essay on that subject. 

Of forty -four fatal cases of well-marked puerperal fever which fell under the 
observation of Dr. Robert Lee, and in which the bodies were carefully examined, 
the -peritoneum and uterine appendages were found inflamed in thirty-two : i. e., in 
eight cases out of every eleven. The inflammation commences, no doubt, in the 
uterine portion of the membrane, and spreads thence over the larger part of its sur- 
face. Now this peritoneal inflammation, occurring in women after childbirth, may 
be accidental and sporadic ; or it may prevail in a district epidemically. And a most 
dreadful and deadly affection it may then become. In either case, the peritonitis 
may commence a few days, or even a few hours after parturitio-n. The pain gene- 
rally begins low in the abdomen, in the situation of the uterus ; which may be felt 
through the abdominal parietes, and is tender on pressure: but soon a universal 
swelling lakes place, and the womb can no longer be distinguished. Cases of this 
kind arise sometimes, apparently from cold ; and exhibit no peculiar feature. It is 
just what we might expect when a female, in a state of weakness and irritabihty, 
happens to be .exposed to the exciting causes of inflammation. In such a state, a 
less degree of the exciting cause would be sufHcient to produce the inflammation : 
and probably a less degree of inflammation may prove fatal. 

But when peritonitis is frequent among women after childbirth in a particular 



732 



DISEASES OF THE ABDOMEN. 



neighbourhood, or in a lying-in hospital, it is marked by greater depression of the 
vital powers, and runs a more irregular course. The nervous system suffers, the 
sensorium is apt to become affected, and the complaint assumes rather the character 
of continued fever than of simple inflammation of the peritoneum. And no wonder; 
since this variety of peritonitis forms part of a disease which, like continued fever, 
is a general disease, and results from contamination of the blood. This, Dr. Fergu- 
son has clearly established. The contamination may originate in the body of the 
patient herself: the noxious material being supphed by putrid coagula, or portions 
of placenta, remaining in the uterus. Or some of the products of inflammation may 
enter the blood-vessels, and constitute the poison. And this it may be difficult or 
impossible to prevent. But, on the other hand, the contamination may arise in the 
way of contagion: this horrible malady may be communicated from one lying-in 
"woman to another by the intervention of a third person ; and doubtless it is so 
carried and propagated, in many instances, by midwives and accoucheurs. Now 
this source of the disorder may be obviated ; and therefore it is of the utmost im- 
portance that it should be clearly recognized, in order that it may be carefully pro- 
vided against. 

You must know, however, that great differences of opinion have existed, and, I ' 
believe, still exist, in respect to the contagious quality of certain forms of peurperal 
peritonitis ; just as great differences exist as to the contagiousness of continued fever, 
of cholera, of the plague. There are parties who regard the whole notion of con- 
tagion as a mere bugbear : and there are others who embrace in their allegations of 
contagion many more diseases than can be proved to be so caused. The same 
strong assertions are made, the same kind of eagerness is displayed (the same party- 
spirit, I had almost said) as mark the strife of ordinary politics. It is our serious 
duty, however, to inquire what is the truth in this matter : for the safety of indivi- 
duals, and the happiness of whole families, may often hang upon our opinions. I 
must trouble you, therefore, with a few facts that bear closely upon the subject. 

We possess some valuable and highly instructive accounts of epidemics of the 
kind T am alluding to. One by Dr. Gordon, on the epidemic peritonitis after child- 
birth, which took place at Aberdeen, in the years 1789, 1790. Another by Mr. Hay, 
on that which happened at Leeds from 1809 to 1812. And a third by the late Dr. 
Armstrong, on that which was observed in Sunderland and its neighbourhood in 
1813. Dr. Robert Lee has also collected some very interesting facts in reference to 
the spreading of the peritonitis by contagion. Dr. Gordon had, he affirms, unques- 
tionable proof that the cause of the disease was a specific contagion, and that it did 
not arise from any noxious constitution of the atmosphere. The disease seized such 
women only as were visited or delivered by a practitioner, or taken care of by a 
nurse, who had previously attended patients affected with the same disorder. And 
Dr. Armstrong observed that forty out of the forty-three cases that happened at Sun- 
derland, occurred in the practice of one surgeon and his assistant. 

From among other histories — all tending to the same conclusion — brought together 
by Dr. Lee, I take the following : — 

"On the 16th of March, 1831, a medical practitioner, who resides in a populous 
parish on the outskirts of London, examined the body of a vt^oman who had died a 
few days after delivery, from inflammation of the peritoneal coat of the uterus. On 
the morning of the 17th of March [i. e., the next morning), he was called to attend a 
private patient in labour, who was safely dehvered on the same day. On the 19th, 
she was attacked with severe rigors, great disturbance of the cerebral functions, rapid 
feeble pulse, with acute pain of the hypogastrium, and a peculiar sallow colour of 
the whole surface of the body. She died on the 4th day after the attack, on the 22d 
of March ; and between that period and the 6th of April, the same practitioner 
attended two other patients, both of whom were attacked by the same disease in a 
mahgnant form, and fell victims to it. On the 30th of March he bled a young woman 
who had pleurisy : the wound became inflamed after a few days ; erysipelatous 
redness and swelling extended from it up the arm ; and in four or five days that 
patient died of phlebitis." 

Mr. Roberton, of Manchester, states the following facts, in a paper in the Medical 



PUERPERAL PERITONITIS. 



733 



j Gazette, — From the 3d of December, 1830, to the 4th of January, 1831, a midwife 
attended thirty patients for a public charity. Sixteen of these were attacked with 

I puerperal fever, and they al^ ultimately died. In the same month, 380 women were 

I delivered by other midwives for that institution ; but none of the 380 suffered in the 
smallest degree. All the sixteen had inflammation of the peritoneal surface of the 
uterus. So, also, Dr. Robert Lee tells us that, in the last two weeks of September, 
1827, five cases came under his observation. All the patients had been attended in 
labour by the same midwife: and no example of a febrile or inflammatory disease 
of a serious nature occurred during that period among the other patients of the 
same dispensary, who had been attended' by the other midwives belonging to the 

I institution. 

Statements of this kind — and they could be largely multiplied — furnish irresistible 
j evidence, thai the peritonitis, which prevails epidemically among lying-in women, 
j is of a specific nature, and communicable from one person to another. It is observed, 
also, to reign as an epidemic especially in lying-in hospitals, and that it recurs at 
j irregular intervals, sometimes leaving them quite exempt from its ravages for years 
' together. 

j Indeed, I beheve that these cases of puerperal fever occurring in succession to the 
j same practitioner, are examples of something more than ordinary contagion, operating 
through the medium of a tainted atmosphere. I believe them to be instances of 
I direct inoculation. Recollect, that the hand of the accoucheur is brought, almost of 
I necessity, into frequent contact with the uterine fluids of the newly-made mother. 
I Recollect, — those among you who have examined the interior of the dead body with 
I your own hands, — recollect, with what tenacity the smell, which is thus contracted, 
j clings to the fingers in spite even of repeated washings ; and whilst this odour re- 
mains, there must remain also the matter that produces it. Recollect how minute a 
quantity of an animal poison may be sufficient to corrupt the whole mass of blood, and 
fill the body with loathsome and fatal disease. Illustrations will occur to you in the 
inoculated small-pox, in hydrophobia, in the viper-bite, in the scratches and punctures 
of the dissecting-room. Recollect the raw and abraded state of the parts concerned 
in parturition; the interior of the uterus forming a large wound, and presenting, as 
Dr. Ferguson observes, an exact analogy to the surface of a stump after amputation ; 
the more external soft parts bruised and sore. Bear in mind the remarkable fact, 
that this contagion does not affect other persons, but only lying-in women. Reflect- 
ing upon these facts, you will see too much likelihood in the dreadful suspicion, that 
the hand which is relied upon for succour in the painful and perilous hour of child- 
birth, and which is intended to secure the safety of both mother and child, but espe- 
cially of the mother, may literally become the innocent cause of her destruction ; 
innocent no longer, however, if, after warning and knowledge of the risk, suitable 
means are not used to avert a catastrophe so shocking. 

I need scarcely point to the practical lesson which these facts inculcate. When- 
ever puerperal fever is rife, or when a practitioner has attended any one instance of 
it, he should use most dihgent ablution ; he should even wash his hands with some 
disinfecting fluid, a weak solution of chlorine for instance : he should avoid going in 
the same dress to any other of his midwifery patients : in short, he should take all 
those precautions which, when the danger is understood, common sense will suggest, 
against his clothes or his body becoming a vehicle of contagion and death between 
one patient and another. And this is a duty so solemn and binding, that I have 
thought it right to bring it distinctly before you. 

In these days of ready invention, a glove, I think, might be devised, which should 
be impervious to fluids, and yet so thin and pliant as not to interfere materially with 
the delicate sense of touch required in these manipulations. One such glove, if such 
shall ever be fabricated and adopted, might well be sacrificed to the safety of the 
mother, in every labour. Should these precautions all prove insufficient, the practi- 
tioner is bound, in honour and conscience, to abandon, for a season, his vocation. 

[The connection between puerperal peritonitis and erysipelas has recently attracted a good 
deal of discussion. In a large number of instances, it has been shown that the two diseases 
prevail simultaneously and in the same localities ; and. facts have been adduced, which would 

3 M 



734 



DISEASES OF THE ABDOMEN. 



even appear to prove that a contagion of some kind may be cominunicated from a patient [ 

labouring under erysipelas to the parturient female, and induce in her an attack of puerperal r 

fever. Until, however, a greater number of facts have been accumulated, and the whole P 

subject more closely investigated, it will be premature to draw any positive conclusions. — C] |^ 

That variety of peritonitis which results from perforation of the stomach or intes- 
tines, and the effusion of their contents into the cavity of the belly, is full of interest, j 
The inflammation is violent in degree ; universal (generally) in extent : and almost y 
always fatal. The attack is characterized by its suddenness. All at once intense 
pain arises in some region of the abdomen, which soon becomes tender in every part. 
The pain is incapable of removal, and generally even of mitigation, by medicine, 
and death takes place in a short time. These are the general features of such cases. 
Occasionally, the symptoms follow some different order. Thus, I have seen a case 
in which no pain was complained of, and the source of the inflammation was not ^ 
suspected until the dead body was examined. This was a case of fever ; and it had 
heen attended with much stupof, which was probably the reason that no indication 
of suffering was made by the patient. Occasionally, but that is uncommon, the pain 
intermits. For the most part, however, it resists all treatment, and ceases only with 
life, or a short time before life is terminated. « i, 

Most of the instances of this kind of peritonitis that I have witnessed have resulted ' 
from perforation of the ileum, in the progress of continued fever. You are already ( 
aware, that the glandules agminatas, which are found only in that bowel, and the ? 
glandulse sohtari^, which are scattered over nearly the whole inner surface of the I 
alimentary tube, are very liable, in continued fever, to inflammation, sloughing and 
ulceration : and sometimes the ulcers go through: the contents of the gut are poured ' 
into the cavity of the serous membrane, and intense inflammation is lighted up. I 
purposely abstain from going into any particulars respecting these ulcers. We are ( 
no further concerned with them at present than as they furnish the channel by which 
the cause of the peritoneal disease is introduced. Once, and once only, as I stated 
before, have I known perforation occur from the extension of scrofulous ulceration 
of the same glands in phthisis. In general, in that disease, the ulcer runs a much 
slower course. As it approaches the peritoneum, circumscribed chronic inflamma- 
tion is set up in that membrane ; lymph is thrown out ; and the bowel becomes 
adherent to some other portion of the canal, or to some of the other viscera of the 
abdomen. In this way the perforation is prevented ; or, should it take place, the 
escape of the contents of the bowel into the peritoneal sac is prevented. Occasion- 
ally, when two portions of the tube thus adhere together, a communication is formed 
between them, and the contents of the intestine either reach an advanced point of 
their stated journey by a short cut, or arc carried back again perhaps to a spot which 
they had already passed. 

A very curious instance of this latter event has been described b}'" Dr. Abercrombie. 
A man, fifty-six years old, who had shown no signs of serious illness, but had laboured 
urjder impaired appetite, languor, and occasional pain in the abdomen, for two or 
three weeks, was suddenly seized, while out walking, with vomiting ; and he ob- 
served that what he brought up was stercoraceous ; and this occurred again and 
again, at variable intervals ; the matter vomited being distinctly fecal, and sometimes 
so solid that he was obliged to swallow warm water to soften it, that it might be ex- 
pelled from the stomach more easily. He never vomited his food; and no tumour,' 
or other sign of organic disease, could be detected by external examination. He 
lived about three months, and died at last of exhaustion ; and then it was discovered 
that the stomach and the transverse arch of the colon were adherent to each other, 
and that a ragged aperture of communication between them existed at the place of 
adhesion. 

It is a curious fact, that the vermiform appendage of the Cc"ecum is not unfrequentiy 
the seat of a penetrating ulcer. I have traced little groups of glands in that slender 
tube : and I have known perforation to happen from the specific ulceration of con- 
tinued fever ; and from the accidental ulceration caused by a cherry-stone lodged^ 
there. 



PERITONITIS FROM PERFORATION. 



735 



[Many cases are related of peritonitis from ulceration of the apendicula vermiformis, 
caused by the impaction of some foreign substance within its cavity. A very interesting 
case of the kind is detailed by Dr. Pepper, in the Transactions of the College of Physicians of 
Philadelphia, vol. i., p. 296, in vs^hich a grape seed had passed into the apendicula, and vv^as 
the cause of its ulceration and perforation. — C] 

Sometimes it is the stomach that is perforated, either by a common or by a spe- 
cific ulcer; and the symptoms are exactly the same as when the howel gives way. 
Sudden, unremitting pain, tenderness, and tympanitic distension of the abdomen ; and 
early death. 

Perforating ulcers of the stomach are of various kinds. It is not uncommon to 
find one small roundish hole, with edges as smooth and clean as if a piece of the 
stomach had been cut out by a punch, and without any surrounding hardness, or 
other mark of disease. Occasionally the orifice is more irregular, and occupies the 
centre of a thickened and indurated patch of the mucous membrane. Several in- 
stances of this sort of perforation have occurred under my own eye ; two within the 
last fourteen months (1839). Almost all the patients have been young women, 
plump, and in good condition ; who, up to the moment of the fatal seizure, either 
seemed to enjoy perfect health, or, at most, had complained of slight and vague feehngs 
of dyspepsia. Ulcers of the stomach are, however, mostly chronic ; and the diseased 
viscus is commonly fenced about and protected by adhesion to the neighbouring 
parts, before its coats are completely penetrated by the ulcer. You are probably 
aware that this happened in the body of Napoleon Bonaparte. , He died oT cancer 
of the stomach. That organ was strongly adherent to the concave surface of the left 
lobe of the liver, which formed a part of the Vv^all of the stomach ; and this adhesion, 
no doubt, prolonged his life. 

Usually the actual perforation, in cases such as we are now considering, takes 
place merely from the natural progress of the ulcer; but sometimes it would appear 
that the thin membrane which remains is broken by some accidental force applied to 
it. Thus the symptoms have immediately followed the act of vomiting, brought on 
by an emetic. Bouillaud relates an instance in which the perforation happened 
while the patient was straining at stool ; and it is conceivable enough, that rough 
pressure of the abdomen might complete the rupture, when the ulcer had already 
eaten through all the coats of the bowel except its peritoneal coat. 

Less commonly than this, in my experience at least, the peritonitis is set up by 
the escape of urine from the urinary bladder, through the extension of an ulcer, or 
from a forcible rupture of that bag by a blow or a fall, when it was distended with 
urine. Rupture of the gall-bladder, whether by violence or from ulceration, has the 
same results ; so also has, in general, the rupture of the uterus, which sometimes 
takes place during the efforts of parturition. Abscess of the liver, bursting into the 
peritoneum, is another occasional source of severe and fatal inflammation of that 
membrane. Acute and general peritonitis sometimes arises, also, in consequence of 
penetration from without; i. e., it succeeds the puncture made by the trocar in the 
operation of tapping the belly : and these cases, too, are almost all of them mortal : 
chiefly, I presume, because, in nine instances out of ten, they occur in an unhealthy 
and debilitated subject. 

I formerly offered you some observations respecting a form of hysteria which very 
closely mimics peritonitis, and would most certainly deceive a medical man who was 
not on his guard against it. We judge by the age and sex of the patient somewhat; 
by the presence of hysteria in other forms, or of the hysteric diathesis ; by the ex- 
cessive tenderness of the abdomen, or rather of its surface ; by the co-existence of the 
same exquisite sensibility in other parts ; and by the incongruity and shifting character 
of the symptoms. The pulse and the tongue will perhaps be natural, while the 
abdominal irriiation is at its height. Forewarned, you will seldom find m.uch dif- 
ficulty in establishing the diagnosis. Of the signs by which peritonitis may be dis- 
tinguished from enteritis, I shall speak when T come to the latter disease. 



736 



ACUTE PERITONITIS. 



LECTURE LXVI. i 

I 

Treatment of Acute Peritonitis; Bleeding, Mercury, Opium. Chronic Peritonitis ; j 

Granular Peritoneum. Ascites ; Ovarian Dropsy ; Diagnosis of these diseases. | 

Other forms of Abdominal Dropsy. 'j 

Acute peritonitis, in its simple form, is always a dangerous, yet frequently a ' 

manageable disease. When it is complicated with other and earlier organic mischief, | 

and especially when it has been excited by the entrance of foreign matters into the j 

cavity of the belly, it is all but hopeless under any treatment. j 

In speaking of the mode of cure, I have again to repeat, mutatis mutandis, the \ 

grand remedies for inflammation, and particularly for the adhesive inflammation i 

proper to serous membranes : blood-letting; mercury. j 

It is of the greatest importance in this, as in many other cases of inflammation, j 

that the blood-letting should be performed early. You must not be deterred from | 

bleeding by the mere smallness of the pulse : a quality which I have frequently i 

shown you to be characteristic of acute inflammation within the abdomen ; and which, 1 

in the disease now in question, is often present from the very beginning. If the ' 

pulse be wiry and hard, we disregard, in these cases, its smallness. Not uncom- I 

monly it is rendered more full, as well as softer, by venesection; and this, when it j 

happens, gives assurance of the propriety of that measure. i 

Topical blood-letting is of nmch efficacy — of greater efficacy perhaps than in most 
other forms of abdominal inflammation. Cupping is out of the question, from the 
tender state of the abdom^en. But in adults, after a full bleeding from the arm, such 

as has produced some sensible impression upon the circulation, or brought the patient , 

to the verge of syncope, the surface of the belly should be covered with leeches. | 

From twenty to forty may be apphed at once ; and sometimes this will make any \ 

further loss of blood unnecessary. But in severe cases, you may expect to find that i 
repetitions of at least the local bleeding will be requisite. 

After the leeches have fallen off", a light poultice may be laid over the abdomen ; j 
or it may be assiduously fomented with flannels wrung out of hot water. These 

means will encourage the bleeding from the leech bites ; and are generally found to j 

afford great comfort to the feelings of the patient. Cold applications have been i 

recommended by some practitioners of high authority. Dr. Sutton injected cold i 

enemata, and applied cloths, made wet with cold evaporating lotions, to the abdo- j 

men with good effect: and Dr. Abercrombie has since reported favourably of the j 

same kind of treatment. However, I should think this a more precarious plan | 

than the opposite : and I have always observed so much relief to be given by | 

warm epithems, that I have never had the inclination, or the courage, to employ I 

cold. ' _ _ I 

It is extremely desirable, in these cases, to obtain as speedily as possible the j 

specific influence of mercury upon the system ; by calomel and opium, or by ^ 

inunction. It cannot be necessary that I should again go over in detail the means \ 

of following out this indication ; but it is an indication which we must diligently | 

pursue. I 

The treatment of puerperal peritonitis is much more uncertain and difficult : for 1 

this reason, that it springs out of an antecedent morbid condition more deepl}'- seated, ! 

more generally diflrised, and less accessible to remedies, than itself. Whenever in- \ 

flammation arises here and there in the body, in consequence of a vitiated state of { 

the blood, we have not only the inflammation itself to deal with, but its physical ' 

cause also, which may still be in uncontrolled operation. I 

Dr. Ferguson justly remarks that "inflammation being made up of vascular and |i 

of nervous action, of the afflux of blood to a part, and of pain, it is not irrational to \ 

act on both the elements of the malady at the same time, or in periods shortly con- It 

secutive of each other." " The abdominal pain that occurs in puerperal fever is [ 

accompanied by two very different states of constitution : one in which little or no jj 



ACUTE PERITONITIS. 737 

depletion is borne, another in which relief is obtained only by very large evacua- 
tions of blood." Between these two there is every conceivable gradation. "In no 
malady are a cautious boldness, and a sagacious adaptation of remedy to constitu- 
tional power, more imperatively demanded." 

" If large bleeding be determined on, it must, to be beneficial, be resort'ed to within 
the first twenty-four hours from the attack. In the second stage of the disease it often 
produces, rapidly, a fatal result." 

In ambiguous cases he gives ten grains of Dover's powder, and covers the whole 
of the abdomen with a large linseed-meal poultice, sufficiently thick to retain warmth 
for four hours. At the end of that time, if the symptoms are alleviated, "ten grains 
more of the Dover's powder, and a fresh poultice, should be prescribed. If within 
four hours from this second medication, the practitioner is not satisfied that the 
malady is yielding, he must at once resort to depletion." 

Of all the means we possess of arresting this malady, bleeding, general or topical, 
is, in Dr. Ferguson's experience, by far the most extensively applicable. " But," he 
says, " while I admit this, I am equally certain that large bleeding has not been 
borne in this complaint, generally speaking, during the last twelve years." 

Another most important truth enunciated by our professor is, that " epidemic 
puerperal fever has, invariably, the character common to the ordinary fevers raging 
with it : if the latter require depletion, the presumption is that the former w^ill also." 

Undoubtedly the very same species of febrile disease is variously affected by 
a given remedy in dififirent places : and during different periods in the same place. 
There is such a thing as an epidemic state of the human constitution, gradually pro- 
duced by a gradual fluctuation in the influences whereby communities of men are 
surrounded and impressed. The fevers that were cured in London ten or fifteen 
years ago by copious blood-letting, would now be rendered by that measure, carried 
to a like extent, irretrievably mortal. There is scarcely a more important object of 
study to the practical physician than this different capacity, exhibited by the average 
of constitutions at different times and seasons, of bearing active depletion. "Nihil 
mihi prius est," says the wary Sydenham, " quam quando novas febres grassari in- 
cipiant, cunctari paulisper, et ad magna prsesertim remedia non nisi suspenso 
pede, ac tardius procedere ; diligenter interim illarura ingenium atque morem obser- 
vare, quibus itidem prsesidiorum generibus mgx'i juventur vel lasdantur, ut quani pri- 
mum his repudiatis, illis utamur." The exciting cause of the fever remains the 
same ; the system upon which it operates undergoes from time to time great changes : 
which are brought to light partly by the altered phenomena of the disease, partly 
and chiefly by the effects of remedial measures. 

Unless you bear these differences in mind, you will be perplexed and disheartened 
by the discrepant accounts given by competent and faithful observers respecting the 
success of different or even opposite plans of treatment, in the same complaint. 

Most writers, whose works I am acquainted with, recommend /jwr^a/fyes as highly 
serviceable in peritonitis. I do not think the good which they are calculated to do 
as antiphlogistic remedies can at all be put in competition with the harm that I am 
persuaded they may produce, by increasing the peristaltic action of the intestines, 
and so causing additional friction and tension of the inflamed membrane. I believe 
that in all cases of well-marked and pure peritonitis, when the inflammation is limited 
to the serous membrane, it is far better and safer to restrain than to solicit the internal 
movements of the alimentary tube. In a pamphlet published several years ago by 
Mr. Bates, of Sudbury, some striking instances are recorded of recovery from severe 
1 peritonitis, under large and frequent doses of opium, and a rigid adherence to the 
! horizontal posture, until all pain had subsided. The patients were not allowed to 
i raise themselves, on any account, into a sitting position: and the opium was admi- 
nistered sometimes by the mouth, sometimes by the rectum. These cases, related 
in an unpretending manner by a practical observer, made a strong impression on 
my mind when I read them. To simple inflammation of the peritoneum, to those 
perilous forms of peritonitis which occur in women after delivery, and to those still 
more terrible cases that follow perforation of the serous membrane, this principle of 
keeping the intestines at rest is alike applicable. I stated a little while ago, that the 
47 3m3 



J 



738 



ACUTE PERITONITIS. 



last-mentioned cases are all but hopeless. That all hut I inserted on the strength of 
some most interesting facts published by Dr. Wilham Stokes, in the second number 
of the Dublin Journal of Medical and Chemical Science. He truly remarks, that 
in most of these accidents the powers of hfe sink so rapidly, that bleeding, either 
local or general, cannot be attempted. Neither can we employ mercury internally, 
for fear of exciting the peristaltic action of the bowels, which action would tend to 
tear asunder recent adhesions, to keep the communication between the mucous and 
serous surfaces open, and to cause a fresh ingress of fecal or other extraneous mat- 
ters into the sac. Yet in a few instances we find that the patients live for several 
days, and that a process of organization commences in the effused lymph. It seems 
that some years before Dr. Stokes wrote this paper, he had witnessed the admirable 
effects of opium in low forms of peritonitis, as administered by Dr. Graves ; who 
thus saved, without abstracting a drop of blood, two individuals in whom that disease 
followed paracentesis. I cannot refrain from quoting to you the particulars of one 
instance, in which the efficacy of the opiate treatmenf was conspicuous. The well- 
known symptoms of perforation of the intestines had existed for two days ; the 
patient was apparently sinking, " his countenance was collapsed, anxious and 
expressive of dreadful sufTering; the extremities were cold, and the pulse hardly 
perceptible. The exhibition of sixty drops, in the twentj'-four hours, of the pre- 
paration called the black drop, was followed by the most signal improvement. The 
pulse regained fullness and softness, the extremities became warm, and the counte- 
nance had lost the' Hippocratic expression. The patient could bear pressure on the 
abdomen, which, the day before, was exquisitely painful. The same treatment was 
continued for twenty-four hours longer; and by the end of that time every symptom 
of abdominal inflammation had completely subsided. The belly felt natural, there 
was no tenderness, the pulse was good, and the patient declared himself well." At 
this period of the case. Dr. Stokes omitted the opium, and gave the mildest possible 
saline laxative, as there had been no stool for forty-eight hours. Four evacuations 
took place, followed by the immediate return of the symptoms of peritonitis, under 
which the patient rapidly sank. - 

" The intestines were everywhere agglutinated together, and adherent to the parie- 
tal peritoneum, except in the left ihac fossa, where a quantity of yellow puriform 
matter was collected. On detaching the caput coh from the peritoneum lining the 
right iliac fossa, a small perforation of the gut was discovered, by the escape of the 
contents of the intestines in a jet," &,c. &c. 

This example puts in a very strong light the good effects of opium ; the danger- 
ous effects of purgatives ; and the 7node in which recovery from these frightful 
accidents may sometimes be brought about. 

Dr. Stokes gives another instance in which the patient did recover ; after taking j 
105 grains of opium, besides what was administered in injections : and he alludes | 
to a third case, in which the employment of opium was successful, when peritonitis | 
had supervened upon the bursting of an hepatic abscess into the cavity of the abdo- 
men. 

Now I would earnestly recommend you to consider the expediency of applying 
the same principle of treatment, as an auxiliary, when the peritonitis does not grow i 
out of previous organic disease : in all cases, in short, of mere peritonitis. The j 
opium is not to supersede the bleeding, or the mercury ; it is not incompatible with [ 
either of those remedies ; and it may, I believe, be most advantageously adopted in 
conjunction with them both. 

I shall relate one example, which has lately occurred to me, of the successful use j 
of opium in simple, but severe, peritonitis. Several of you saw this patient. His \ 
case is pubhshed in the appendix to Dr. Ferguson's volume. j 

H. Middlehurst, a tailor, seventeen years old, was admitted into the Middlesex ) 
Hospital on the 17th of September : looking very ill, and complaining of pain in the ! 
epigastrium, with extreme tenderness over the whole abdomen, which was full and ' 
tense. He had been ill several days ; had shivered in the outset : and had vomited ,i 
frequently, up to the period of his admission. His bowels were confined ; his [ 
tongue was dr^-^ and white. f. 



CHRONIC PERITONITIS. 



739 



Twelve leeches were placed upon his abdomen, and calomel, in five-grain doses, 
was given tvi^o or three times at intervals of four hours. An enema of warm water 
was injected, and retained. In the evening sixteen more leeches were applied, and 
a drachm of mercurial ointment was rubbed into his arm. 

I first saw him on the 18th. His countenance was then pinched and anxious, 
and he lay moaning with pain ; his knees being drawn up towards his hellj, which 
was tense, and exquisitely sensible to pressure. He complained of nausea and 
retching, but had not vomited since his admission. His tongue was thickly coated ; 
his pulse small, sharp, 108 in number. No permanent relief had been obtained 
from the leeches. 

I directed immediate venesection ; but not more than four ounces of blood could 
be got from the arm. Thirty fresh leeches were therefore put upon the abdomen, 
and afterwards a warm poultice to receive the blood from their bites. Three grains 
of calomel, and three of blue pill, were ordered to be given every four hours. 

The last leeches mitigated the pain ; but it returned in the evening, with in- 
creased severity, and he vomited the pills. Fie appeared to be in great agony. In 
this state the apothecary gave him twelve grains of calomel, and five grains of 
opium, in one dose. Soon, after this he fell asleep ; and slept during the greater 
part of the night. Next morning his countenance had lost, in a great degree, its ex- 
pression of anxiety ; his belly was less tender, but still tense ; and his tongue 
cleaner. No stool. 

Capiat pilulsB saponis cum opio gr. v. 8va. quaq. hora. 

On the 20th, the bowels were freely open, the dejections dark and watery ; the 
abdomen v^as less tender. Pulse 114. He continued to take a grain of opium 
thrice daily till the 3d of October: the bowels being every day moved; the pulse 
and tongue gradually improving; and the abdomen painless even under firm pres- 
sure. On the 3d, as the bowels had not acted for the last two days, I discontinued 
the opium. On the 5th, diarrhcea set in, with some renewed tenderness of the 
belly; and the pinched and anxious countenance returned. He had then an opiate 
enema ; and resumed the opiate pills as before. Under this treatment he at length 
got quite well ; and left the hospital on the 30th. 

Chronic peritonitis is sometimes merely the sequel of that acute form of inflam- 
mation of the peritoneum, which I have just been describing. Plastic lymph is 
effused, and becomes organized ; serous fluid is poured out, and is not absorbed 
again ; the products of the original inflammation remain ; a low degree of inflamma- 
tory action perhaps remains also, or is re-excited by shght causes ; the mischief 
augments ; and the patient is slowly conducted to the grave. 

There is, however, another, not at all uncommon, and equally formidable source 
of chronic peritonitis ; the presence, I mean, of a multitude of little granules, lying 
within or immediately beneath the membrane, or occupying, in countless numbers, 
those folds of the peritoneum w^hich compose the omentum. These granules occur 
principally, if not exclusively, in scrofulous persons. Louis, indeed, who considers 
them to be tubercles, affirms that they are never met with in the peritoneum, without 
being met with also — and usually in a more advanced state and greater abundance — 
in the lungs ; but this rule is not universally true. I have seen more than one 
instance of well-marked granular disease of the serous membrane of the abdomen, 
without a single tubercle in the pulmonary tissues. Still the observation of Louis 
holds good in a vast majority of cases : and when we have symptoms of chronic 
peritonitis, w^hich were not preceded by those of acute inflammation of the mem- 
brane, and when we perceive at the same time indications of phthisis, or of any 
other unequivocal form of scrofula, we shall seldom be wrong in connecting the 
chronic peritonitis with the presence of these miliary granulations. Whether they 
are truly scrofulous tubercles, or whether, as some suppose, they are sui generis, or, 
again, simply minute spherules of coagulable lymph, I do not undertake to deter- 
mine. I have been in the habit of regarding them as the cause, and not as the con- 
sequence, of the inflammation with which they are found associated. 



740 



ASCITES. 



The symptoms of chronic inflammation of the peritoneum are more obscure, in 
general, than those of the acute disease. And when the disorder is primitiv^e, not 
the rehcs T mean of more active inflammation, it often begins, and steals on, in a very 
insidious manner. The patient complains of abdominal pains : sometimes slight, 
amounting to scarcely more than uneasiness, but abiding; sometimes occasional 
only. Usually there is a sensaiion of fullness and tension in the belly, although its 
bulk may not be sensibly altered. Sometimes there is a sense of pricking felt. Dr. 
Pemberlon remarks, that you may detect a sort of deep-seated tension ; that the skin 
and muscles lie loosely on the peritoneum, which gives to the hand a sensation as of 
a tight bandage underneath, over which the inteq:uments appear to slide. The 
uneasiness, or the pain, is augmented by pressure ; or perhaps is felt only when 
pressure is made. Sometimes the functions of the intestinal canal are disturbed : 
there are loss of appetite ; nausea and vomiting ; an irregular state of the bowels, 
and unnatural evacuations from them. Sometimes, on the contrarv% the digestive 
organs perform their office in a tolerably healthy manner. These differences depend 
apparently upon the circumstance of the inflammation visiting, or sparing, the peri- 
toneal covering of the stomach and bowels ; and of the parts concerned in the secre- 
tion of bile. Sooner or later, in most cases, the abdomen enlarges, and fluctuation is 
felt. All along there is some fever, more or less distinctly marked ; with progressive 
emaciation and debihty. The face is pale and sallow, and wears an expression of 
languor. 

Very much the same set of symptoms are apt to result from scrofulous disease and 
enlargement of the mesenteric glands : and consecutive slow inflamm.ation of the 
peritoneal membrane. 

Accordingly, after death, we often find those glands swelled, and red, and hard ; 
sometimes forming very large tumours : or we discover the whole surface of the 
membrane thickly bestrevred Vv'ith innumerable small, round, grayish or white 
granules : sometimes it is covered, here and there, or everywhere, with false mem- 
branes : the intestines are frequently agglutinated into one mass ; or they are ad- 
herent to each other, or to the other parts of the peritoneum, in places only. The 
omentum is generally thick, red, and fleshy, as if its component parts had been mat- 
ted together ; and there is more or less fluid, commonly turbid and fiaky, in so much 
of the cavity as happens to be left. 

These are very unpromising forms of disease; and it is seldom that we can do 
more than mitigate the most distressing of the s3'mptoms, or retard, perhaps, the 
march of the disorder. Leeches to the abdomen, in moderate numbers, and fre- 
quently repeated, and followed by soft warm poultices. Blisters, when the pain is 
not severe, and the tenderness less. Attention to the state of the bowels, v/hich 
should be regulated by mild laxatives, rather than by drastic purges. A nourishing, 
but unstimulant diet. These are the measures to which we must look for benefit. 
It has been thought that frictions upon the belly, w^ith ointments containing iodine, 
have done good ; so that it will be well to make trial of such. But, do what we 
may, in nine cases out of ten, our best-directed eflbrts will be disappointed. 

When there is much fluid collected in the abdominal cavity in these cases, they 
take their character from this predominant symptom, and are called cases of ascites. 
But this is only one form of ascites — that form which results from chronic inflam- 
mation of the peritoneal membrane. I shall pass, however, by an easy transition, to 
the other forms of dropsy of the belly. 

There is another form of ascites, not very common, which approaches in its cha- 
racter to inflammation, and which, is therefore called active ascites. I mean that we 
som.etimes see persons, who were previously in good health, become rapidh-- ascitic, 
after exposure to cold and V\'et, and rapidly recover again under the remedies that 
are used to subdue inflammation. Perhaps it may be said that these ore cases of 
inflammation ; and it may be so. But they want many of the ordinary symptoms 
of peritonitis; and if inflammation he present, it has no worse efl!ect than the effusion 
of serum, which, under depletion or mercury, is speedily taken up again. I should i 
rather conceive, however, that these cases are to be included in that category of drop- 



ASCITES. 



74T 



sical effusions which I spoke of formerly, as resulting from the detention or absorp 
tion, in the first place, of an undue quantity of watery fluid into the blood, and its 
subsequent discharge, by a kind of secretion, either into shut cavities, or through 
some one of the natural vents of the body. The balance of the circulation between 
the skin and the internal surfaces appears to be destroyed, on these occasions, by the 
operation of external cold upon the tegumentary membranes. 

But by far the greater number of cases of aijcites are cases of passive dropsy which 
arise slowly from a mechanical obstacle to the free return of the venous blood 
towards the heart. 

Ascites occurs, as yoa know, in general dropsy, with anasarca of the universal 
areolar tissue ; and this general effusion of fluid depends, in almost every case, either 
upon a pecuhar renal disorder, or upon organic disease of the viscera of the thorax ; 
of the lungs, or of the heart, or of both ; and, above all, upon such disorder as is 
attended with dilatation of the right chambers of the heart. 

But I exclude this form of ascites, wherein the dropsy of the belly is only a por- 
tion of more general disease of the same kind, and limit myself at present to that 
kind of passive ascites which is unattended with dropsy elsewhere, or which at any 
rate precedes the occurrence of serous accumulation in other parts. 

The symptom which first leads us to suspect ascites, is the progressive enlarge- 
ment of the abdomen. But the abdomen may grow gradually large and prominent 
when there is no disease whatever: in pregnancy, for example, or in mere obesity. 
It is n> cessary, therefore, to search for more definite signs of peritoneal dropsy. 

In order to make an accurate diagnosis of ascites, we must know what are the 
morbid conditions with which it is most liable to be confounded. Solid tumours and 
simple corpulency are readily enough distinguished. But there are certain kinds 
of encysleil dropsy of the abdomen, of vvhich the recognition is not so easy and 
obvious. Of these, what is called ovarian drcpsT/ is the chief. In some of its symp- 
toms, this complaint closely resembles ascites ; in some, it differs from it widely. So, 
also, the treatment of the two disorders is alike in some respects ; dissimilar in others. 
For these reasons, and because I am more solicitous to be practical than to be me- 
thodical, I shall consider these tvv^o maladies together ; turning first to the one, and 
then to the other, and marking, as I go on, the various points of similitude and con- 
trast which they mutually offer. 

Recollect that ascites signifies the accumulation of serous liquid in the bag^ of the 
peritoneum ; whereas ovarian dropsy consists in the collection of fluid in one or 
more cells within the ovary, or in a serous cyst connected with the uterine ap- 
pendages. 

One source of distinction between the two is furnished by the condition of the 
abdomen during their early stages. 

In ascites the enlargement is uniform and symmetrical, in reference to the two 
sides of the body. When the patient lies on her back, the flanks bulge outwards, 
or swag over, from the weight and lateral pressure of the augmenting fluid. This 
increased breadth of the trunk is not observable in the case of an ovarian tumour ; 
nor, I may add, in pregnancy. 

When we are able to trace the early history of ovarian dropsy, we find, in most 
instances, that the abdominal tumour was first perceived on one side ; in one or the 
other of the iliac fossee, or somewhere betv/een the ribs and the ilium. But when 
the enlargement of the abdomen is great, the distinction between ascites and encysted 
dropsy, drawn from the shape of the swelling, ceases. The ovarian tumour distends 
the abdomen, if not uniformly, yet nearly or quite as much on one side as on the 
other. 

The next thing we do, when the visible bulk and shape of the abdomen have 
suogested a suspicion of ascites, is to employ the sense of touch. 

Examination by pressure will sometimes suffice to assure us that there is fluid in 
the peritoneum. If you press suddenly with the tips of your fingers, in a direction 
perpendicular to the surface, you will often become aware of a sensation which it is 
difficult to describe in w^ords, yet which is quite decisive, and not to be mistaken ; a 
sensation of the displacement of liquid, and of the impinging of your fingers upon 



742 



ASCITES. 



some solid substance beJow. So that, by this manoBuvre, you frequently detect, not 
merely the presence of the liquid, but an enlarged liver, or spleen, or (it may be) an 
ovarian or other tumour; even when simple palpation, or handling in the ordinary 
way, would not enable you to ascertain these enlargements. 

Agmn, percifssiofi of the abdomen is fertile of information in these cases. First, 
by the sense of fluctuation which, it causes when hquid is collected within. The 
left hand being laid flat against one side of the tumid abdomen, if a slight blow be 
struck wllh the fingers of the right upon the opposite side, the impulse is conveyed 
by a wave of the liquid to the open flat hand, which feels a little shock that is per- 
fectly distinctive. The larger the amount of the accumulated liquid, and the thinner 
and tighter the walls within which it is confined, the more sensible and decided is 
this fluctuation. Even when the quantity is small, not exceeding a few ounces, a 
little practice and management will enable you to detect it. Percuss with one finger 
the most depending part of the cavity, and apply at the same time a finger of the 
other hand, very near the part struck; and, if liquid be there, you will perceive a 
limited yet distinct fluctuation. In the same way, the presence of liquid in a small 
cyst may sometimes be ascertained. Much more when the cyst is large. And the 
cyst, in ovarian dropsy, is often very large, and the hquid it contains is often thin and 
aqueous ; and then the fluctuation may be quite as perfect and perceptible as ever it 
is in ascites. 

Hence, mere fluctuation is not a discriminating symptom between ascites and 
ovarian dropsy. 

But, secondly, percussion is full of instruction in the sounds it elicits. The sense 
of hearing will generally supply what the sense of touch may leave wanting. 

In true ascites, the relative place of the liquid and of the intestines is determined 
by the posture of the patient. The bowels, which always contain some gas, float 
to the upper part of the liquid, and there give out (when the finger, as a pleximeter, 
is apphed to the corresponding surface, and struck) their peculiar resonance. Me- 
diate percussion will thus follow the gravitating fluid, and discover always a dull 
sound in the lowermost, and a hollow sound in the uppermost, part of the abdomen. 

But it is not so in ovarian dropsy. The cyst, in a diseased and enlarging ovary, 
rises in front of the intestines, which, being tied down by the mesentery, cannot 
embrace the tumour so as to reach its anterior aspect, but are in fact pressed back by 
it towards the spine. Hence, if there be any resonance produced by percussion, it 
is in one, or the other, or in both, of the flanks; and the umbihcal region yields a 
dull sound, whatever the position of the patient may be. The same is true of the 
enlarging womb in pregnancy. 

The simple expedient, then, is quite decisive. In ascites the epigastric and umbi- 
lical regions- a,re tympanitic on percussion ; in ovarian dropsy the latter, at least, is 
dulL To be quite sure it is well to make the patient assume different postures in 
succession. If the person affected with ascites turns upon her side, the uppermost 
flank will become resonant ; the umbilical region dull: whereas in ovarian dropsy, 
the sounds remain severally where they were under every change of position. In 
ascites, with a little care, you may ascertain the exact level at which the contained 
liquid stands ; and measure its rise or fall from day to day. 

This mode of diagnosis is scarcely open, under ordinary circumstances, to fallacy 
or exception. Yet there are two or three possible conditions in which it may fail ; 
and these it is right that I should briefly mention. 

1. The distension, in true ascites, may be so great, that the mesentery shall not 
be broad enough to allow the buoyant intestines to reach the surface, when the 
patient is supine. This impediment to the eflicacy of the proposed test I have met 
with in practice. A woman came under my charge in the hospital with ascites. 
Fluctuation of the belly was unequivocal. While she lay on her back, the umbili- 
cal and epigastric regions were resonant when percussed ; the flanks were dull. 
When she turned upon either side, the other side, previously dull, gave the hollow 
sound ; the umbilical and epigastric regions, previously resonant, gave the dull flat 
sound. Under the treatment employed, the accumulated hquid was removed, and 
she left the hospital. 



ASCITES. 



743 



Some time afterwards, as I was going round the wards, I recognized the same 
woman among the patients recently admitted by my colleague, Dr. Hawkins. The 
ascites had returned. The abdomen, enormously distended, projected upwards, 
as she lay on her back, to an excessive height. 1 found that fluctuation was very 
distinct, as before : but every part of the belly yielded a dull sound when struck by 
the fingers. At length this patient died : and it was seen, after death, that there 
was nothing to prevent the rising of the intestines. They had floated, at the utmost 
tether of the mesentery, as high as they could, without reaching the surface of the 
prominent belly. 

2. Another occasional source of fallacy I have just now hinted at. The intestines 
may be tied down, and so prevented from ascending by their specific lightness, to 
the upper part of the surrounding liquid. And this may happen, either in conse- 
quence of the adhesion of the various coils of the intestines to each other, and to the 
parts behind them : which is not an uncommon occurrence : — or the intestines, 
though unadherent, may be swathed, as it were, and bandaged down, by a thickened 
and diseased omentum. This also I have myself seen. A man died in the hospi- 
tal, who had manifest ascites. Yet his whole abdomen, though not so much distended 
as to hinder the intestines, had they been free to rise, from reaching its walls, 
sounded dull on percussion. - Inspection of the body explained this circumstance. 
When the peritoneum was opened by an incision carried through the fore-part of 
the abdomen, a quantity of serous liquid gushed out. The floor of the cavity which 
it had occupied was smooth and level ; and was found, on further examination, to be 
formed by a thick cake of omentum, strapped tightly over the subjacent intestines. 
Of course, the same diseased condition may occur in the fem.ale. 

3. On the other hand, I have once known an ovarian cyst to exist, when the um- 
bilical region was tympanitic under percussion. The case furnished just that kind of 
exception which serves to prove a rule. This was also a hospital-patient. Her his- 
tory was the history of ovarian dropsy. Some time previously she had discovered 
a small tumour in one of the iliac regions. It increased without much disturbance 
of her general health, until it became very inconvenient from its bulk. She was 
then tapped in one of the Borough hospitals : and she stated distinctly that it was 
not a clear watery fluid that was evacuated ; but a glutinous, mixed, and grumous 
matter: such as belongs to ovarian disease. No doubt could be entertained that the 
enlargement of the abdomen resulted from disease of that kind. Yet the umbilical 
region, when percussed, always rendered a hollow sound. Upon the death of the 
patient the mystery was solved. Air hissed forth from the opening made by the 
scalpel through the abdominal parietes : and the source of it being traced, an ovariaa 
cyst, of considerable magnitude, was found adhering to the peritoneum in front of 
the belly, and containing no liquid, but some yellowish shreds only; the remains, 
apparently, of some smaller included cysts. This ovarian bag had been filled with 

^ir, an J had given occasion to the equivocal sounds. 

These sources of possible mistake or obscurity very seldom occur; and the phy- 
sical diagnosis, as I have now pointed it out, is very sure and valuable. So com- 
pletely physical, indeed, are these tests, that we recognize ascites by them as readily 
and certainly in the dead, as in the living body. 

Other points of distinction may frequently be derived from the history and progress 
of the two disorders. 

The equable enlargement of the abdomen, on both sides, in ascites ; and its une- 
qual prominence on one side in the early stages of ovarian disease ; I have already 
mentioned. 

Again, it is observable that in true ascites, there are almost always manifest indi- 
cations of constitutional suffering and disturbance: a sallow complexion ; debility; 
emaciation. The morbid accumulation results (as we shall see) from disease in 
some organ, of which the functions cannot be impaired without injury to the whole 
system. 

Ovarian dropsy, on the other hand, may last long, and be extreme in degree, 
while the general health is scarcely affected. The very bulk and weight of the 
swelling, produce, indeed, much inconvenience and discomfort ; but, in other re- 



744 



CHRONIC ASCITES. 



spects, the patient often remains in good health. This appears to be owing to the 
circumstance that the ovary is not directly necessary to the life or well-being of 
the individual, but is merely subservient, for a limited time, to the purpose of repro- 
duction. 

Among the symptoms that are common to ascites and ovarian dropsy in their 
advanced stages, are all those which are occasioned by weight and pressure : viz., 
shortness of breath, from the resistance opposed to the descent of the diaphragm ; 
anasarca of the legs and thighs, from pressure upon the inferior cava and its branches; 
and a peculiarity of carriage and gait, like those of a woman big with child, and de- 
pending upon the same cause, the necessity of throwing the head and shoulders back- 
wards, to balance the weight of the distended abdomen in front. 

It is necessary to caution you against mistaking a distended bladder for dropsy of 
the abdomen. An old Frenchman was brought into the Middlesex Hospital, afflicted 
(so his friends said) with dropsy. He had been treated for that complaint. The 
abdomen was large, and dull under percussion from the pubes to above the umbili- 
cus. In the hypogastric region I could detect an obscure sense of fluctuation. I 
noticed a strong smell of urine about this patient. Being interrogated, he said that 
he had formerly had some "stoppage," but that he now passed plenty of water; 
that it even ran from him. It was obvious that his bladder was enormously distended, 
unable to contract upon its contents, and overflowing. With some difficulty a cha- 
theter was introduced, and some quarts, I forget the exact quantity, of turbid and 
stinking urine were drawn off. The patient sunk at length, and the bladder was 
found to be much diseased. I have known similar mistakes occur in private prac- 
tice. You win not think the caution I am now giving you superfluous, when I tell 
you, on the authority of Sir Everard Home, that John Hunter once actually tapped 
a distended bladder, in the belief that the disorder was ascites. 

Encysted dropsy, in the abdomen, is not always ovarian dropsy. Omental 
dropsy is described : the omental cavity alone being unfolded, and full of liquid. 
This I have never seen. Cysts containing a considerable quantity of a clear thin 
liquid, and connected with the liver, are common. Probably these are in all cases 
(they certainly are in many) the effects of the growth of hydatids. Dropsy of the 
Fallopian lubes : dropsy of the uterus : large serous cysts in the kidney : constitute 
other forms of abdominal encysted dropsy. Such states must be discovered by their 
own particular circumstances. None of them are very common. 



LECTURE LXVII. 

Pathology of Chronic Ascites; of Ovarian Dropsy. Treatment of these two 
disorders. Internal remedies : Extirpation of the ovarian sac : Paracentesis 
Abdominis. 

In my last lecture I pointed out the means we possess of distinguishing ascites 
from ovarian dropsy. Continuing the parallel between these two disorders, I have 
still to consider their pathology ; and to prescribe their treatment. 

I mentioned that chronic ascites is sometimes the sequel of acute inflammation of 
the peritoneum. In such cases, the abdomen is usually uneasy, and tender under 
pressure ; or at any rate, more sensible than common : and I believe more hot also 
than common. Whereas when ascites is passive as well as chronic, you may make 
the requisite examination without causing any distress to your patient. There is no 
pain produced by palpation, by pressure, or by percussion. Even when the dropsy 
has resulted from bygone inflammation, it does occasionally, though rarely, happen, 
that no other trace of such inflammation is discoverable in the living patient. The 
absorbing function of the membrane having, however, been spoiled, the collected 
liquid remains. Such a condition, I believe, I have witnessed. The history of su i- 



\ 



CHRONIC ASCITES. 



745 



j den and sharp pain, and tenderness of the abdomen, with fever, immediately before 
I the dropsical swelling took place, made it probable that it was the consequence of 
inflammatory effusion. But the fever had entirely subsided ; no tenderness was 
left ; no large veins were visible on the surface of the belly, denoting internal ob- 
struction ; and the general health was good. The patient had no other dropsy. 
The main exciting cause, however, of true and uncombined ascites, when no 
j inflammation is, or has been, at work, is some impediment to the venous circulation 
in the abdomen. Whereabouts, and of what kind,, is this impediment ? That is the 
question which, in each particular instance, we ask ourselves. 
'! The old doctrine respecting the causes of ascites, vaguely referred the collection 
] of liquid to obstruction ; and to organic diseases of the abdominal viscera ; and, 
i above all, to hepatic disease. But as we are now better instructed, and know that 
i organic diseases produce the dropsy, ultimately, by retarding the flow of blood through 
I the system of the vena portaB^ we see that the truth was only half perceived by the 
ancient pathologists. We can now understand why some organic diseases of the 
! abdomen lead to dropsy of the peritoneum, and others (even of the same viscus) do 
ji cot. And we have no difficulty in comprehending why, of all the abdominal viscera, 
the liver is the one whose diseases are the most frequendy connected with ascites : 
! that gland being traversed by the converging branches of the venous trunk, through 
' which passes by far the greater part of the serosity absorbed from the surface of the 
vast membrane that emvraps most of the abdominal organs, and hnes the cavity con- 
; taining them. It is plain that an accumulation of serum in the peritoneal sac may 
! arise from a mechanical obstruction in the trunk of the vena portae, or in some of the 
i principal branches that unite to form that vein ; or from certain diseases of the liver 
itself. But we know that disease of the liver is of very common occurrence, and 
oftentimes very obvious, while there is no ascites. And a further question arises— 
With what kinds of disease of the liver is hepatic ascites most apt to be associated? 

In truth, there is one special form of liver-disease which, though not the sole, is 
the grand cause, of passive and simple ascites. It has long been noticed that mere 
, enlargement is not the most common condition of the liver met with in hepatic 
dropsy ; but rather the small, hard, contracted viscus. Mere increase in the size 
of the organ may interfere but little with the portal circulation ; whereas a shrink- 
ing and diminution of its bulk must needs do so. In point of fact, that particular 
state of the liver which the French have termed cirr/iose, and which is familiar to 
morbid anatomists in this country as the hobnail liver, is the great source of passive 
ascites. 

The true character of this remarkable condition of the liver is of modern discovery. 
The credit of correcting the erroneous opinions which had been entertained respect- 
ing it is due, I believe, to Mr. Kiernan. The change undergone by the organ has 
also been clearly described by Dr. Carswell; whose delineations of its physical 
appearance are now before you. The change results from chronic inflammation, and 
chronic thickening (miscalled hypertrophy) of Glisson's capsule. Since Mr. Kier- 
nan's admirable exposition of the minute anatomy of the liver has been given to the 
world, few can be ignorant that the areolar tissue, termed the capsule of Glisson, 
accompanies the portal vein, the hepatic artery, and the bihary ducts ; and forms a 
sheath around these vessels in their course through the liver: wliile the hepatic vein 
and its branches are lodged in the proper substance of the gland without any such 
investing membrane. It follows that a general thickening of this tissue must produce 
a general pressure upon the portal veins, and hinder the return of the venous blood 
from the intestines. Hence, as in analogous cases, congestion of the capillaries, 
arrested absorption, mechanical transudation of serous liquid. The pressure affects 
also the nutrient vessel, the artery of the liver ; so that, in most instances, there are 
atrophy and shrinking of the organ. And sometimes, but not always, from pressure 
upon the biliary vessels, there is jaundice also. By degrees, the areolar tissue 
itself begins to shrink ; and the spaces in which it ramifies on the surface of the Hver 
are pulled inwards; the lobules appear to be prominent; and the surface becomes 
irregular and knobby, and studded with little roundish eminences like the heads 



746 



CHRONIC ASCITES. 



of nails. The constricted lobules are very conspicuous in the cut surface also of the 
liver. 

In the living body the presence of this hepatic disease is, for the most part, a 
matter of inference only. It is rendered probable by its ascertained frequency in 
connection with ascites, and by the absence of any other obvious cause for the 
dropsy. But sometimes the irregular surface can be felt through the walls of the 
abdomen. 

The nature of this morbid change affords a reason for the intractable and unpro- 
mising character of ascites in general. The obstructed blood seeks, indeed, new 
channels ; but the compensation they furnish is rarely sufficient. The superficial 
veins become obvious, numerous, large ; and wander with many inosculations over 
the surface of the belly. Large veins, significant of the same compensating effort, 
have been met with also in the adhesions which previous inflammation had left be- 
tween the liver and the diaphragm. 

Among the causes to which the thickening of the capsule of Glisson may be as- 
cribed, habitual intemperance holds the chief place. 

But this condition of Glisson's capsule, though it is the principal, and by far the 
most frequent, is not the only cause of obstruction to the current of the blood in the 
portal vessels, and of consequent ascites. In those specific forms of liver disease in 
which separate tumours are scattered through its substance, one of these tumours 
may be so placed as to press upon the trunk of the vein. So, obviously, may ab- 
dominal tumours of any kind ; enlarged mesenteric glands; cancer of the pylorus ; 
cancer of the head of the pancreas ; and the like. 

Ascites is found to be not unfrequently associated with disease and enlargement 
of the spleen also; but in most instances of this kind, the enlargement of the spleen 
and the peritoneal dropsy are not connected as cause and effect ; but are both conse- 
quences of portal obstruction. 

When, after death preceded by ascites, the cavity of the abdomen is laid open, its 
contents present a bleached and sodden appearance. It has been made a question 
whether this be the result of the long-continued immersion of the living tissues in 
the accumulated water; or of their short maceration after death. The question has 
no practical importance. 

Dropsy of the ovary, in its ordinary form, consists (I believe) in disease and 
enlargement of one, or more, of the Graafian vesicles ; or of the ova which they 
inclose. 

The actual condition of the dropsical ovary is subject to much variety. Sometimes 
there is but one cyst ; and this may be no bigger than a pea ; or it may be large 
enough to contain many gallons. Its walls may be as thin and flexible as those of 
the healthy urinary bladder ; or they may be firm, and half an inch or more in thick- 
ness. It may spring from a small pedicle, and lie free and unattached to the cavity 
of the peritoneum ; or it may adhere, partially or at all points, to the contiguous 
parts ; or it may be tied down by bands of coagulable lymph. Its inner surface may 
be smooth and even, or knobby and irregular. Lastly, the fluid contained in the 
cyst may be thin, or consistent ; limpid, or glutinous ; opaque, or transparent ; and 
of various tints ; so that, in different cases, it may be colourless, green, purple, red ; 
and more or less resemble in appearance pure water, white of egg, jelly, glue, bird- 
lime, or treacle. Most commonly, however, when the cyst is single, its contents are 
thin and aqueous. 

Again, the dropsical ovary may be multilocular, composed of many cysts, which 
are usually distinct, but which sometimes communicate together; and these cysts, 
in the same ovary, while they vary much in size, may differ also from each other in 
any or all the particulars just enumerated as being incidental to a solitary cyst. 

Commonly one of the cysts is much more capacious than the rest ; and some part 
of its inner surface is frequently embossed, as it were, by the projecting outline of 
a group of small nodules, which seem to lie within the parietes of the largiT cyst, 
but which, in truth, are cysts of similar origin with it, but of more stunted growth. 

The external surface also of the multilocular ovary is generally lobulated ; and its 



OVARIAN DROPSY. 



747 



inequalities may often be discovered by a careful examination of the abdomen in the 
living subject. 

Sometimes the tumour is sohd throughout ; in which case the term dropsy is alto- 
gether misapplied. 

These differences are not without occasional importance, in reference to some 
points in the treatment of the disease. 

The progress of ovarian dropsy is no less wanting in uniformity. Sometimes it 
is very rapid ; sometimes it is very slow. It may destroy hfe in a few months ; it 
may continue, a mere burden, with scarcely any fatal tendency, for many years. Not 
unfrequently, after a period of active increase in the tumour, the morbid process, 
without any obvious cause, suddenly stops : and the pause may be final ; or, after 
an uncertain interval, the disease may resume its former activity. 

Under all circumstances the malady is a serious one : for its possible grievances 
are many ; and its issue is precarious and unpromising. Although, in some cases, 
the general health for a long time is but slightly or not at all impaired, in others 
the disease runs a short course ; the tumour increasing rapidly and proving ulti- 
mately fatal by its bulk and pressure ; or embittering and abridging the unhappy 
patient's existence by some accident of growth or position. Even when of no vast 
magnitude, it may be so situated as to impede or prevent the expulsion of the 
feces from the bowel, of the urine from the bladder, or of the foetus from the gravid 
uterus. 

The single cysts, having thin parietes, and containing a serous liquid, are not 
always produced by disease and distension of a Graafian vesicle ; for they sometimes 
have no connection with the ovary, but spring from some other part of the uterine 
appendages. 

Neither, perhaps, can it be demonstrated that the complaint originated within the 
Graafian vesicles, when it exists in its more complicated form ; when the cysts are 
many, and their contents various. But the shape of the cysts, which are more or 
less spherical, their number, their isolation in most cases, and the diversity in the 
matters by which they are filled, render this view of their origin at least a probable 
one. 

This form of the disorder has been considered as belonging to the category of 
malignant diseases ; but, in my judgment, without sufficient reason. It is true that 
the tumour does sometimes involve one or more of those morbid conditions, which 
have been denominated scirrhus, fungus hsematodes, cerebriform disease, or mela- 
nosis, and which all, or nearly all, appear to be varying results of the same morbid 
process, and to be referable to the genus carcinoma: but whenever this is observed 
to be the case, other structures also are found to be infested with analogous chani^res. 
The so-called malignant disease occupies the ovary in common with other parts ; and 
this is one of its most constant characters, namely, that proceeding from some vice 
in the constitution, or disseminated from some local germ, it pervades diffiirent organs 
of the body at the same time, or in succession ; whereas, in by far the majority of 
instances of ovarian dropsy, these pecuhar products are met with neither in the 
diseased gland, nor in any other place. It has already been remarked that man}'- 
women, labouring under ovarian dropsy, enjoy, nevertheless, in all other respects, 
very good health, even for many years. The victims of malignant disease are not 
so fortunate. They either are soon cut off", or if they linger, they seldom fail to ex- 
hibit, in their complexion and general condition, notable indications of the mischief 
which is in progress, and gradually undermining the powers of life. 

If it be admitted, as a reasonable conjecture, that the Graafian vesicles, or the ova 
they contain, are the seat of the primary changes, we may push our speculations a 
little further. These ova are destined, under the peculiar stimulus of impregnation, 
to build up the fabric of the body in all its parts and qualities. And we may sup- 
pose that, in consequence of some unnatural and morbid stimulus, perverted and * 
erring action may be set up, and strange products result. It is not uncommon to 
find fat, hair, cholesterine, teeth, and other bones, in the diseased ovaria, even of 
virgins. 

This view of the matter is strengthened by the fact, that dropsy of the ovary ^ of 



748 



TREATxMENT OF OVARIAN DROPSY. 



the ordinary kind, has not been known to commence before the age of puberty ; nor 
often after the capability of child-bearing had ceased; but only, or chiefly, during 
that period in which the organ, if healthy, is susceptible of its proper and temporary 
functions. Virgins, and barren and fruitful wives, are alike subject to the 'disease ; 
but in what relative proportions, statistical inquiry has not yet (so far as I know) 
determined. Where it accompanies, it may also account for, sterihty. 

The catamenia during the progress of the malady sornxOtimes appear with more or 
less of regularity and quantitj^ ; sometimes are entirely suspended. This function 
is so often interrupted under other circumstances, that its derangements shed but 
little light upon cases that are otherwise obscure. When the discharge continues 
to recur, we may presume that one, at least, of the ovaries is in a tolerably healthy 
state : when both are sensibly diseased, the catamenia may be expected to be 
wanting. 

The treatment of these two forms of abdominal dropsy must, up to a certam point, 
at which the operation of tapping becomes expedient, be considered separately. Of 
both it may be said, that their cure is seldom accomplished ; yet, for reasons already 
assigned, ascites has, upon the whole, a more certain progress towards the destruc- 
tion of life than ovarian disease : while, perhaps, it is oftener cured. 

In passive ascites, when the distension of the peritoneum has crept on without 
pain, fever, or other marks of inflammatory action, our first and best hope of evacuat- 
ing the collected hquid will rest upon diuretics. Hepatic ascites and renal disease 
may be sometimes found in conjunction, but according to my experience, they seldom 
are so : and except that both may probably owe their occasional origin to habits of 
intemperance, there appears no reason why they should be. Diuretics may be ad- 
ministered, therefore, without scruple. The hydragogue purgatives are to be em- 
ployed, also, when diuretics fail to act, or to reduce the swelling; and when the 
disease is not already comphcated with diarrhoea. And inferring with more or less 
certainty the existence of hepatic disease — sometimes from palpation of the enlarged 
or altered liver, sometimes from the coincidence of jaundice, but most of all from the 
result of accumulated experience respecting the morbid anatomy of such cases — we 
give the patient the chance of the remedial influence of mercury. The disorder 
being chronic, the introduction of that drug should be gradual. The iodide of potas- 
sium is held by some physicians to be especially serviceable in hepatic ascites. 
Compounds of mercury and iodine may be applied, by inunction, to the surface of 
the abdomen, and to the right hypochondrium in particular. In Germany, the 
muriate of ammonia is in much repute as a therapeutic agent. This diuretic salt, 
though seldom administered internally in this country, is believed by some practical 
men who have employed it, to exercise the same beneficial influence upon the func- 
tions of the liver, as is commonly attributed to preparations of mercury ; while it is 
less productive of distress or inconvenience. My own experience upon this point is 
too limited to justify me in expressing any confident opinion about it ; but in some 
recent instances I certainly have noticed a remarkable improvement in the character 
of the biliary excretion, after the daily exhibition of sal-ammoniac combined with the 
extract of taraxacum. 

You will generally be obliged to try, in their turn, all the diuretics within 3:^our 
reach, and frequendy to no purpose. Our efforts to remove by medicine the accu- 
mulated liquid, or to cure the morbid condition on which the accumulation depends, 
are too often made in vain. The distension of the peritoneum continues to augment ; 
the distress arising therefrom becomes urgent and extreme ; and at length, to afford 
temporary ease to the patient, and in the faint hope also of giving him permanent 
rehef, we resort to the mechanical expedient of paracentesis. 

When we have the opportunity of treating ovarian dropsy from its commence- 
ment, we sometimes find that the enlarging ovary is painful, or tender. This is an 
indication for antiphlogistic measures. But from such remedies, or from any reme- 
dies, httie more than temporary rehef is to be expected. x\Iy position as physician 
to a hospital, has brought under my notice several cases of ovarian swelling, at a very 
early period of its development ; when all that could be detected by careful exami- 



TREATMENT OF OVARIAN DROPSY. 



749 



nation of the abdomen was a small tumour, not larger, perhaps, than an egs, and 
occupying the situation of the ovary; to which the attention of the patient had been 
i drawn by some pain or uneasy feehng in that part. I have treated such cases assi- 
duously, with the remedies of chronic inflammation, frequent topical bleedings, and 
the use of mercury till the gums were affected ; with the remedies of ordinary dropsy, 
! diuretics and drastic purgatives ; and with remedies accounted specific, the liquor 
j potassEe, tho various preparations of iodine ; and I must honestly confess to you that 
I I am unable to reckon one single instance of success. Yet these are the measures 
I that we are bound to try. They have succeeded — as we are assured by competent 
' and credible witnesses ; they may therefore succeed again. The amount of my own 
! experience, however, tends to the persuasion that medicine has, in general, very 
' small influence over the progress of this disorder. The cases that do well, do well 
1 we scarcely know how or why ; the cases that prove fatal run their course in spite 
' of us. 

I Sometimes, as has been stated, these ovarian tumours reach a certain magnitude, 
I and then (wherefore we cannot tell), enlarge no more ; but remain a mere inconve- 
I nience and deformity, for many years. Occasionally, either spontaneously, or in 
i corjsequence of some accidental violence, they burst into the cavity of the perito- 
i nemn, whence the effused fluid may be absorbed ; but more commonly it causes fatal 
inflauimation. Or the bursting tumour may empty itself harmlessly (adhesion having 
previously taken place), through some channel of communication with the bowels or 
with the bladder; or externally through the parietes of the abdomen. 

Tumours, supposed to be ovarian, do sometimes disappear entirely. It may, 
however, be doubted whether all, or even many, of the enlargements which have 
had this fortunate issue, were really connected with the ovary. One source of mis- 
take 1 have myself more than once encountered, and I believe it to be not uncom- 
mon. A brief statement of the circumstances under which 1 first observed the falla- 
cious symptom, will show you at once what 1 mean. Some years ago I was sent 
for by a lady, who for many days had been labouring under an ordinary attack of 
continued fever. While examining the abdomen by pressure, I discovered, on the 
right side, between the ilium and umbihcus, a round, hard, painless tumour, as big 
as a swan's egg. The patient was aware of it ; and thought it had existed for some 
time. At the next visit it was gone. In the interim, very abundant discharges from 
the bowels had followed the administration of purgative medicine. The tumour had 
obviously been formed by the accumulation of fecal matters in the caecum. 

Similar collections take place, less frequently, on the left side, just above the sigmoid 
flexure. 

The parts concerned in this disorder are not essential to life, or to the enjoyment 
of health. On some of the lower animals the operation of spaying is as customary 
in the one sex, and is performed with as little risk, as that of castration in the other. 
The ovaries have in several instances" been extracted from the living human body, 
without any ill consequences. These facts, and the intractable character of the dis- 
ease, have naturally suggested the expediency of extirpating the tumour in cases of 
ovarian dropsy. 

But -although the ovary, when healthy, or when not much enlarged, may be re- 
moved without much difficulty or hazard, the operation becomes always perilous, and 
often impracticable, when the altered gland has attained any considerable magnitude. 
Yet these are the very cases for which the remedy is needed. A large ovarian 
tumour is usually multilocular, with firm parietes, and thick internal septa ; and is 
therefore incapable of collapsing much when punctured. To extirpate such a tumour, 
the abdomen must be (as it frequently has been) laid open from the sternum to the 
pubes. Most commonly, also, a large ovarian swelling is adherent to the contiguous 
parts; a circumstance' which either makes the proposed removal of the tumour im- 
possible, or, if the connections admit of being broken down, augments in a fearful 
manner the jeopardy of the patient. It is not surprising, therefore, that the results 
of experience have been so discouraging as well nigh, in most minds, to prohibit 
such attempts in future. The operation has, indeed, in several authentic cases, 
been quite successful. In other instances, the surgeon, after exposing the adherent 

3n3 



750 TREATMENT OF OVARIAN DROPSY. \ 

I 

mass, has been fain to replace the effused bowels, and to sew up the abdomen, as : 
speedily as possible ; and the patient, having suffered all this in vain, has sometimes i 
been fortunate enough to escape with life ; but not always. In others, the adhering i 
tumour has been separated, and the object achieved ; and the woman has lived there- ' 
after for some hours. Three times, at least (one of the cases is recorded by Mr* i 
Lizars, another by Mr. King, the third fell under the cognizance of Dr. Richard • 
Bright), the abdominal muscles and the peritoneum have been sht open, for the pur- j 
pose of extracting a diseased ovary, — when no disease existed. j 

But of late, a modification of the process of excision — whereby it is adapted to ' 
certain forms or conditions of the disease — has been proposed and practised ; and -i 
holds out somewhat more of promise. 

It consists in making, not a long, but a small incision through the walls of the 
abdomen, and through the peritoneum, so as to bring the surface of the diseased 
ovary into view. The cyst is then secured, by means of a tenaculum, or of a ligature, 
from receding inwards, and punctured, and its contents are suffered to escape. When 
the sac has emptied itself, it is withdrawn through the external orifice by gentle 
traction, until its stalk, or place of attachment to the broad ligament, comes near the 
wound. A thread is tied round this stalk, the cyst is cut off, the uterine appendages 
are put back into the cavity of the abdomen, and the lips of the wound are brought 
together. 

Although this method does not appear to have been actimWj perfor7ned till very 
recently, it had been suggested as long ago, at least, as the time of Dr. William 
Hunter, who, in a paper on the disease, has these remarks: — "If it be proposed, 
indeed, to make such a wound in the belly as will admit only two fingers or so, and 
then to tap the bag, and draw it out, so as to bring its root or peduncle close to the 
wound of the -belly, that the surgeon may cut it wkhout introducing his hand, surely 
in a case otherwise so desperate, it might be advisable to do it, could we beforehand 
know that the circumstances would admit of that treatment." 

In these few words. Dr. William Hunter not only describes the mode of excision, 
but alludes to circumstances that may render it inadmissible, as well as to the uncer- 
tainty that may arise about the existence of those circumstances. What the circum- 
stances are is sufiiciently obvious. 

How^ever, this suggestion has been carried into successful practice by Mr. West, 
Mr. King, and others. To an interesting paper on the subject, pubhshed by Mr. 
Gorham, in the Lancet, is appended a summary account of ten cases ; by which 
account it appears, that five of the ten patients were cured by the operation ; two 
recovered from the attempt to extract, which was unsuccessful ; two died very soon 
after the operation, and evidently in consequence of it. The remaining patient, 
whose case has already been adverted to, recovered also from the incision : but there 
was no diseased ovary to amputate : so fallacious, sometimes, is the diagnosis. 

This mode of operating merits careful consideration, and further trial. Its recom- 
mendations are — 

1. That the first steps — the incision and the puncture — are the same in kind as 
the first steps in ordinary paracentesis, and not much more severe or dangerous ; the 
only difference being that the incision requires to be somewhat larger in the one case 
than in the other. 

2. That, when successful, it affords a complete and permanent cure, which can 
hardly be hoped for from any other plan. 

The objections to its general use are — 

1. That the single sacs, with thin and flexible walls, do not, commonly, reach a 
very large size. When small, or of moderate dimensions, they produce so little 
distress or inconvenience, that an operation, which must ahvays be uncertain and 
tentative, ought not to be recommended. 

2. That the mukilocular tumours, with solid walls and partitions, can scarcely be 
so drawn through the opening made into the abdomen. 

3. And above all, that adhesion of the tumour to the neighbouring parts would 
interfere with and prevent the success of the operation. 

In most, however, of the five cases of cure referred to by Mr. Gorham, the sacs 



TREATMENT OF OVARIAN DROPSY. 



751 



thus removed were large. From one of them 12 pints of fluid were let out ; from 
another, 27 pints ; from a third, upwards of 20 ; and from a fourth, 24 pints. 

It is difficult to guess beforehand, whether the tumour be attached to the parts 
surrounding it or no. If it be readily movable by the fingers applied to the surface 
of the belly, so as to admit of being pushed hither and thither without pain or dis- 
tress to the patient, it is probably unadherent. In one of the same five cases, the 
patient being in labour, Mr. West found that the tumour lay between the uterus and 
the brim of the pelvis. By gentle pressure, per vaginam, it was made to recede 
into the cavity of the abdomen. This afforded a presumption that it was free from 
adhesion ; accordingly the sac was afterwards easily excised. The tumour is at- 
tached anteriorly to the peritoneum lining the front of the abdomen more frequently 
than to any other part. This Mr. Gorham attributes to partial inflammation pro- 
duced by the puncture in the operation of tapping; hence the presumption that the 
cyst is loose is, ceteris paribus, the stronger, when paracentesis has never been 
performed. 

If this mode of excision should be thought advisable, it ought to be attempted 
while the tumour is yet of moderate bulk, before the peritoneum has been much 
stretched, and while the chance of adhesion is the least. When any distinct history 
of bygone peritonitis can be traced, the existence of adhesions may be confidently 
reckoned upon.* 

To'the simpler operation of tapping, the contrary precept applies. Neither in 
ascites, nor in ovarian dropsy, should paracentesis be resorted to, until it seems abso- 
lutely indispensable. To this rule there are, in my opinion, very few exceptions. 

The operation itself, though commonly esteemed a trivial one, is not without its 
dangers. The instances are not few in which it has been followed by fatal peritonitis, 
excited either by the mere passage of the lancet or trocar through a previously un- 
healthy membrane, or, (in the case of ovarian dropsy,) by the escape of some portion 
of the contents of the cyst into the cavity of the abdomen. Formerly, the rapid 
evacuation of a large quantity of liquid from the belly was often attended by terrify- 
ing effects; fainting, convulsions, almost instant death. This made the ancient 
physicians afraid of the operation: and when they could no longer avoid it, they 
let the accumulated fluid out by little and httle, and at short intervals. 

The cause of these alarming symptoms is now well understood, and easily obviated. 
They were owing, doubtless, to the sudden removal of the pressure to which the 
viscera and large blood-vessels had been for some time submitted and accustomed. 
For this explanation of the fact we are indebted to the sagacity of our celebrated 
countryman, Dr. Mead, who was the first to suggest that external compression should 
be substituted, in lieu of the tension taken off by the operation. The complete 
success of that expedient fully justified his ingenious opinion. We now drain the 
cavity of its liquid contents without scruple or delay. A sheet, or broad roller, is 
thrown round the patient's body, and tightened as the fluid escapes, so as to main- 

* Since this lecture was first printed, an interesting paper by Mr. Phillips upon the ques- 
tion of extirpating ovarian cysts lias been published in the 27th volume of the Mcdico-Chirur- 
gical Transactions. 

Mr. Phillips exhibits, in a tabular form, " the results of 81 operations, performed for the 
purpose of extracting ovarian tumours. In 61 cases the tumour was extracted; in 15 cases 
adliesions, or other circumstances, prevented its removal; in 5 instances no tumour was 
found. Of the cases in which the operation was completed, the tumour being extracted, 35 
terminated favourably; the patient recovered. In 26 instances the termination was unfa- 
vourable ; the patient died. Of the five cases in which no tumour was discovered, all 
recovered. 

" Of the 15 cases in which adhesions or other circumstances prevented the extraction of 
the tumour, 9 recovered, 6 died." 

In two other tables Mr. Phillips collects together : — 

I. Cases in which a large incision was made, 55 in all : and among these cases there were 
26 deaths, 23 cures, and 6 recoveries which were not cures. 

II. Cases in which the incision was small (usually under six inches), am.ounting in all to 
27. Among these there were 7 deaths, 13 cures, and 7 recoveries from the unsuccessful 
operation. 



752 



TREATMENT OF OVARIAN DROPSY. 



tain an equable pressure, which is continued for a while, and at length gradually 
withdrawn. 

Other casualties occasionally happen ; the trocar has sometimes pierced the intes- 
tine. In one instance which I mj^self witnessed, clear serum issued for some time 
through the canula, but at length pure blood ; not less than a pint. The patient 
sank ; and no opportunity was given to investigate the cause of the bleeding. In 
another strange but well-authenticated case, the almost incredible quantity, twenty- 
six pints, of blood flowed out at the orifice made by the trocar, and afterwards sepa- 
rated into clot and serum. To the wonder of those who saw the incident, this 
patient recovered from the tapping; and the source of the hemorrhage is still a mat- 
ter of conjecture. 

And apart from these mischances — which, after all, are not of frequent occurrence 
— you must bear in mind that paracentesis can seldom be contemplated as a mode 
of cure, but simply of temporary relief from distress. A few instances have hap- 
pened where the liquid has been draiA^n off, and has not again collected : but such 
cases are very few. So, also, according to my experience, are those, much talked 
of by authors, in which the kidneys resume their activity upon the removal of the 
dropsical fluid. Ordinarily, the hquid re-accumulates, often with more rapidity than 
before; and again, and again, the pain and the hazard of the operation must be 
repeated : wherefore, in my judgment, paracentesis in abdominal dropsy ought 
seldom to be performed, unless the quantity of hquid is so great as to occasion pain- 
ful distension ; or causes great distress of breathing by its upward pressure against 
the diaphragm ; or gives rise to some positive suffering or urgent inconvenience, 
which the evacuation of the water may be expected to remedy. 

Acifpunciure of the dropsical abdomen has of late been recommended; and 
cures, thus effected, have been announced. It is said, or supposed, that the inclosed 
liquid, oozing gradually into the areolar tissue of the integuments of the abdomen, 
, is thence removed, gradually, by absorption. Of this method of treatment I have 
no practical knowledge. 

It is seldom that tapping is many times performed upon the same person, when 
the complaint is mere passive ascites. The dropsy returns indeed, and again the 
operation is required ; meanwhile, in most cases, the health and strength rapidly 
deteriorate, and the patient sinks. 

The same speedy declension and early death occur sometimes in ovarian dropsy 
also ; yet the operation commonly bears to be repeated more often than in ascites, 
without serious detriment to the general health. Sometimes the liquid re-accumu- 
lates in the cyst very quickly, sometimes slowly ; in a very few instances not at all. 
I have had under my own care a patient who had been tapped for this disease thirty- 
eight or thirty-nine times. Extraordinary examples of a similar kind are on record ; 
one or two I may mention as specimens. 

Dr. Mead narrates the case of a lady, who, " for the information of posterity, 
ordered by her will that the following English inscription should be engraved on her 
monument, in Bunhill Fields : — 

Here lies Dame Mary Page, 
Relict of Sir Gregory Page, Bart. 
She departed this life, March 4, 1728, 
In the 56th year of her age. 
In 67 months she was tapped 66 times: 
Had taken away 240 gallons of water, 
Avithout ever repining at her case, 
or ever fearing the operation." 

Among authenticated instances, the most remarkable that I have met with is 
detailed in the Philosophical Transactions for 1784, by Mr. Martineau, who was at 
that time surgeon to the Norfolk and Norwich Hospital. An abstract of the case is 
given in the printed catalogue of the Hunterian Museum, where the cyst is pre- 
served : it belonged to the left ovary of Sarah Kippus, a widow, fifty-five years old. 
*' The complaint began after a miscarriage, at the age of twenty-seven. From the 
year 1757, to August, 1783, when she died, she had been tapped eighty times, and 



ACUTE GASTRITIS. 



753 



had, in all, had taken from her 6631 pints of fluid, or upwards of thirteen hogs- 
heads. 108 pints was the largest quantity ever taken away at any one time. But 
after death Mr. Martineau could not make the sac contain more than fifty pints." 

Upon the whole, it may be stated of this operation, as apphed to ovarian dropsy, 

1» That when it is essential to the comfort and continued existence of the patient, 
it brings sensible rehef to her distress, and often materially prolongs her life. 

But, 2. That when it is performed under less pressing circumstances, it tends to 
shorten the patient's days. Dr. Bright is of opinion that the number is small of 
those who survive the first tapping more than four years. A respectable woman 
having very large ovarian dropsy, entered the Middlesex Hospital, under my care, 
for the express purpose of being tapped. The tumour incommoded her by its bulk 
and weight, but in no other way ; and she had carried it for thirteen years. I felt 
that I should not be justified in sanctioning the operation in such a case. The 
patient was made to understand that the performance of it would not be akogether 
free from immediate danger: and that if she went through it safely, the swelling 
would return, and the same kind of remedy again become equally necessary. She 
was instructed how to suspend the heavy overhanging abdomen by a sling passing 
over her shoulders. There appeared no reason why she should not continue in 
good health for another period of thirteen years. 

I am aware of another instance, in which a woman, similarly burdened, but other- 
wise in comfortable health, has lived, not without enjoying hfe, between twenty and 
thirty years. Had she been tapped when the mere enlargement might have seemed 
to justify the operation, she would probably have been for twenty years in her grave. 



LECTURE LXVIII. 

Mcute Gastritis : symptoms ; anatomical characters ; treatment. Chronic Inflam- 
mation of the Stomach; thickening of the Mucous Membrane; Ulceration; 
symptoms and treatment of the disorder. Cancer of the stomach. 

Acute inflammation, when it aflfects the peritoneum, usually spreads with rapidity 
over the whole surface of the membrane. This is characteristic of inflammation of 
the serous membranes generally. But it is not so with the other tissues that com- 
pose the alimentary canal. Inflammation of the mucous membrane may be, and 
often is, very hmited in extent : and the different portions of the intestinal tube, as 
they differ in function, so also they differ somewhat in their diseases, and still more 
in the symptoms by which those diseases are revealed. Not being fettered by any 
artificial system of arrangement, I shall take the course which promises to be prac- 
tically most useful, and consider separately the maladies of the several parts of the 
alimentary canal in the abdomen, extending my remarks occasionally to the whole 
of the tube, when speaking of disorders that are common to all portions of it. 

Let me, then, in the first place, draw your attention to the organic diseases, and 
the morbid conditions, of the stomach. 

It is remarkable, all things considered, how seldom the stomach is affected with 
acute inflammation. Scarcely ever do we find either the organ as a whole, or any 
one of its tissues separately, the subject of spontaneous acute inflammation. What 
is described in books as gastritis, means inflammation of the mucous membrane of 
the stomach ; and almost all that we know, for certain, of this disease, we derive 
from observation of the effects of strongly irritant substances upon that membrane. 
Idiopathic gastritis, in an acute form, I never saw. Acute gastritis, from the contact 
of corrosive or acrid poisons, I have frequently seen : and a highly interesting affec- 
tion it then becomes. This is a subject that cannot be thoroughly discussed in this 
course of lectures : neither may it be altogether omitted. 



754 



ACUTE GASTRITIS. 



When an irritant poison has been received into the stomach and excites inflam- 
mation there — or when acute inflammation arises from any cause — the symptoms 
which mark that inflammation are pain, usually of a burning character, in the epi- 
gastrium ; with frequent vomiting, especially upon the entrance of anything into the 
stomach ; and often with hiccup, and with tension of the upper part of the abdoijien. 
To these local symptoms are added fever of a low type ; and a small and weak pulse. 
At first, indeed, the pulse, although small, is generally sharp and hard ; but it soon 
becomes thready and feeble. The muscular power undergoes a corresponding de- 
pression ; the patient is pale and faint, with collapsed features, cold extremities, and 
a damp skin. 

In all this we see a strong tendency to death by asthenia. It is clear that the 
subdued state of the circulation is dependent upon the inflammation, for it is often 
relieved by the remedies of inflammation. In acute gastritis, as well as in peritonitis, 
you will find that the pulse expands, becomes more distinct and full, under early 
bleeding : sometimes even while the blood is flowing. 

Upon this remarkable sympathy between the heart and the stomach I have fre- 
quently had occasion to insist. You are aware that a smart blow upon the epigas- 
trium may put a sudden stop to the movements of the heart, and induce mortal 
syncope, without leaving any local trace of its operation. On the other hand, a 
person in a state of extreme exhaustion and faintness, will sometimes revive at once, 
upon swallowing into the stomach an ounce or two of brandy, and recover his pulse 
and colour much too speedily to allow of our ascribing these effects to the absorption 
of the alcohol into the blood. Dr. Ahson suggests that the depression of the circu- 
lation may be attributable to the peculiar sickening pain which accompanies inflam- 
mation or sudden injury of the stomach. It appears, however, more probable (as 
has been intimated to me by an obliging correspondent) that the remarkable sympathy 
in question is governed by the nerves of organic life. The great solar plexus of the 
ganglionic system hes upon the spinal column immediately behind the stomach. 
The heart is largely supplied with nervous filaments from the same system. Hence 
we might almost expect that any sudden stimulus applied to this important plexus 
would excite, and that any sudden depressing influence would subdue, the natural 
action of the heart. Upon the same principle may be explained the facts that deadly 
faintness and nausea are apt to result from injury of the testes, which are also 
abundantly endowed with influence from the nerves of organic life. Be this as it 
may, it is important for you to know that the mode of dying in these cases is pre- 
cisely what Bichat describes as death beginning at the heart. 

The pain that accompanies gastritis is augmented by pressure upon the epigas- 
trium. It is increased also by the full descent of the diaphragm, and the breathing 
is consequently short and constrained. In the most exquisite cases of gastritis, pro- 
duced by chemical or mechanical irritants apphed to the interior of the stomach, the 
inflammation probably reaches and involves, more or less, the peritoneum. The 
patients speak of the pain as a pricking and burning sensation ; it is attended with 
great anxiety and restlessness. The suflerer is tormented with extreme thirst, while 
all that he drinks, even cold water, is almost instantly rejected by vomiting. 

Hiccup does not always accompany acute gastritis. It sometimes occurs early ; 
but more generally it comes on late in the disease, when the patient is sunk and 
much debihtated. 

The bowels, in this complaint, are sometimes bound : sometimes, on the contrary — 
especially when the inflammation has been caused by corrosive poison^ — dysenteric 
diarrhoea ensues, with much griping and tenesmus. 

Such, then, are the symptoms that indicate the existence of acute gastritis ; but 
you ought to be aware that they occur in varying combinations, and with different 
degrees of severity ; and consequently that the course of the disease is not uniformly 
the same in all cases. When the symptoms are the most violent, and the progress 
of the complaint is the most rapid, the peritoneal coat of the stomach is usually, T 
believe, more or less implicated. 

Intense inflammation of the stomach may be expected to be rapid in its progress. 
It may destroy life within twenty-four, or even twelve hours. When it is fatal, it 



GASTRITIS. 



755 



generally is so within a few days ; and death takes place by fainting : with a remis- 
sion of the pain, sometimes very sudden, and sometimes occurring only just before 
dissolution. But as idiopathic gastritis is rare, fatal idiopathic gastritis is, of course, 
still more so. Louis states, that during six years' experience at La Charite, in which 
period he noted the details of 6000 cases of disease, and of 500 dissections, he did 
not meet with a single instance of fatal idiopathic gastritis. The subject derives 
almost all its importance, therefore, from its connection with poisoning ; and the many 
interesting points of inquiry which arise out of that connection will be brought before 
I you by the Professor of Forensic Medicine. This consideration is a great satisfac- 
tion and relief to me ; because I find that the limits of my own course will not 
permit me to go into any detail in this matter. 

The morbid appearances to be looked for after death by acute gastritis, are redness 
of the mucous membrane, softening, sloughing, and even (after the action of strongly 
corrosive poisons) perforation of all the coats of the stomach. 

I wish particularly to caution you against being misled by mere redness of the 
interior of the stomach ; or of the inner surface of the alimentary canal in general ; 
or of any mucous membrane ; and indeed I may add, of any serous membrane also. 
Redness and inflammation have been made, too often, convertible terms. Persons 
finding the inner surface of the stomach red, have instantly concluded, from that cir- 
cumstance, that suspicions of poisoning, which had arisen, were well founded. We 
are indebted to Dr. Yelloly, in the first instance, and to M. Billard and some other 
Frenchmen, in the second, for correcting this error — an error which not only was of 
importance in questions of imputed poisoning, but has run through and vitiated 
almost the whole of pathology, both lately and heretofore. Mistaking mere redness 
for evidence of inflammation, Cullen divided gastritis into two species — one of v/hich 
he called gastritis erythematica ; and he inferred from the observation of cases in 
which redness of the membrane had been met with after death, that this pecuhar 
kind of inflammation of the mucous coat of the stomach might take place, without 
fever, pain, or vomiting, or any other symptom indicative of gastritis : whereas it is 
almost certain that, in the cases to which he refers, there really was no inflammation 
at all. So also Morgagni, puzzled by intestinal vascularity, was disposed to attribute 
the absence of pain, in what he believed to have been inflammation of the bowels, 
to a paralytic affection, which blunted the sensibifity of the parts ; and Halier con- 
ceived, from so constantly meeting with this vascularity in his inspections of the body, 
that inflammation of the bowels was almost always present in fevers of all kinds ; 
and was frequent in every other complaint. And the same doctrine has been strenu- 
ously inculcated of late years, as I dare say you know, by Broussais, in France, and 
adopted by a vast host of his disciples. Finding the lining membrane of the stomach 
and intestines red and vascular in most of the bodies of patients who had died of 
fever, Broussais concluded that fever depends, in all cases, upon inflammation of the 
gastro-enteric mucous membrane. You will perceive that this doctrine must exer- 
cise a vast influence upon the practice of those who entertain it. If inflammation 
constitute an essential part of any disorder, it follows that the remedies of inflamma- 
tion will be adapted to that disorder ; and thus, even so slight a mistake as that may 
appear to be, against which I am now cautioning you, of regarding every surface 
which is red as being inflamed also, may lead to very mischievous views in respect 
to treatment. 

The redness that is ^^?dependent of inflammation may be of various kinds ; but 
the principal cause of it is venous congestion. " The appearances of vascular full- 
ness (says Dr. Yelloly) in the villous coat of the stomach, whether florid or dark- 
coloured, in distinct vessels, or in extravasations of different sizes, are not to be 
regarded as unequivocal marks of disease, inasmuch as they occur in every variety 
of degree and character, under every circumstance of previous indisposition, and in 
situations where the most healthy aspect of the organ may be expected." To the 
truth of this statement I can bear witness, having at one time of my life carefully 
examined, with a view to this matter, a great number of stomachs in succession, in 
the dead-house of a large hospital. " The vascularity (according to Dr. Yelloly) is 
entirely venous, and depends on a power capable of being exercised on the artery 



756 



GASTRITIS, 



itself at the close of life, which carries on the blood to the veins, after the further 
supply of fresh blood from the heart is stopped. The branched or stellated form of 
vessels, under which the vascularity usually appears, is capable of being imitated^ 
either by injecting the veins with fine injection, or by forcing back with the finger, 
or the back of a scalpel, the blood from the larger branches of veins into the smaller." 
" And this vascularity soon becomes diffused redness, by transudation of the blood 
through the coats of the containing vessels, just as happens with the bile in the gall- 
bladder." 

Redness, from mere repletion of the smaller veins, is usually extensive and unde- 
fined ; except that, being influenced by the force of gravity^ it settles into the most 
depending parts of the organ, which are either its exclusive seat, or, at any rate, are 
of a deeper colour than the parts more elevated. It is attended with an empty state 
of the arteries, and with a full state of the larger veins. Hence, the condition of the 
venous and arterial trunks, and especially of the vena portse, should, in doubtful 
cases, be ascertained before the main blood-vessels are laid open and drained of their 
contents. 

The redness that belongs to inflammation is generally circumscribed, and of limited 
extent ; it occupies indiscriminately the upper or the lower side of the tube (for these 
remarks apply alike to the stomach and to the intestines) ; it is attended with some 
fullness of the corresponding arterial trunks : and it may or may not be coincident 
with comparative emptiness of the venous system within the abdomen. Much will 
depend, in this respect, upon the mode of dying, as I have fully explained to you 
on a former occasion. 

You will please to remember, then, in all your future investigations into morbid 
anatomy, that it is generally difficult, and often impossible, to determine, from the 
aspect of the vessels of a dead part, from its redness, that inflammation had been 
present in that part during life, unless the unequivocal products or effects of inflam- 
matory action are present also. 

A much more certain evidence of inflammation of the mucous membrane of the 
stomach and intestines, is its softening. This can be attributed to nothing else, 
except it be to decomposition ; and it is well known that this membrane is slow and 
late in passing into the state of putrefaction after death. To certain questions respect- 
ing perforations of the stomach, I shall by and by return. 

I say that gastritis is most commonly the effect of poisons applied to the mucous 
surface of the stomach ; but I must include under that head certain substances which, 
to most people, are not poisonous or injurious at al], and which only become so to 
some persons under particular circumstances. Thus, large draughts of cold drink, 
taken when the body is hot, and rapidly parting with its heat, and especially large 
draughts of cold sour liquors., as cider or stale beer, are apt to give rise to acuie gas- 
tritis. Another occasional cause of gastritis is the ingestion of very large quantities 
of food at one time, especially during convalescence from any serious disorder. It 
is an exceedingly curious fact, too, but one which I merely mention without dwelling 
upon, that certain poisons introduced into the body through some other channel, will 
cause inflammation of the mucous membrane of the stomach, with which they have 
not been in contact. Corrosive subhmate and arsenic excite inflammation, with 
ulceration or sloughing of the mucous membrane, even when they are merely 
rubbed, in a certain quantity, upon the skin, or when they are inserted into the 
rectum. 

The treatnjent of acute gastritis is simple. The chief nicety respects the employ- 
ment of blood-letting. Early in the disease, if the pain be severe, you must try the 
effect of venesection, notw^ithstanding the smallness and feebleness of the pulse. 
How much blood you are to abstract cannot be told beforehand. Take away a small 
teacupful, keeping, meanwhile, your finger on the wrist. If the beat of the artery 
does not grow weaker, and still more if it becomes fuller and stronger, go on with 
the bleeding, and take another cupful, and another, according to the circumstances 
of the case and to the effects produced. Apply leeches to the epigastrium, and cover 
the bleeding bites with a sofi, light poultice. Keep the patient as strictly as you can 
in the horizontal posture ; in other words, see that the depressing influence of the 



CHRONIC INFLAMMATION OF THE STOMACH. 



757 



disease upon the action of the heart is not aided and augmented by the position of 
the body. If cold water is retained, that is the best medicine which you can give by 
the mouth ; purgatives so administered would be almost sure to be rejected, and, if 
not rejected, they would be hkely to increase the existing inflammation of the organ. 
Enemata are, however, extremely useful: of warm water, if the bowels are not 
much confined ; of purgative materials, if they are. After the intestines have been 
thus cleared— or when they are. loose and irritable — opiate injections (thirty or forty 
drops of laudanum, with three or four ounces of starch or gruelj do much good. 
They often have a very tranquiUizing effect upon the irritable stomach, and check 
the vomiting. These measures are to be pursued until the intiummation has 
subsided. 

When any corrosive substance has been swallowed, I scarcely need say that pains 
should be taken to remove it as speedily as possible from the stomach, or to admin- 
ister such remedies as are known to be capable of decomposing the poison, or of 
affording a specific antidote to it. Not that the stomach-pump should be employed 
in such cases, as it too often is. These, however, are points that must be fully treated 
of in the lectures on forensic medicine, and therefore I shall dwell upon them no 
longer here. 

Chronic inflammation of the stomach is probably a very common disorder. It 
does not put fife in immediate jeopard}-, and it is often recovered from. It deranges, 
however, the functions, and perverts the feehngs of the stomach : it gives rise to the 
manifold and multiform symptoms of dyspepsia. But dyspepsia, with its manifold 
and multiform symptoms, may be, and often is, entirely independent of inflamma- 
tion. You see, then, why the effects of chronic gastritis are various, and why the 
symptoms that are supposed to denote its presence are apt to be obscure, uncertain, 
and equivocal. I intend, before I quit the subject of the stomach, to investigate the 
principal circumstances that mark its functional disorders, and to describe the means 
which we sometimes find effectual for their relief. I shall therefore restrict myself 
at present to a few points which seem to have been fairly ascertained' respecting 
chronic gastritis. 

We know that chronic inflammation had been goino; on in the stomach when, after 
death, we see that its coats are thickened, or when we perceive that a portion of one 
or more of them has been removed by ulceration. 

It is not at all uncommon to find the mucous membrane of the stomach, over a 
larger or smaller space, thick, granular, uneven, and of an unnatural colour. Gray, 
or slate-coloured, it often is. This slate-colour is much dwelt upon by the French 
writers, as being a sure and unequivocal impress of chronic inflammation. The 
colour proceeds, 1 believe, from the operation of the gastric acids upon the blood, 
which, under habitual congestion or slow inflammation, is detained in the vessels of 
the altered part. The ulcers that result from chronic inflammatory action are usually 
small, varying from the size of a spht pea to that of a shilling; sometimes with no 
surrounding vascularity or thickening at all, but looking exactly as though a piece 
of the mucous membrane had been struck out by a stamp ; sometimes with rounded 
and elevated edges only ; and sometimes they occupy patches of thickening and 
induration of the parietes of the stomach. There may be one solitary ulcer, or a 
few, or many. It is seldom, however, that they are numerous. 

Ulcerative disease of the stomach may prove fatal in various ways. The ulcer 
may penetrate as far as the peritoneum, and excite inflammation of that membrane, 
whereby the stomach becomes adherent to the neighbouring parts. In these cases, 
prior or subsequently to adhesion, death may at length ensue, from gradual ex- 
haustion and protracted suffering. 

If an ulcer happen to lie over the track of a large blood-vessel in the stomach, it 
may eat its way into that vessel, and give rise to fatal hemorrhage. 

Or the ulcer may perforate the walls of the stomach, without any previous adhe- 
sion, and suffer the food, or the secretions of the stomach, to pass into the peritoneal 
cavity, where intense inflammation is lighted up, and the patient soon perishes. 

3o 



758 



CHRONIC INFLAMMATION 



Or the ulcers may at length heal. Of this we are certain, because, we sometimes 
find cicatrices marking the spots which the ulcers had occupied. 

The symptoms of chronic gastritis are pain or uneasiness in the epigastrium, 
increased by pressure ; increased also on the introduction of food, or perhaps felt 
only while digestion is in progress; flatulence and eructation; vomiting of mucus, and 
of ihe meals; loss of sleep; languor and debihty. 

Not that even these symptoms are constant in all cases. Sometimes there is no 
actual pain, but a sense of heat or of acidity. The vomiting, too, in the outset, is occa- 
sional only ; and is then attributable, often, to some error or imprudence in respect 
to diet. And sometimes the complaint may run nearly its whole course, up to one 
of the fatal terminations just now mentioned, with scarcely any other sign of its ex- 
istence than uneasiness after meals, which subsides in two or three hours entirely. 
With the local symptoms I have been describing there are often conjoined some 
acceleration and hardness of the pulse : more or less thirst : a dry skin : scanty and 
deep-coloured urine: a red tongue; red especially at its tips and edg'es ; patchy and 
fissured perhaps ; or smooth and glossy, like a slice of raw meat. The throat is also 
frequently tender ; and the pharynx and palate unnaturally vascular. 

In attempting to relieve or cure chronic gastritis we have to guard against apply- 
ing anything to the inflamed surface w^hich may be likely to add to the existing 
mischief, or which has been found, upon trial, to give pain. We employ at the 
same time the ordinary remedies of chronic inflammation. Leeches may be put 
upon the epigastrium, and repeated day by day, or every other day, in small num- 
bers, so long as there is much tenderness on pressure. When the tenderness is less, 
counter-irritation is very useful: repeated blisters; or friction with the tartar emetic 
ointment over the region of the stomach. But, after all, the main dependence must 
be placed in the due regulation of the food, which should be mild and unstimulating 
in quality, and sparing in quantity. The well-known farinaceous substances which 
figure in the bill of f^re of a sick chamber : arrow-root ; sago ; tapioca ; gruel ; milk 
also ; and jelhes. And even these bland articles of nourishment must be given in 
moderation, so as never to distend the stomach or to stretch its coats by their bulk, 
or to overtask its power of digestion. It is difficult, in such cases, to give precise 
rules for the management of the diet, which must be left to the common sense of the 
practitioner. 

With respect to internal medicines, they must be such as appear to be called for 
by particular symptoms. Of these, which are in fact the symptoms of dyspepsia, I 
postpone the further consideration. Appropriate means must be used for the regu- 
lation of the bowels : mild laxatives by the mouth ; emollient or purgative enemata 
by the rectum. 

When I say that a good deal must be left, in these cases of chronic disease o«f the 
stomach, to the judgment and good sense of the practitioner, I am forcibly reminded 
of a most striking and instructive case, beautifully told by the celebrated Dr. Wm. 
Hunter, in the sixth volume of the Medical Observations and Inquiries. The 
perusal of that history has afforded me hints upon which I have often acted with 
great advantage to my patients, and with some credit to myself. As I doubt whether 
many of you would find immediate opportunity or leisure for referring to the narra- 
tive, and as I should spoil it by attempting to give you an abstract of it, I am tempted 
to read it here in Dr. Hunter's own Avords. 

" Many years ago (he says) a gentleman came to me from the eastern part of the 
city, with his son, about eight or nine years old, to ask my advice for him. The 
complaint was pain in the stomach, frequent and violent vomitings, great weakness, 
and wasting of flesh. I think 1 hardly ever saw a human creature more emaciated, 
or with a look more expressive of being near the end of all the miseries of fife. The 
disorder was of some months' standing, and from the beginning to that time had been 
daily growing more desperate. He was at school when first taken ill, and concealed 
his disorder for some time : but growing much worse he was compelled to complain, 
and was brought home to be more carefully attended. From his sickly look, his 
total loss of appetite, besides what he said of the pain which he suffered, but espe- 



OF THE STOMACH. 



759 



ciaily from his vomiting up almost everything which he swallowed, it was evident 
that his disorder was very serious. 

" Three of the most eminent physicians of that time attended him in succession : 
and tried a variety of medicines without the least good effect. They had all, as the 
father told me, after sufficient trial, given the patient up, having nothing further to 
propose. The last prescription was a pill of solid opium ; for in the fluid state, 
though at first the opiate had stayed, some time upon his stomach, and brought a 
temporary relief, it failed at length, and like food, drink, and every medicine which 
had been given, was presently brought up again by vomiting. The opiate pill was 
therefore given in hopes that it would elude the expulsive efforts of the stomach. It 
did so for a time ; but after a little use, that likewise brought on vomiting. Then it 
was that his physician was consulted for the last time, who said that he had nothing 
further to propose. 

" Though at first the boy professed that he could assign no cause for his complaint, 
being strictly interrogated by his father, if he had ever swallowed anything that 
could hurt his stomach, or received any injury by a blow, or otherwise, he confessed 
that the usher in the school had grasped him by the waistcoat at the pit of the sto- 
mach, in a peevish fit, and shaken him rudely, for not havmg come up to the usher's 
expectation in a school-exercise.' That though it was not very painful at the time, 
the disorder came on soon after. This account disposed the father to suspect that the 
rude grasp and shake had hurt the stomach. With that idea he brought him to me, 
as an anatomist, that an accurate examination might if possible discover the cause or 
nature of the disorder. 

" He was stripped before the fire, and examined with attention in various situa- 
tions and postures; but no fulness, hardness, or tumour whatever could be discovered; 
on the contrary, he appeared everywhere like a skeleton covered with a mere skin ; 
and the abdomen was as flat, or rather as much drawn inwards, as if it had not con- 
tained half the usual quantity of bowels. 

" Having received all the information that I could expect, and reflected some little 
time upon the case, I wished to speak with the father alone, in another room ; and 
to give my patient some employment as well as refreshment, asked him to take a 
little milk in the mean time. But his father begged that taking any thing into his 
stomach might be put off till he got home, because he Avas certain that it would 
make him sick ; ' just before we set out (said he) I gave him a little milk ; but he 
was sick, and brought it all up in the coach, before we had got many paces from the 
house.' 

"In the adjacent room I said to the father. This case, sir, appears to me so despe- 
rate, that I could not tell you my thoughts before your son. I think it most probable, 
no doubt, that he wifi sink under it; I believe that no human sagacity or experience 
could pretend to ascertain the cause of his complaint : and without supposing a par- 
ticular or specific cause, there is hardly any thing to be aimed at in the way of a cure. 
Yet, dreadful as this language must be to your ear, I think you are not to be without 
hope. As we do not know the cause, it may happen to be of a temporar}'' nature, 
and may of itself take a favourable turn; we see such wonderful changes every day, 
in cases that appear the most desperate, and especially in young people. In thera 
the resources of nature are astonishing. 

"Then he asked me if I could communicate any rules or directions, for giving 
him a better chance of getting that cure from nature, which he saw he must despair 
of from art. 

" I told him that there were two things which I would recommend. The first was 
not so important indeed, yet I thought it might be useful, and certainly could do no 
harm. It was to have his son well rubbed, for half an hour together, with warm oil 
and a warm hand, before a fire, over and all around his stomach, every morning and 
evening. The oil, perhaps, would do little more than make the friction harmless, 
as well as easy ; and the friction would both soothe pain, and be a healthful exercise 
to a weak body. 

" The second thing that I had to propose, I imagined to be of the utmost conse- 
quence. It was something which I had particularly attended to in the disorders, 



760 



CHRONIC INFLAMMATION 



the stomach, especially vomitings. It was, carefully to avoid offending a very weak 
stomach, either with the quantity, or quality, of what is taken down ; and yet to get 
enough retained for supporting life. I need not tell you, sir, said I, that your son 
cannot live long, without taking some nourishment; he must be supported to allow 
of any chance in his favour. You think that for some time he has kept nothing of 
what he has swallowed ; but a smaU part must have remained, else he could not 
have lived till now. Do you not think, then, that it would have been better for him 
if he had only taken the very sm.all quantity which remained Vv-ith him, and was 
converted to nourishment ? It would have answered the end of supporting life as 
w^ell, and perhaps have saved him such constant distress of being sick, and of vomit- 
ing. The nourishment which he takes should not only be in very small quantity at 
a time, but in quantity the most inoffensive to a weak stomach that can be found. 
Milk is that kind of nourishment. It is what Providence has contrived for support- 
ing animals in the most tender stage of life. Take your son home, and as soon as 
he has rested a httle, give him one spoonful of milk. If he keeps it some time, 
without sickness or vomiting, repeat the meal, and so on. If he vomits it, after a 
Httle rest, try him with a smaller quantity, viz., with a dessert, or even a teaspoonful. 
If he can but bear the smallest quantity, you will be sure of being able to give him 
nourishment. Let it be the sole business of one perlon to feed him. If you succeed 
in the beginning, persevere with great caution, and proceed very gradually to a 
greater quantity, and to other fluid food, especially to what his own fancy may invite 
him ; such as smooth gruel, or panada, milk boiled with a little flour of wheat or 
rice ; thin chocolate and milk ; any broth without fat, or with a little jelly or rice or 
barley in it, &c. &c. 

" We then went in to our patient again ; and that he might be encouraged with 
hope, and at\ his part with resolution, I repeated the directions with an air of being 
confident of success. The plan was simple, and perfectly understood. They 
left me. 

" I heard nothing of the case till, I believe, between two and three months after. 
His father came to me with a most joyful countenance, and with kind expressions 
of gratitude told me, that the plan had been pursued with scrupulous exactness, and 
with astonishing success ; that his son had never vomited since I had seen him; that 
he was daily gaining flesh, and strength, and colour, and spirits, and now grown 
very importunate to have more substantial food. I recommended a change to be 
made by degrees. He recovered completely ; and many years ago he was a healthy 
and a very strong young man." 

[Acute gastritis is a disease of by no means unfrequent occurrence during infancy, and 
then frequently causes a softening of the mucous membrane of the stomach, to which much 
attention has of late years been directed by the observations of Cruveilheir, Louis, Laisne, 
Billard^ and others; by several of whom it is described as a specific disease. It is to this 
particular lesion that we wish to direct attention in the present note, referring the reader for 
information on the subject of the inflammatory affections of the stomach generally, that occur 
during the early period of life, to the Editor's Treatise on the Diseases of Children. 

The symptoms of the particular form of acute gastritis, to which we have reference, are 
■I'ery accurately described by Billard. The disease commences with the phenomena of a 
violent inflammation of the stomach ; as tension of the epi gastrin n:i, which is painful to 
the touch; frequent vomiting, not only of the milk and drinks taken, but also of a green or 
yellow fluid ; the vomiting occurring every moment, without any reference to the period 
when the child has taken food or drink. There is, sometimes, diarrhcea, varying in difierent 
subjects, and returning after having ceased for a day or two; the matters discharged from 
the bowels being often green, and similar to those brought up from the stomach by vomiting. 
The extremities are cold; the pulse is generally irregular ; the countenance has a permanent 
(ixpression of suffering, the face remaining furrowed, as if the infant were crying; the cry 
is expressive of pain; the respiration is interrupted, and the general agitation so great that 
ihe existence of a cerebral aflection might be suspected. At the end of six, eight, or fifteen 
days, the patient sinks exhausted from the want of sleep, Constant vomiting, and pain : in 
very young infants the disease is attended with little or no fever. 

Dr. Iselin, of Miihlheim, -who had an opportunity of studying the disease during its exten- 
sive prevalence as an epidemic at Gottingen, gives the following description of its phe* 
nomena : 

. Previous to the attack, the child is often, for several days, unusually restless and fretful — 



OF THE STOMACH. 



761 



finally, a decided febrile attack occurs, attended with a quick pulse, hot and dry skin, intense 
thirst, sleeplessness, and constant vomiting, increased upon food or drink being taken into the 
stomach. To these symptoms is speedily added a copious diarrhoea — the dejections being, 
at first, of a grayish colour, and of some degree of consistence, but subsequently of a yellow- 
ish or greenish serum, decidedly acid. The evacuations are usually preceded by contortions 
of the countenance indicative of pain, which are likewise induced by pressure on the abdo- 
men. The latter is always much, often enormously distended, and its temperature, especially 
at the epigastrium, is often considerably elevated, while the extremities are cool, or even de- 
cidedly cold. The patient exhibits great prostration of strength, and a profuse partial per- 
spiration soon breaks out, particularly about the head. 

The disease varies in its duration — proving fatal, in some cases, within twenty-four hours, 
and in others, not until after a continuance of several days, or even weeks. 

In the more violent cases, its onset is very sudden — and it is attended with frequent faint- 
ing, and an irregular and very quick pulse — the eyes and features are sunken — the body is 
bathed in a profuse perspiration. Convulsions, more or less severe, often attended with stra- 
bismus, sooner or later, occur ; the face becomes of a bluish tint; the diarrhoea or vomiting, 
or both, soon become suspended ; the accessions of fainting and convulsions become more 
frequent, and during one of these, death usually takes place. 

The intumescence and augmented heat of the abdomen, particularly of the epigastric 
region, and the coldness of the extremities, are, according to Dr. Iselin, to be considered as 
among the most constant and characteristic symptoms of the disease. The agonized expres- 
sion of countenance, and sunken appearance of the eyes, are likewise almost invariably pre- 
sent, even from its earliest stages. 

The age at which this form of gastritis usually occurs is within the first year ; it is 
not, however, necessarily restricted to this period of life. 

The most constant lesion discovered after death is a softening of the mucous membrane 
of the stomach, and often of the small and great intestines ; the membrane being reduced to 
a disorganized and gelatinous pulp ; or, the softening may extend to all the tissues of the 
stomach, rendering them liable to be perforated by the slightest force. In the stomach these 
softenings occur especially, according to Baron, Billard, and Iselin, at the great curvature, sel- 
dom extending beyond the most depending parts. Distinct traces of inflammation are occa- 
sionally observed, surrounding the softened parts, and patches of inflammation often exist, 
also, in different portions of the intestinal canal, especially in the small intestines. The pa- 
rietes of the stomach frequently present a serous infiltration. 

Carswell, Burns, Gairdner, Carwell, Hope, and other pathologists, deny the connection in 
these cases, of the softening of the gastro-intestinal mucous membrane and inflammation, and 
maintain that, in general, it is to be viewed as a cadaveric phenomenon, resulting from the 
action of the gastric juice upon the tissues of the stomach ; others, with Jaeger, Zeller, and 
Camerer, refer it to a paralysis of the nerves of the stomach, with increased acidity of the 
gastric juices, by which the tissues of the organ are dissolved during the lifetime of the pa- 
tient. A somewhat similar opinion is entertained by Laisne, Chaussier, Desbarreaux, Ber- 
nard, and others. Without denying that the softening observed after death in the stomachs 
of children may be, in many cases, strictly a cadaveric phenomenon, and that, in other cases, 
it may result, during the lifetime of the patient, from other caixses than inflammation, we are, 
nevertheless, well convinced from the result of repeated and cautious observations, that the 
gelatinous softening so frequently met with in the stomach of those infants who die after 
exhibiting all the symptoms of acute gastritis, is invariably the effect of an intense inflamma- 
tion commencing in the mucous tissue of the organ. 

Softening of the parietes of the stomach, as well as of the intestines, unquestionably often 
takes place previously to the death of the patient, in cases where it cannot be supj)osed to be 
the result of inflammation. Thus, we not imfrequently observe in infants brought up by the 
hand, or improperly fed subsequently to weaning, a loss of appetite, peevishness, great rest- 
lessness, and want of sleep; the tongue becomes coated with a layer of white or -yellowish 
mucus ; and in some instances aphthse appear upon the parietes of the mouth, and the breath 
has usually a decidedly acid odour. There are a constant diarrhcsa, and intense thirst. The 
diarrhoea, after a time, frequently diminishes, or entirely ceases — but soon returns again with 
increased violence — the discharges being a thin serous fluid of a yellow or greenish hue, and 
having a very strong acid smell ; great emaciation and exhaustion soon ensue ; the face and 
extremities become cold; the pulse small and irregular; the respiration quick and short. 
The child utters continually a low piteous moan, or lies upon his back with the eyes fixed, 
glassy, and half closed. No pain or tenderness is indicated upon gentle pressure of the ab- 
domen ; the latter is, however, often greatly swollen and tympanitic. The child becomes 
more and more exhausted, and, finally, expires quietly, and without convulsions. 

This train of symptoms, with slight variations, marks that form of disease described by 
Camerer, Pommer, Hergt, Romberg, Droste and others, as gastro-malacia, and in which the 
stomach, and often the intestines likewise, present a gelatinous softening of their parietes, to 
a greater or less extent, but without the slightest indication of inflammation : the softening 

3o3 



762 



CARCINOMA OF THE STOMACH. 



appearing to depend upon a diminished cohesion of the tissues — the result probably of dis- 
ordered or suspended nutrition. 

Acute gastritis as it occurs in the infant, is under all circumstances, and throughout all its 
stages, difficult to manage, and but little under the control of remedies. At its very onset 
leeches to the epigastrium, followed by warm fomentations or soft emollient poultices, assi 
duously applied, will be found advantageous. Internally, minute doses of calomel wil often 
remain upon the stomach and allay the excessive irritability of that organ ; we have occa- 
sionally combined the calomel with the acetate of lead ; one-fourth of a grain of the first 
with half a grain to a grain of the second, will, in a large number of instances, very speedily 
control the vomiting and purging, and aiibrd us time to reduce the local inflammation by 
leeches to the epigastrium, followed by blisters, kept on for one or two hours, and then re- 
placed by an emollient poultice. The thirst oY the child should be allayed by small quanti- 
ties of some bland mucilaginous fluid, given cold, and repeated at short intervals. Slightly 
astringent and bitter infusions are recommended by some practitioners during the period of 
convalescence, and we think that we have seen very decided benefit result at this period 
from the proto-carbonate of iron in moderate doses. — C] 

The stomach is very frequently the seat of specific malignant disease ; of cancer, 
in its various forms and denominations. The fatal nature of this complaint ; the 
obscurity in which it is sometimes wrapped ; the possibihty of overlooking it alto- 
gether, or of confounding it with disease of a more innocent character, combine to 
invest it with pecuhar interest. 

Carcinoma of the stomach has sometimes no symptoms at all, or none which the 
most sagacious practitioner would refer to the organ affected. Not long since I saw, 
in consultation, an elderly clergyman, who complained of pains in his back, which 
were brought on or aggravated by certain movements of the bod)^ His bowels 
were costive ; and purgatives always relieved his pains. He was passing lithic acid 
gravel. The pains were felt in or near the renal region. Several yeaj-s before he 
had suffered in a similar manner; and had then been cured by being cupped in the 
loins. What was the matter here ? Was it lumbago ? Was there a calculus in one of 
his kidneys? These were the best guesses that 1 could make. The eminent phy- 
sician whom I met, and a surgeon of no less eminence, who had seen the patient 
previously, had not been able to obtain any more exact diagnosis. Upon this gen- 
tleman's death, which occurred not long afterwards, his disorder was discovered to 
have been cancer of the stomach. Excepting slight sickness a day or two before he 
died, there had been no symptom to direct attention to that part. 

A young woman came into the Middlesex Hospital, under one of my colleagues, 
with a pulsating tumour in her epigastrium. It was thought, at first, to be an aneu- 
rism, and the case attracted, on that account, a good deal of notice. But the tumour 
subsided very much after free purgation. This led some to suppose that it was formed 
by accumulated feces in the transverse colon. There was no sickness; nor indeed 
any one symptom referable to the stomach. She died. The tumour was cancerous ; 
and in the stomach. Lying in front of the abdominal aorta, it had been lifted by its 
pulsations. 

Cases to the same effect are related by Dr. Seymour in the Medico- Chirurgical 
Transactions ; and by M. Andral in his Clinique Medicate. 

But even when the stomach is the organ pointed out, by the symptoms, as the 
probable seat of the malady, those symptoms fail, often, to indicate with any cer- 
tainty its nature. The effects of the carcinomatous disease exhibit no uniformity. 
The ingestion of food is apt to produce great distress; but differently indifferent 
cases: sometimes as soon as the food is swallowed; sometimes not for an hour 
or two afterwards. Some cases are attended with much pain ; some with none 
at all. One patient vomits continually : another has little or no vomiting from first 
to last. 

Can these differences be in any way accounted for ? Partly they may. By ana- 
lyzing case after case, we approximate to a knowledge of their causes. But this 
knowledge is yet far from being complete. 

One circumstance that has a considerable influence upon the symptoms, is the 
situation of the disease. In respect to this point there are certain general rules 
which are for the most part true. Still we can speak of them only as applicable on 
the average; they are not absolute or infalHble. 



CARCINOMA OF THE STOMACH. 



763 



The rules I mean are these : 

1st. That there is more suffering, cseteris 'paribus, when the cancerous disease is 
situated at, or very near, either extremity or orifice of the stomach, than when it 
occupies the intermediate parts ; whether in the greater or in the lesser curvature. 

2d. That when the cardia, and its immediate neighbourhood, is the part solely or 
principally diseased, the food and drink find a hinderance in passing into the sto- 
mach ; but being once there, the distress is over. The symptoms are very like those 
of stricture of the oesophagus. The morsel reaches the bottom of that tube, and there 
causes uneasiness, till at length it is brought up again through the mouth, or passes 
gradually in the natural direction. 

3d. That when, on the other hand, the disease is hmited to the pyloric end of the 
stomach, the food enters that bag readily enough, and remains there for a certain 
time ; then uneasy sensations arise, and the imperfectly digested meal is apt to be 
rejected by vomiting. 

It is the difficulty of passing the doorway in these cases, that gives rise to the 
principal suffering; the difficulty of getting into, or the difficulty of getting out of 
the stomach. But when the disease is confined to the intermediate space, no such 
difficulty occurs ; and therefore little or no pain. 

You must expect, I say, to meet with individual variations from these rules. A 
remarkable example of such variation was presented by one of my hospital pa- 
tients, in the year 1837. I have the notes of that case before me, which I will read 
sfiort. 

Simon Ailes, aged thirty-six, admitted March 14. His main complaint was of pain 
in the epigastrium, always present, but augmented in frequent paroxysms, to an ex- 
treme degree of severity. At first, pressure gave him some relief. The pain was 
most violent an hour or two after he ate. He was troubled also with flatulence, and 
with sour eructations. Occasionally a clear tasteless fluid, looking like vi^ater, rose 
into his mouth. His bowels were costive. 

At this time his countenance was natural and placid ; but it gradually assumed 
that pinched and anxious expression, and that peculiar yellowish hue, which are so 
significant of organic visceral disease. He wasted fast. At length the epigastrium 
became tender as well as painful : but no tumour, except the left edge of the fiver, 
could be felt there. He died on the 11th of May, about eight months from the 
commencement of the pain. A week before his death he vomited some dark, 
grumous, offensive fluid, evidently containing blood. With this exception he had 
no vomiting. 

Many remedies were tried, which I do not specify, for none of them gave him any 
sensible or continued rehef. 

In the smaller curvature of the stomach we found a ragged, sloughy surface, as 
big as the palm of one's hand, and extending to within half an inch from the pylorus. 
A section of this diseased portion exhibited the characters of true scirrhus: a white 
and hard mass, nearly half an inch across at its thickest part. The mucous mem- 
brane of the duodenum was congested, and dark-coloured. The rest of the intestines 
were healthy except the rectum, which was surrounded, towards the anus, by scir- 
rhus and thickened areolar tissue, intermixed in laminjE. The gut itself was not 
affected. 

The diseased stomach was removed, and examined by Mr. Kiernan, who found, 
upon careful dissection, that the trunk of the gastric branch of the par vagum run 
directly into, and was lost in, the scirrhous mass. This sufficiently accounted for 
the dreadful sufferings of the patient. 

And I am here reminded that, with regard 'to the structural alteration itself, there 
are some circumstances well worth attending to. 

Andrai places all these organic affections of the stomach in the class of chronic 
gastritis. But it is clear that he is wrong : and you will perceive at once that it is 
of immense importance to recognize the specific disease from the mere result of 
common inflammation. 

But though cancer is not, in any case, a mere product of common inflammation, 
neither is all that is called cancer really such. Specimens of morbid texture^ mi» 



764 



CARClNOxMA OF THE STOMACH. 



named scirrhus of the pylorus, are not uncommon in anatomical museums. I show 
you some from our own ; not so denominated, however. The correct labeling would 
be hypertrophy. You may perceive that the areolar and the muscular tissues near 
the pylorus, are very much thickened. A section of the thickened parts presents 
an appearance somewhat like horn ; and is crossed by whitish lines that run nearly 
parallel to each other. The morbid structure is quite definite and uniform ; and 
very dissimilar, in that respect, to the irregular masses of scirrhus, and to the amor- 
phous deposits of encephaloid cancer. Neither does it at all resemble that of the 
colloid variety of carcinoma. Changes of this kind are liable to occur in the mus- 
cular tissue of this, as of other organs, whenever a permanent obstacle is opposed to 
the onward progress of the contents of the hollow viscus. The impediment may 
have been originally produced by inflammatory thickening of the textures composing 
the pylorus ; and then the hypertrophy may, in a certain sense, be accounted a con- 
sequence of inflammation. To that extent alone is M. Andral right. He has un- 
questionably pushed his theory on this subject too far. Whatever narrows the 
pyloric orifice leads to increased effort of the propelling muscle, and to augmenta- 
tion of its bulk and power. Now cancer itself, situated at, or close upon, the pylorus, 
may impede the exit of the digested aliment ; and then it causes a gradual hyper- 
trophy of the muscular coat. In these cases there is a mixture of the two changes ; 
of the cancerous growth, with the muscular hypertrophy : and this is one reason 
why they have been confounded together. Here are several preparations, exhibiting 
true cancer of the stomach. At the bottom of each bottle may be seen a sort of 
whitish powder, or sediment, consisting of some of the matters pecuhar to cancer. 
This fact has been pointed out to me by Mr. Kiernan in the numerous specimens 
contained in his private collection. But there is no such deposit w^hen the hyper- 
trophy is not combined with malignant disease. 

It has long been thought and asserted, that cancer of the stomach is not so apt to 
be attended, as cancer of other parts, with a disposition to present itself in various 
organs of the body at the same time, or in succession. Now I believe — and I am 
glad to add the weight of Mr. Kiernan's authority to my statement — that this is not 
really so. Cancer is a constitutional aflection: or, if local and solitary in the outset, 
is prone to disseminate itself. The error has arisen out of that confounding of one 
morbid condition with another, against which I have been warning you. Instances 
are not at all uncommon of thickening of the areolar and mucous tissues about the 
pylorus, producing first a mechanical impediment to the passage of the food, then 
more energetic muscular efforts towards its expulsion from the stomach, and at last 
hypertrophy of the muscular tunic. In these cases, you do not find cancer in other 
organs : because, in fact, there is no cancer in the stomach. 

You may say that as both forms of disease are alike fatal, it signifies nothing 
whether there be really cancer or not. But it is alwa3^s satisfactory to clear away 
an apparent anomaly, and to show that it has no real existence. Besides, you know 
with how much anxiety the relatives of the dead inquire concerning these matters. 
That cancer "runs in families" is well understood even by the pubhc : and the dis- 
tinctions I have been pointing out are surely Avorth learning, if they do no more than 
enable us to comfort the minds of survivors, and to relieve them from the apprehen- 
sion that they also may be doomed or likely to become the victims of cancer. 

Notwithstanding what I have now been saying, it must be allowed that genuine 
cancer of the stomach is accompanied less frequently than some other modes of car- 
cinomatous disease, by cancer elsewhere. In fact cancer of the stomach is most 
often of the scirrhous variety, which until it softens is not so readily disseminated as 
the others, and which is apt to prove fatal before it softens. 

When primary cancer of the stomach is of the encephaloid kind, or when, being 
scirrhous, it begins to grow soft, — you would expect, after what was stated respecting 
suppurative phlebitis, that its secondary manifestation should occur chiefly in the 
liver. And it is so : the reason being that the veins of the stomach conmiunicate 
with the general system not directly, but through the hepatic capillary system. 

But to return to the symptoms of carcinoma of the stomach. In some cases, I say, 
the food is rejected by vomiting : in some cases it is not. Now^ it has been argued 



CARCINOMA OF THE STOMACH. 



765 



that this difference depends upon the condition of the pyloric outlet ; whether it be 
free and open, or contracted and shut. The explanation is more plausible than 
sound. It is not strictly consistent with facts. Vomiting of the food has been an ur- 
gent symptom, when there was no mechanical bar to its passage into the duodenum. 
The pylorus is a sphincter muscle, of which the natural and habitual state is that of 
contraction. It yields, however, in health, to the pressure of the digested aliment, 
which is driven forwards by the muscular fibres that surround, and compress by their 
action, the. pyloric end of the stomach. If there be a mechanical impediment, that 
affords a sufficient reason why the food should be thrown up again. But sometimes, 
I repeat, the orifice is wide open, and yet the food is rejected : and it is rejected be- 
cause the disease so involves the pyloric end of the stomach, that the propelling force 
cannot be exercised. 

When there is a mechanical obstacle, the disposition to hypertrophy of the mus- 
cular coat is conservative. But in feeble and delicate persons, the baffled muscles 
may never acquire strength enough to overcome the impediment ; and then the very 
opposite condition is apt to take place : the coats all become very thin ; meal after 
meal is retained ; the stomach is enormously distended, and relieves itself now and 
then, at distant intervals, by copious vomiting ; until at last it is unequal to that effort, 
and the patient dies. 

Sometimes the sickness and vomiting are urgent even when the stomach contains 
no food : and the matters rejected are of various character and appearance. They 
often resemble coffee-ofrounds, and consist, no doubt, of altered blood. Vomiting of 
this kind is a very pregnant sign of organic mischief in the stomach. 

Emaciation is another ugly circumstance in these cases ; and forms a strong ground 
of presumption that the symptoms depend upon structural disease. Yet it is not a 
uniform consequence, even of malignant disorganization of the stomach. Napoleon 
Bonaparte was very fat when he died. His omentum is described as having been 
"remarkably fat;" and the "fat was upwards of an inch thick upon his sternum, 
and one inch and a half upon his abdomen." 

The existence of a palpable tumour strengthens the unfavourable diagnosis. But 
this is far from being a constant phenomenon. It is not even pathognomonic when 
it does occur. The diseased head of the pancreas has been mistaken for a thickened 
pylorus. The stomach is liable also to be dragged much out of its place ; and then 
a thickened pylorus may be mistaken for something else. Sometimes the form of 
the stomach may be distinctly traced. In the person of a medical practitioner who 
died lately in this neighbourhood, the shape of the organ, its occasional peristaltic 
motions, and the irregular and hardened pylorus, were plainly to be felt. They 
might indeed almost be seen, in the hollow and attenuated abdomen. When a 
tumour is ascertained to belong to the stomach, it indicates disease of the pylorus 
rather than of the cardia. 

It is a curious feature in these mahgnant diseases of the stomach, that the symp- 
toms sometimes remit, in a remarkable manner, so as to excite a hope in the mind 
of the patient, and in that of his medical attendant, that the nature of the malady 
had been mistaken, and that recovery is about to take place. But the truce is not 
for long. Frightful disorganization is at length produced, ragged ulceration, perfora- 
tion of the coats of the stomach, adhesion to the parts adjacent, which thus are con- 
stituted adventitious walls ; — and inevitable death at last. 

The treatment of this dreadful complaint can only be palliative. If there be pain, 
we are driven, sooner or later, to opium. Anodyne enemata have often as good an 
effect in reheving the pain as opium given by the mouth ; and they have this advan- 
tage, that their constipating properties are more easily obviated than when that drug 
is put into the stomach. Nutritive injections are proper when food taken through 
the natural channel is not retained. 

Other palhative measures may be aimed at particular symptoms ; of these I pro- 
pose to speak when I come to the symptoms and remedies of dyspepsia. 



766 



HiEMATEMESIS. 



LECTURE LXIX. 

Hemorrhage from the Stomach : sometimes from a large vessel, usually by exha- 
lation. Idiopathic Hxmatemesis. Vicarious Hsematemesis : Hxmatemesis 
from Gastric disease or injury: from disease in other organs. Melscna. 
Hscmatemesis from a morbid state of the blood. General phenomena of Haema- 
temesis. Diagnosis. Treatment. 

Hemorrhage from the stomach, to which I wish next to direct your attention, is 
of much more frequent occurrence than acute gastritis. It is a complaint, or a symp- 
tom, that presents several points of interest and importance. I use the phrase 
" hemorrhage from the stomach," rather than the single term " h^matemesis," be- 
cause that term, signifying strictly a vomiting of blood, does not necessarily imply 
hemorrhage from the stomach; nor, indeed, does it alv/ays accompany such hemor- 
rhage, although it is one of its most common and most striking symptoms. 

What I have so frequently mentioned in respect to hemorrhages from the mucous 
membranes generally, viz., that the efflux of the blood is seldom owing to the rupture 
of a large blood-vessel, holds true in this. It can rarely happen that any vein or 
artery, belonging to the stomach is divided or laid open by accidental injur}?-, so as to 
pour forth its blood. When hemorrhage does proceed from one or more of the 
larger blood-vessels, the opening by which the blood escapes is commonly the result 
of chronic ulceration ; such as I spoke of yesterday. I have not, myself, met with 
an instance of that kind. Andral states, that, at most, there are but five or six such 
cases to be found in the records of medicine. Since his work on Pathological 
Anatomy was pubhshed, another examxpie of the same lesion has been detailed in 
the Journal Hebdomadaire for May, 1830. I show you a drawing after Dr. Cars- 
well, representing an ulcer which laid open the coronary artery of the stomach, and 
caused fatal hemorrhage. In these cases, we have, first, the symptoms of chronic 
gastritis ; next, faintness, or actual syncope, from the sudden abstraction of a large 
quantity of the vital fluid; and lastly, the visible eruption of the blood itself; for 
vomiting seldom occurs until a large quantity of blood has accumulated in the sto- 
mach. 

As this variety of gastric hemorrhage is rare, I will briefly relate an instance of it, 
which occurred in the year 1831, at St. Bartholomew's Hospital. Dr. Latham, who 
had charge of the case, was good enough, some time ago, to give me the following 
history of it. The subject of the disorder was a man thirty-eight years old. He was 
admitted on the 19th January. His countenance was dusky, but exsanguine ; his 
pulse 100, and weak ; his tongue pale, and slightly furred. He made no complaint 
of pain anywhere. 

He had been ailing for two years; had. suffered much pain across the epigastric 
region ; and had frequently vomited his meals. Two days before, he had been 
suddenly attacked with faintness and giddiness, and then vomited about two quarts 
of blood. He was an habitual spirit drinker. 

In the afternoon of the day on which he entered the hospital, he was again seized 
with giddiness ; and fell into a state of syncope, in which he remained for several 
minutes. Upon recovering, he vomited a large quantity of blood, not less than 
three pints. The next morning, early, he brought up a like quantity, under similar 
circumstances; and he passed three evacuations from the bowels, all of them black. 
He was gradually sinking during the w^hole of that day, the 20th. Towards the 
evening, he vomited about half a pint more blood. He died quietly the next 
morning. 

When the abdomen was laid open, the stomach was seen to be distended. The 
intestines had, in several places, a black appearance, from the colour of their con- 
tents. The stomach contained about two pints of coagula, and of a dirty red liquid. 
At the upper part of its lesser arch was a small excavated ulcer, with hardened 



HJEMATEMESIS. 



767 



edges. In the centre of this ulcer there were visible the orifices of three or four 
arteries, filled with minute clots of blood. 

It would seem as if gastric hemorrhage, having this origin, were capable of being 
stanched by some natural process ; and as if the injury done to the stomach were 
susceptible of repair. Andral describes a curious case, in which an open blood- 
vessel was found in an ulcer of the stomach ; but no hemorrhage had occurred. 
That mere ulcers in the stomach may heal, there can be no doubt : two or three 
scars of healed ulcers are represented in Dr. Carswell's drawing. The patient 
whose case is related in the Journal Hebdomadaire had vomited considerable 
quantities of blood for eight days in succession, five years previously to the attack 
which terminated his fife. So that hsematemesis from this cause is not absolutely 
hopeless. 

But (as T have already said) hemorrhage from the mucous membrane of the sto- 
mach, and from that of the alimentary canal generally, takes place far more com- 
monly by exhalation. The evidence that the blood really does ooze from the 
membrane is the same as that to which I have so often had occasion to advert ; and 
it is very satisfactory and conclusive in these cases, because we are able to scrutinize 
closely the whole extent of the mucous surface. This cannot so well be done in 
regard to the mucous membrane of the lungs. When death has followed imme- 
diately upon the hemorrhage, and has indeed been its rapid effect, the membrane 
has been found quite entire, and of its natural consistence and texture throughout. 
Sometimes partially red and pulpy, and vascular; sometimes universally so, the 
submucous capillary net-work of vessels being still gorged with blood ; sometimes 
quite pale, the same system of vessels having been completely em^ptied by the last 
attack of hemorrhage ; and sometimes studded with minute dark points, which could 
be made, by slight pressure, to start from the surface, and looked like grains of 
black sand. This latter appearance, as I once before remarked, is very corroborative 
of the opinion that the blood escapes through the natural pores or channels : which 
it cannot enter so long as the solids and fluids of the body retain their healthy con- 
dition. These sand-like bodies are, doubtless, small portions of blood, which have 
coagulated in the exhalant orifices of the membrane, and received from them their 
shape. 

This kind of hemorrhage happens under various circumstances ; and is attended 
with different degrees of danger. 1. The bleeding may be idiopathic. 2. It may 
be vicarious of some other habitual hemorrhage. 3. It m.ay depend upon disease 
or injury of the stomach itself. 4. It may be the consequence of disease situated 
elsewhere, and producing, mechanically, a plethora of the veins of the stomach. 
5. It may result from a morbid condition of the blood, and form one symptom of a 
more general disease ; as in the passive hemorrhages of purpura and sea-scurvy. 
Each of these varieties requires a short notice. 

1. Hemorrhage strictly idiopathic — i. e., independent of any apparent change 
of texture, whether in the surface itself, or in any part obviously capable of influ- 
encing its blood-vessels — is as rare, I believe, from the mucous membrane of the 
stomach, as from that of the lungs. I have never seen, nor do I recollect to have - 
read of, any instance of hsematemesis analogous to the epistaxis which is so common 
in children and young persons ; and which affords the most familiar example of idio- 
pathic hemorrhage. 

2. But hemorrhage from the stomach, occurring in connection with other consti- 
tutional hemorrhages, or in their stead — and above all, occuring vicariously of men- 
struation — is abundantly common. It is the most common, indeed, of all the species 
of hemorrhage by deviation. I told you^ in a former lecture, that patients will 
sometimes menstruate for years together through the lungs ; without any apparent 
injury to their general health. More commonly still do they menstruate through 
the stomach. I will mention one concise but singular example of this which I had 
from Dr. Latham, and which came within his own knowledge. A young woman 
became the subject of hsematemesis, recurring at monthly periods, about the age of 
fourteen. She had never menstruated. This continued until she married, and in 
due time, fell with child. Thereupon the hjEmatemesis ceased. She brought forth 



768 



HiEMATEMESIS. 



and suckled her infant. During lactation the hemorrhage did not recur. It came 
on again soon after she ceased to nurse the child ; no regular menstruation by the 
uterus having ever happened. This was the woman's own account, and there ap- 
peared no reason to question its accuracy. 

Gastric hemorrhage of this kind, vicarious of regular menstruation, is not generally 
thought to have any tendency to shorten the existence of those who are afflicted with 
it. Cullen states broadly that this species of heematemesis is hardly ever a dangerous 
disorder : and this is true. Yet it is not so entirely free from peril as to preclude 
the necessity of some caution and qualification in stating the prognosis. The ex- 
haustion from the mere loss of blood is sometimes so great as to create serious alarm 
for the patient's safety. And Mr. North has recorded (in the London Medical and 
Physical Journal) two instances in which suppressed menstruation was followed by 
repeated and at length fatal hsematemesis. In neither of these women was the 
health seriously deranged ; nor, previously to the hemorrhage, did there exist j 
debihty, or any other symptom calculated to excite the apprehension of danger. In i 
fact, in both of these cases, a strongly favourable prognosis was given by experienced i 
physicians, a very short time only before the fatal event. ' 

3. Gastric hemorrhage, by the way of exhalation, is often a consequence of dis- i 
ease or injury of the stomach itself It is sometimes one of the earliest declaratory 
symptoms of scirrhus or cancer of that organ — occurring long prior to ulceration. ' 
Hoematemesis attends, also, very commonly, the ultimate stages of that fatal disease : j 
and then it may be owing to the erosion of some vessel of notable magnitude, in the ' 
course of the process of disorganization, as in the examples already spoken of : or ; 
(what I believe is far more common) it may result from a kind of general oozing or 
exhalation from the ulcerating surface. Blood is often vomited soon after the recep- ' 
lion of strongly irritant poisons into the stomach. I show you again Dr. Roupel's ' 
plate, representing the crimson surface of a portion of the stomach of a dog which 
had been killed shortly after the administration of a dose of alcohol. The intense 
congestion thus produced is doubtless active congestion ; congestion belonging to 
inordinate arterial action. Pushed a degree further, such congestion passes into 
hemorrhage. 

4. On the other hand, intense passive congestion — congestion arising from the ^ 
detention of blood in the veins by some mechanical obstacle to its progress — is a very 
common source of gastric hemorrhage. Hsematemesis is therefore an occasional ' 
symptom of obstructive disease of the heart. Much more frequently, however, it ; 
depends upon abdominal changes. The hemorrhage is symptomatic of disease ! 
situated not in the stomach itself, but elsewhere. And the viscera, with the diseases ! 
or morbid conditions of which, bleeding from the stomach is most often connected, I 
are the liver and the spleen.' ' 

All this is well known ; and it is easy to see, from the peculiar construction of the j 
venous apparatus in the abdomen, how disease of one or both of these viscera may • 
produce mechanical congestion of the submucous capillary tissue; and how that i 
congestion may be relieved, under certain circumstances, by the effusion of serous 
fluid on the one or the other surface, constituting ascites or diarrhoea, as the case 
may be ; or under other circumstances, not perhaps easily discriminated or well j 
understood, by the extravasation of the collected blood itself. It would be super- 
fluous to describe the peculiar distribution and functions of the vessels which return 
the main portion of the venous blood from the stomach and intestines towards the 
heart. It seems to me highly probable that one at least of the offices of the spleen 
is to provide a receptacle or reservoir for this blood Avhen its free passage through 
the portal vessels is temporarily obstructed. It then becomes a sort of safety-valve 
(if such an illustration be allowable), which obviates the danger that might otherwise 
arise to more vital parts from any great or sudden disturbance of the venous circu- 
lation. The stress of the congestion is continually felt in the submucous capillary 
system ; and the hemorrhage, which is apt in such cases to occur from the loaded 
membrane, receives a simple solution upon principles almost purely mechanical. 
Nay, the very circumstances which lead to the effusion of the blood from the mucous 
surface on the one side, rather than from the serous on the other, may perhaps (as 1 



HiEMATEMESIS. 



769 



Stated more at large in an early part of the course) be themselves susceptible of 
mechanical explanation. 

Gastric hemorrhage, symptomatic of hepatic disease, is chiefly to be looked for in 
those morbid conditions of the liver which imply obstruction of the portal vein and 
of its ramifications. We are not surprised, therefore, to find it coincident, often, 
with a contracted and shrunken state of that organ. The state of the spleen, on the 
contrary, for reasons that must be obvious to you, is uniformly, in the cases we are 
now considering, a state of enlargement. And the augmentation of ^ulk is not so 
much to be ascribed to disease inherent in its proper texture, as to distension by the 
mere quantity of blood which it holds. The internal structure of the spleen furnishes 
a credible presumption in favour of that view of one of its uses to which I just now 
alluded ; and this structure, and this presumed function, when considered together, 
throw a strong fight upon some of the pathological relations of the spleen which well 
deserve attention. 

Numerous instances are on record of hsematemesis going along with evident 
enlargement of the spleen ; and in some of them that organ has been observed to 
diminish in bulk, in proportion as blood was poured out by the stomach. If I am 
not greatly mistaken, I have more than once seen this myself. In such cases the 
tumid condition of the spleen may be regarded as an evidence of venous obstruction 
elsewhere; and, as depending, sometimes at least, upon disease of a less striking 
and prominent character in the liver, impeding the progress of the blood through the 
vena portag. Of this kind would seem to have been a case related by Morgagni, 
wherein, after repeated attacks of haematemesis, under which the patient sank at 
last, the spleen was found to weigh four pounds, and to be gorged with dark blood ; 
while the liver was pale and exsanguine. Frank gives the history of a patient, who 
had vomitings of blood, and whose spleen, taken from the body after death, weighed 
sixteen pounds : the ordinary weight of the spleen in a healthy adult being from 
eight to ten ounces. In Latour's work on Hemorrhage, which is remarkable for the 
number of examples it contains, collected from various sources, and amounting to 
nearly a thousand, several instances are detailed of this combination of splenic en- 
largement with hsematemesis. One of these occurred in the person of a friend of 
his, who had been living in a malarious district, and who had laboured for nearly 
two years under obstinate intermittent fever. This was followed by an immense 
enlargement of the spleen — a great ague-cake — which came to occupy almost the 
whole of the abdomen. Latour's experience enabled him to predict that hgemate- 
mesis would -probably supervene upon this condition of the spleen ; and, accord- 
ingly, one night he was called in a hurry to his friend, and found that he had 
vomited an enormous quantity of clotted blood. A great deal passed away through 
the bowels also. The hemorrhage recurred from time to time, till in the course 
of a month the spleen was so far reduced in bulk, that it could no longer be felt in 
the belly; and the patient lived and enjoyed good health, for twenty-five years 
afterwards. 

It is necessary, therefore, in marking the connection which frequently subsists 
between haematemesis and enlargement of the spleen, to guard ourselves against con- 
ckiding that these two circumstances hold always the relation of cause and effect. 
In many such cases, probably in most of them, they are simply concurrent effects of 
one common cause ; and that cause is chiefly to be sought in such morbid conditions 
of the liver — or of other parts within the abdomen — as are competent to produce a 
considerable impediment to the free transmission of blood through the system of the 
vena portae. 

When gastric hemorrhage results from hepatic obstruction, there is almost always 
intestinal hemorrhage also. At any rate there are almost always black alvine 
evacuations, like tar or dark paint. This form of disease has therefore been 
called melsena. The ancients supposed that the unnatural stools consisted of black 
bile. 

Hemorrhage from the stomach, independent of disease in that or any other part, 
sometimes happens in the advanced periods of utero-gestation. Yet, though it does 
not result in these cases from disease, it is difficuk to class it among idiopathic 
49 3p 



770 



H^MATEMESIS. 



hemorrhages. The want of periodical recurrence, and the absence of the hemor- 
rhage during the earlier months of pregnancy, are circumstances which sufficiently i 
refute the old notion, that this form of hsematemesis depends also upon the suspen- ' 
sion of the catamenia. It is caused, no doubt, by the pressure of the gravid uterus, 
which impedes mechanically the venous circulation in the abdomen. 

5. Gastric hemorrhage, resulting from changes in the blood itself, occurs in sea- ^ 
scurvy, in purpura hemorrhagica, and in the yellow fever. Being merely a symp- j 
torn in these^ases, it requires no separate consideration here. ^ 

When a large quantity of blood is poured into the stomach, whatever may have , 
been its source, it appears to have a nauseating and emetic effect. At least the blood \ 
ejected in hssmatemesis is almost always considerable in amount. The vomiting 
may, for aught I know, be dependent on the mere distension of the stomach, which ; 
appears to be tolerant of the presence of the blood up to a certain point, but no further. \ 
A small quantity may, doubtless, pass all of it onwards through the pylorus, after \ 
undergoing, more or less completely, the process of digestion in the stomach ; and a i 
portion of the blood pursues that co.urse in most instances. But when it is vomited, 
it comes up in large quantities, usually of a dark colour, and more or less coagulated. 1 
Sometimes the coagula have evidently been moulded in the stomach ; and sometimes 
clots are thrown up, partially deprived of the colouring matter of the blood, and re- 
sembhng the fibrinous polypi so often met with in the cavities of the heart. Of course 
the degree of coagulation of the blood, and of its separation into serum and crassa- 
mentum, will depend upon the time that it remains in the stomach ; and this again 
would seem to bear a proportion to the rate of its effusion. 

The blood that js vomited is almost always of a dark colour; while that which is 
coughed up is most frequently florid and bright. Why is this ? We are told that I 
the blood which comes from the lungs is rendered florid by the admixture of atmo- 
spheric air. But this is not the whole of the matter. Neither can we say that the 
dark hue of the blood ejected in hi^matemesis is always, or solely due to some morbid 
alteration effected in that fluid while yet circulating in its proper vessels. There is 
another cause, which till of late years, was much overlooked, but which frequently j 
changes the colour and appearance of the blood after it has been extravasated into the I 
stomach ; and that in so great a degree as sometimes to render doubtful, or to disguise 
altogether, the real nature of the fluid vomited. I mean the chemical agency of the | 
gastric acid. The effect of acids in blackening the blood out of the body is well | 
known ; and it is somewhat singular that the ascertained existence of an acid secre- j 
tion in the stomach, varying in quantity at different times and under different circum- | 
stances, was not sooner apphed in explanation of the dark colour of the blood, and | 
its occasional blackness, when vomited. The degree of blackness will be in propor- | 
tion to the relative quantity of acid which it meets with in the stomach, and the inti- I 
macy of the admixture. Sometimes the blood is clotted and not very much altered | 
in colour; sometimes it is grumous, brown, of a chocolate tint, or like coffee-grounds, j 
This generally denotes the existence of organic disease; and the appearance of the , 
blood is probably modified in some degree by the morbid process that leads to its i 
effusion. There is good reason for believing that in the black vomit of the yellow 
fever, the colour of the blood undergoes alteration, even while it is yet circulating 
through the blood-vessels : but that the black appearance of the matter vomited is in j 
great part owing to the chemical action of the gastric acid, may be inferred from the 
fact, that the fluid so discharged is always (so I am informed) intensely acid. Andral 
has described an effusion of black liquid into the stomach, as an example of mela- 
nosis. He states at the same time that an accurate analysis of the liquid showed 
its composition to be very nearly the same with that of the blood. May we not sus- 
pect «that this inky fluid really consisted of blood that had been blackened, subse- 
quently to its extravasation, by the acid with which it mixed in the stomach ? Upon , 
the same principle may be explained the dark brown or almost black colour of the 
spots which are sometimes seen (I presume when there has been a great predomi- f 
nance of acid) in the substance of the mucous membrane of the stomach, or even j. 
beneath it ; and which have also been set down as melanotic. They are so like, in ■ 



DIAGNOSIS OF GASTRIC HEMORRHAGE. 



771 



all circumstances, except in the single particular of colour, to the crimson spots which 
are obviously formed by minute extravasations of blood in the same parts, that we 
can scarcely refer them to any other source. The slate-coloured patches, which I 
spoke of yesterday as being vestiges of chronic gastritis, depend likewise upon the 
blackening effect of the gastric acid upon the congested surface. We have the same 
dark colour of the effused blood, in many cases, when it is poured out in the intes- 
tines. Here, of course, its colour is not referable to the gastric juice ; but it is black- 
ened by some of the intestinal gases: probably by the sulphuretted hydrogen, for 
example, or the carbonic acid that enters into their composition. 

There can be no doubt that this gastric acid, when intense in strength, or copious 
in quantity, is capable of changing the colour of the blood, after death, even while 
it is contained in the sub-niucous blood-vessels. In these cases it must be conveyed 
to the blood by imbibition. And the very same thing takes place when strong acids 
are introduced into the stomach from without. When, for instance, the sulphuric 
acid, or what is perhaps more to our present purpose, the vegetable oxalic acid, has 
been taken as a poison, it has the effect of blackening, and, as it were, charring the 
blood, with which the membrane becomes loaded in consequence of the irritation 
produced by the poison. It does this when no destruction of the mucous membrane 
has been produced. 

It is but justice to observe, that the credit of having been the first to perceive, and 
to explain, this cause of the blackened state of the blood, while yet remaining in its 
proper vessels, is due to Dr. Carswell. 

When the blood is injected through the oesophagus and mouth, we have demon- 
strative evidence of the existence of hemorrhage ; and the diagnosis of hasmatemesis 
may appear to be so simple as to admit of neither mistake nor doubt. The diagno- 
sis of hemorrhage from the stomach, however, is really oftentimes difficult and ob- 
scure, and to be estabhshed by presumptive evidence alone. 

In the first place, bleeding may take place from the mucous membrane of the 
stomach, and no haematemesis ensue, especially when the blood is poured forth in 
small quantities and slowly. In these cases the blood becomes visible only in the 
stools, where it may not be looked for, and where, if seen, it may not always be 
recognized, in consequence of the changes it has undergone during its passage 
through the intestinal canal. And even supposing that its presence is delected in 
the alvine evacuations, it will remain uncertain in what part of that long canal it 
was effused. The hemorrhage may even be profuse, and the patient may die, with- 
out any escape of the blood externally. There is a case related by Frank, in which 
death took place from hemorrhage of the stomach without hsematemesis ; and both 
the stomach and the intestines were found distended by an enormous coagulum of 
blood which had assumed their form. 

Even when tlffe blood is ejected by the mouth, the exercise of some care and 
sagacity is occasionally, though not always required, in order to determine the part 
from which it was originally poured out. 

Thus blood may be swallowed, and afterwards vomited : and so we may have 
hsematemesis without hemorrhage from the stomach ; just as we may have hemor- 
rhage from the stomach without hsematemesis. There are cases of slow bleeding 
from the lungs, the fauces, the mouth, or the nasal cavities, where the blood, col- 
lecting in the pharynx, provokes, from time to time, an instinctive and involuntary 
act of deglutition; and thus is gradually accumulated in the stomach up to that 
point at which the organ becomes impatient of its contents, and ejects them by vo- 
miting. This is very apt to happen during sleep, and especially to young children : 
and as the blood, when vomited, is coagulated, and in considerable quantity, it is 
scarcely possible to conclude, from its mere appearance, that it has proceeded from 
any otiher source than the stomach itself. If, how;.wer, we mistake such cases, our 
error is likely to produce much needless alarm, and to lead us to unnecessary acti- 
vity in treating them. We are assisted towards forming a right judgment (when 
our attention happens to be directed to this source of fallacy), partly by the general 
history and symptoms, and partly by an examination of the mouth, fauces and nos- 



772 



DIAGNOSIS OF GASTRIC HEMORRHAGE. 



trils, to ascertain whether any coagula, or other marks of hemorrhage, are visible on 
the mucous membrane belonging to those parts. 

But blood may be swallowed knowingly and purposely by impostors, and after- 
wards vomited. Hasmatemesis is one of the complaints which have frequently been 
feigned; either for the sake of avoiding some imminent punishment, or distasteful 
service ; or with the view of exching compassion, and of profiting by the contribu- 
tions of the charitable and the credulous ; or sometimes from a kind of wilful per- 
versity, akin to insanity. In treatises on forensic medicine, you will generally find 
reference made to an instance of this kind recorded by Sauvages, in his Nosology. 
A young girl, who was anxious at all hazards to escape the constraints of a convent, 
pretended that she was suffering from violent hasmatemesis. In fact she did, for 
several days in succession, vomit large quantities of blood in the presence of the 
physician who had been summoned to her assistance. It was afterwards discovered 
that on each of those days she had swallowed blood which had been secretly con- 
veyed to her from the neighbouring shambles. A case of precisely the same kind 
occurred (as I was informed by a gentleman who witnessed ii) in the Bristol Infirm- 
ary some years ago. A girl had long been a patient there, labouring (as was sup- 
posed) under hsematemesis ; but it was at length discovered that she was a malin- 
gerer. She was in the habit of assisting the nurses in their work ; and this afforded 
her opportunities — of which she availed herself — of drinking the blood which had 
been drawn from the veins of other patients : and this blood she afterwards vomited. 

And even where no fraud is attempted, nor any blood swallowed, it occasionally 
becomes a nice matter to determine the origin of the hemorrhage, when blood is 
ejected in large quantities from the mouth : to decide, namely, whether the blood 
has come originally from the lungs or from the stomach. In copious haemoptysis, 
the blood issues from the mouth in gushes as it does in hsematemesis ; and the reflux 
of the blood into the pharynx, the tickhng sensation it there produces, and the cough 
(which we know> even when the expectoration is not of blood, frequently excites 
retchings); these causes, acting singly, or together, occasion sometimes a convulsive 
contraction of the muscles of the thorax, which looks like the effort of vomiting: and 
they often indeed give rise to actual vomiting. On the other hand, in sudden and 
profuse hasmatemesis, the irritation caused by the blood as it passes over the upper 
part of the larynx, is apt to provoke a paroxysm of choking cough. 

Now when I was speaking, some lectures back, of hsemopiysis, I promised that I 
would point out the means of distinguishing it from hsematemesis, when I came to 
the consideration of the latter complaint. I have now therefore to redeem my 
promise. 

However equivocal certain cases may be at first sight, we may generally guide 
ourselves to a correct decision by a careful investigation of the circumstances that 
precede, accompany, and follow the hemorrhage. Vorniting of blood is commonly 
preceded by a sensation of weight and uneasiness in the epigastrium ; and by nausea. 
Hsematemesis is also, more frequently than heemoptysis, ushered in by paleness of 
the face, dimness of vision, and an approach to syncope, or even actual fainting. 
These symptoms are not to be regarded (I apprehend) as premonitory of the hemor- 
rhage, although they have been so considered by some ; they are rather a sign that 
it has already taken place ; and yet they are prehminary of the hsematemesis. 
Occurring before the blood comes up, they cannot be ascribed to alarm at the sight 
of it. On the other hand, haemoptysis is wont to be announced by dyspncea, cough, 
tickling in the throat, and a sensation as if of bubbling within the thorax. Most 
commonly, too, before the expulsion of much blood from the lungs, some sputa are 
coughed up, composed more or less of that fluid. The symptoms that usually suc- 
ceed the hemorrhage, in either case, afford equally valuable assistance to our judg- 
ment, in cases that might otherwise be doubtful. Generally copious hEemoptysis 
goes on, in a succession of mouthfuls, for some time : whereas there is, mostly, only 
one access of full vomiting. At any rate, at the close of abundant pulmonary he- 
morrhage, the patient manifestly coughs up, and expectorates, smaller quantities of 
blood ; while we usually may observe that, a few hours after hcematemesis has 



DIAGNOSIS OF GASTRIC HEMORRHAGE. 



773 



occurred, slight griping pains come on in the abdomen, and a portion of blood is got 
rid of from the bowels. 

Other questions, often of much importance in regard to the ultimate diagnosis, 
when the blood is traceable with certainty to the stomach, are, whether it be idio- 
pathic, if, indeed, it ever be so : whether it be supplemental of some other discharge : 
whether it depend on disease of the stomach itself; of one, or more, of the contigu- 
ous viscera ; or of the system at large. Certainly, in a very great majority of cases, 
gastric hemorrhage is symptomatic ; and the nature and seat of the disease of which 
the bleeding is a symptom, may, in many instances, be determined without much 
difficulty. That which depends upon incipient cancer of the stomach, while it is 
by no means of rare occurrence, is also, (I think,) more frequently than other forms 
of hemorrhage from that organ, obscure. It must be obvious to you, and therefore 
I need not dwell upon this part of the subject, that a httle attention to the symptoms 
and past history of the patient will usually suffice to elucidate the nature of the case, 
where hsBmatemesis supervenes immediately upon the introduction of corrosive poi- 
sons, or within a certain interval after they have been swallowed : where it depends 
upon the bursting of a large aneurism : where it breaks forth among other symp- 
toms of scurvy or purpura : where it is the result of an advanced stage of cancer of 
the stomach : where it accompanies organic disease of the liver, spleen, or heart : 
where it occurs as a symptom of yellow fever : where it takes the place of suppressed 
or imperfect menstruation; or where it is occasioned by the pressure of the gravid 
uterus. In all these cases, there is, ordinarily, no room for mistaking the one dis- 
ease for the other ; or for regarding the hemorrhage as idiopathic. 

With respect to the treatment that should be adopted in cases of hemorrhage from 
the stomach, it must be apparent, from what has just been said of the many different 
morbid conditions upon which it may depend, or with which it may be essentially 
connected, that remedies 'are, in most cases, rather to be directed against the disease 
of which the hsematemesis is a symptom, than against that symptom itself. But 
sometimes we are obliged to treat the symptom, either because we are not certain of 
the exact nature of its cause, or because the condition out of which it springs is not 
within our reach. 

Cases of meldena (I have told you what is meant by that term) require hard purg- 
ing^; and many patients recover thoroughly under that mode of treatment. You 
may prescribe five grains of calomel every night, and a black dose every morning, 
till the stools lose their pitchy colour. Do not be afraid of purging your patients in. 
such cases. If they are curable at all, that is the way to cure them. I have pur- 
sued that plan with perfect success, even with patients whom the previous hemor- 
rhages had blanched, and whose pulse was feeble and irregular. You may sustain 
them, at the same time, by a full allow^ance of nourishing broths. The portal system 
is drained and unburdened by this active depletion. And if there be no irremediable 
change of texture in the liver, the recurrence of the hemorrhage may often, by a 
proper regulation of the habits and diet, be obviated. The ancients had learned by 
observation the efficacy of treatment of this kind ; but they used a different form of 
medicine, and purged away the atra bilis with hellebore. 

It is plain that for meltena, dependent on mechanical congestion, styptic substances 
would be worse than useless. They are more adapted to those cases (could we but 
surely distinguish them) in which the hemorrhage proceeds from a bleeding vessel. 
This is indeed the mode whereby we often succeed in stanching external hemor- 
rhages ; namely, by applying astringents to the very part. Similar means may be 
employed when hasmatemesis, of a purely passive character, depends upon some 
modification of the circulating blood. There is one remedy which is thought to 
have a sort of specific effect upon hemorrhages of the gastro-intestinal canal : I mean 
the oil of turpentine, given in small doses; from twenty minims to half a drachm, 
every four or six hours. I cannot say that I have had much experience of it. Of 
course the patient must be kept cool and quiet; whatever he drinks, he should drink 
cold ; even ice is often both grateful and e^ctual. If ordinary measures fail, recourse 
may be had to the acetate of lead ; or even to the quack medicine, Ruspini's styptic. 
Not that I think you will often find the latter expedient successful, when more 

3p2 



774 



DYSPEPSIA. 



rational treatment has failed ; but in obstinate and dangerous cases it ought to be 
tried. If, with the hasniatemesis, there be any fever, it may be proper and necessary 
to abstract blood from a vein, and to employ refrigerant substances as remedies ; and 
if, with or without much fever, there be tenderness at the epigastrium, leeches, or a 
blister, should be apphed. In cases where the catamenia desert their natural chan- 
nel, and seek an outlet through the mucous membrane of the stomach, it will be 
well, while means are taken to discourage the hsematemesis, as iced drinks and so 
forth, to endeavour to solicit the discharge in the right direction. And we often suc- 
ceed in this object by placing leeches upon the groins of these patients immediately 
before the period when the vicarious menstruation is expected, and by putting their 
feet at the same time into hot water, or even laying them in a warm hip bath. 



LECTURE LXX. 

Dyspepsia. Physiology of Digestion, Symptoms of Dyspepsia, Treatment 
and Prevention, Dietetic and Medicinal. 

It is my intention to appropriate this evening's lecture to a cursory account of 
dyspepsia^ by which I mean some evident derangement in the natural process of 
digesting and assimilating our food, and, more especially, a faulty performance of the 
functions of the stomach. Indigestion is the prevailing malady of civilized hfe. 
We are more often consulted about the disorders that belong to eating and drinking, 
than perhaps about any others; and I know of no medical topic concerning which 
there is afloat, both within and beyond the profession, so much ignorant dogmatism 
and quackery. 

CuUen, in his definition of dyspepsia, enumerates the various symptoms, by the 
occurrence of more or fewer of which that complaint is most commonly manifested : 
"Anorexia, nausea, vomitus, inflatio, ructus, ruminatio, cardialgia, gastrodynia : pau- 
ciora saltem vel plura horum simul concurrentia, plerumque cum alvo adstricta, et 
sine alio vel ventricuh ipsius, vel aliarum partium, morbo." 

The variety in the actual presence and combinations of these symptoms is very 
great ; and any attempt to give a perfect or complete history of dyspepsia in these 
lectures is quite out of the question. But I will endeavour to draw such a general 
outline of the disorder as may assist and direct your observation of it hereafter. 

I shall first take a brief view of the pathology of indigestion, so far as it is under- 
stood ; and to make this intelligible, it will be necessary to interweave something of 
the physiology of the subject. To these preliminary considerations, I shall add a 
short comment upon the several symptoms of dyspepsia, enumerated in CuUen's 
definition ; and, lastly, I shall state what I know respecting the means of curing and 
preventing this familiar disorder. 

The conditions of healthy digestion are these : that the food should be masticated, 
mixed with saHva, and swallowed into the stomach ; that in the stomach it should be 
reduced to a semi-fluid consistence, and converted into a uniform pulp, called chyme ; 
that the chyme should be transmitted through the pylorus into the duodenum, and 
there mixed with the bile, the pancreatic secretion, and the intestinal mucus : in 
consequence, as it would seem, of which admixture, the whole is separated into two 
parts, viz. : the chyle, or the nutritive portion of the food, now in a fit state to be 
taken up by the lacteals which open upon the mucous surface of the intestines, and 
to be carried by them into the blood ; and the excrementitious portion, which at 
length is conveyed out of the body. 

The food is dissolved and transformed, in the stomach, by the chemical agency 
of the gastric juice. This is a secretion peculiar to the stomach. All that need be 
stated of it here— almost all, indeed, that is known — is, first, that it oozes forth in 
minute drops from the mucous surface ; but only when food (or some sohd sub- 



DYSPEPSIA. 



775 



stance) is present in the stomach ; and, secondly, that it is always ac'i l. It appears 
to owe its solvent power to a special principle, which chemists have named pepsin. 

The food, having arrived in the stomach, is moved about by a sort of churning or 
revolving movement, and mixed with the gastric juice, and gradually changed into 
chyme, which also is acid. Finally, the chyme is propelled by degrees into the 
duodenum by the ^essure of the transverse band of muscular fibres v/hich embraces 
the pyloric extrei^ty of the stomach. The time in which the whole operation is 
completed varies from two to four or five hours. 

Liquids introduced into the stomach disappear much more speedily ; either by 
i direct absorption, or through the pylorus. 

All this we know, not from mere speculation on the anatomy and uses of the 
organ, but from actual observation. An American physician had, for several months 
in succession, the curious privilege of looking, whenever he pleased, into a healthy 
human stomach, and of watching its condition, its movements, and its contents, during 
the process of digestion. A young Canadian had a portion of the skin, muscles 
and ribs of the left side of the body blown away in a gunshot wound, which laid 
open the stomach also. He recovered from this frightful injury with a permanent 
aperture in the side, communicating directly with the stomach. Through this loop- 
hole Dr. Beaumont was allowed to introduce various articles of food ; and to with- 
draw from time to time the gastric secretions ; and the aliment, in the different stages 
of its digestion. He has published a very interesting account of these experiments, 
which have set at rest some points in the physiology of the stomach that were pre- 
viously uncertain. I shall embody his deductions in what I have further to say on 
the subject. 

In order that digestion may be perfect and easy, it is requisite that the food be in 
a state of minute division. This object is attained by mastication. A weak dys- 
peptic stomach acts slowly, or not at all, on soHd lumps and tough masses of food. 
The delayed morsels undergo spontaneous changes, promoted by the mere warmth 
and moisture of the stomach: gases are extricated : acids are formed: perhaps the 
half-digested mass is at length expelled by vomiting ; or it passes undissolved into 
the duodenum, and becomes a source of irritation and disturbance during the whole 
of its journey through the intestines. Here then we have one common cause of 
dyspepsia; and an easy and obvious preventive. Dyspeptic persons should not eat 
in a hurry, as busy men, and studious and solitary men, are apt to eat. They are 
to be cautioned against bolting their food : it must be well ground in the mill that 
nature has provided for that purpose. I am not at all sure that the increased lon- 
gevity of modern generations is not, in some degree, attributable to the capability 
of chewing their food which the skill of the dentist prolongs to persons far advanced 
in life. 

There are certain things upon which the gastric juice has no power. The green 
colouring matter of certain vegetables ; the husks of seeds ; the rinds of many fruits. 
You may perhaps have observed that dry currants, and the pips of apples, swallowed 
entire, reappear, unchanged, among the egesta. Whatever passes the stomach un- 
touched by the gastric liquor, passes undissolved through the whole of the aHmentary 
canal ; provoking disorder sometimes in its transit ; forming sometimes a nucleus for 
intestinal concretions. These substances are therefore unfit for a weak stomach. 
Y/hen the digestive powers are active, and the bowels slow, they may perhaps occa- 
sionally be even useful. Thus brown bread — i. e., the indigestible bran, or tegu- 
ment of the kernel of wheat — stimulates the peristakic motions of the intestines, 
and averts, in certain persons, the necessity of more direct purgatives. Unbruised 
mustard-seed, once so much in vogue, owed much of whatever virtue it possessed to 
this principle. But if these intractable substances fail to excite the proper action 
of the bowels, they are apt to accumulate, and to lay the foundation of serious 
disease. 

Indigestible matters, to which the pylorus refuses a passage, may remain in the 
stomach, and disturb its functions, for days, or even sometimes for weeks, together. 
If we could ascertain their presence, an emetic would be the remedy. And^sooner 
or later vomiting is set up, and the offending substance expelled. I lately saw a 



776 



DYSPEPSIA. 



mass of hard curd — a small cream cheese in respect to consistence — which was 
thrown up after several days of severe gastric pain and disorder. The relief was 
immediate and complete. The patient had been taking large quantities of cream 
with his tea and coffee. In another person a similar fit of indigestion terminated in 
the ejection of a mass of snuff. This is no unusual source of derangement of the 
stomach among those who use lavishly that nasty luxury. ^ 

The essential change which the chyme undergoes after leavii^ the stomach, ap- 
pears to consist in its separation into two parts : namely, into chyle, which is taken 
up by the lacteals ; and into excrement, which is discharged from the body. Any 
undissolved portions of the food become attached to this last part. We do not know 
exactly what is the function or agency of the pancreatic hquor; but with regard to 
the bile our knowledge is somewhat more definite. The acid developed in the 
stomach combines in the duodenum with the alkah of the bile, and is more or less 
neutralized. Dr. Prout conjectures that in a healthy state of the organs it is entirely 
neutralized. Bile is, moreover, the natural stimulus of the intestines: when its 
secretion is stopped, or its passage into the duodenum prevented, digestion and assi- 
milation may go on, but the bowels are usually sluggish. The hepatic secretion has, 
doubtless, other important uses ; but with these we are not at present concerned. It 
is pretty evident that the state of the bihary functions can have no direct influence in 
the production of mere dyspepsia. When the constituents of the bile are imper- 
fectly eliminated from the blood, various parts of the body may suffer detriment. 
And when the functions of the stomach and the functions of the liver are both disor- 
dered, it may be that the former organ sympathizes indirectly with the morbid state 
of the latter : or it may be that one and the same cause operates in producing the 
derangement of both organs. 

Let us now review the symptoms of dyspepsia which are mentioned in Cullen's 
definition. The first of these is anorexia: want of the natural appetite. Sometimes 
this is almost the only symptom observable. The patient is warned, by loss of appe- 
tite, not 10 take too much food ; he refrains instinctively from certain kinds of food ; 
or he feels perhaps absolute repugnance and disgust at the very thought of eating. 
Various have been the speculations respecting the immediate cause of hunger. It 
has been ascribed to the action of the gastric juice upon the surface of the empty 
stomach. But during health the gastric juice is never present in an empty stomach. 
Neither can the appetite depend upon contraction of the muscular fibres of the 
stomach ; for the empty stomach, during health, is always contracted upon itself. No 
doubt the sensation of hunger, hke all other sensations, arises from some particular 
condition of the nen^es of the part. It returns periodically, acknowledging in this 
respect the influence of habit. It is sensibly affected by agencies which operate upon 
and through the nervous system. The receipt of a piece of bad news will destroy, 
in a moment, the keenest appetite. 

Sometimes there is no anorexia. The appetite may even be morbidly craving and 
ravenous ; or capricious and uncertain. 

W^hen defect of appetite is the only symptom, it may be remedied, often, by the 
employment of bitters, or of the mineral acids, taken twice or thrice daily, for some 
time together. It would be out of place for me to speak in detail of particular me- 
dicines of this kind ; it is enough if I indicate quina, columbo, gentian, quassia ; the 
dilute sulphuric and nitric acids ; or a mixture of the nitric and muriatic. 

Nausea — vomitus. These are, in some instances, the most distressing results and 
signs of the dyspepsia. Sometimes nausea comes on soon after the food is swal- 
lowed. Sometimes there is no nausea; but after the lapse of a certain period, an 
hour or two generally, the food is rejected by vomiting. The matters thus thrown 
up are most frequently sour. Not seldom they are mixed also with bile, especially 
if the retching has been violent, or long continued; and then the patient is apt to 
ascribe the whole of his complaint to "an overflow of bile," although in fact the 
secretions of the liver have nothing whatever to do with it; the appearance of bile 
in the fluids ejected from the stomach proceeding from an inverted action of the 
duodenum. The effort of vomiting, however induced, will, if often repeated, be 
attended with the expulsion of yellow biie. I have more than once referred you, for 



DYSPEPSIA. 



777 



an illustration of this fact, to the phenomena of sea-sickness. The fallacy I now 
point out has been one cause of the notion that is prevalent among patients, and the 
I pubhc — and not unfrequently perhaps among practitioners — that dyspepsia very 

commonly depends upon a disordered state of the biliary organs. 
' The vomiting which occurs in dyspepsia is often connected with a morbid irrita- 
bility of 'the stomach ; and it is sometimes a very troublesome symptom to treat. 
I The carbonic acid has certainly a marked effect in allaying it, in many cases. We 
give it, as you know, in the effervescing sahne draught, made with the carbonate of 
' potash, or soda, and lemon-juice. Sometimes the mineral acids answer belter. Some- 
1 times, on the other hand, alkalies — the liquor potassje, for example — or hme-water, 
I are more effectual. In these latter cases we may presume that there is a morbid 
i acidity of the stomach. Small doses of opium are occasionally successful when 
I 'Other means fail. Opiates thrown into the rectum — opium plasters to the epigastri- 
um — blisters to the same part : these are measures which you will sometimes have 
j to try one after another. There are two special remedies which have been greatly 
extolled for their virtue in abating sickness : the hydrocyanic acid is one of them ; 
I creasote is the other. The hydrocyanic acid I have found exceedingly useful in 
1 obstinate cases. It may be given alone — or mixed with the effervescing draught — 
' or combined with a few grains of the sesquicarbonate of soda. The creasote has 
■ disappointed me oftener than it has answered my hopes from it. Yet it has a de- 
j cided influence in checking some forms of nausea ; and it is the more Hkely to suc- 
I ceed, in proportion as the condition of the stomach is remote from inflammation. 
I But after ail, the grand principle on which to treat chronic vomiting — not depend- 
ent upon disease in other parts, as the head, the kidney, or the uterus — is that laid 
down by Dr. William Hunter ; of reducing the quantity of food to that amount, 
whatever it may be, which the stomach is able and willing to retain, and of making 
its quality as bland and nutritious as possible. The most satisfactory case which 1 
have had to treat upon this principle occurred some years ago, in the person of one 
of my hospital patients. She was brought out of Kent by her father. She had 
been under the care of several medical men, one of whom had been a pupil at the 
hospital, and recommended her as a proper patient for admission there. Her age 
was sixteen. She and her father both agreed in the same story ; viz., that she con- 
stantly vomited her meals ; the food generally coming up again immediately after it 
was swallowed, and never remaining longer in her stomach than ten minutes. The 
vomiting was described as being easy ; and was neither preceded nor accompanied 
by nausea. 

She had been ill for four years : ever since a severe attack of scarlet fever. At 
first she vomited her meals now and then — three or four times a week — but the 
vomiting gradually became more and more frequent ; and at the time of her admis- 
sion she had vomited after every meal, for three months in succession. She had 
grown considerably in the four years ; and was tolerably plump ; and looked healthy; 
and the catamenia had begun to appear, though scantily, in the same period : but 
they had been altogether suspended for a year. 

It was clear that a good deal of her food must have remained ; and, bearing Wil- 
liam Hunter's case in mind, I directed that she should have a very small quantity of 
roast meat for dinner, and a coffee cup of milk occasionally during the day ; and no 
other food. I prescribed also some pills consisting of aloes and soap, to act mode- 
rately on the bowels. I expected to have been obliged still further to limit her food: 
but she never vomited again, from that time. This distressful and protracted disor- 
der, after long and fruitless treatment previously, yielded thus at once and easily to 
very simple means. 

Injlatio — ructus. Flatulence, and belching. The gas that produces these symp- 
toms is sometimes extricated from undigested food detained in the stomach, and in a 
state of fermentation : sometimes secreted, apparently, by the stomach itself ; for the 
flatulence comes on when the stomach is empty of food. It is apt to arise, in d3''s- 
peptic persons, if a meal happens to be delayed beyond the accustomed hour. Pa- 
tients complain grievously of these symptoms, and accuse the " wind in their stomach," 
as being at once the essence and the cause of all their complaints. They ask for 



778 



DYSPEPSIA. 



medicines to get rid of the wind ; and its escape may indeed be promoted by warm 
aromatics, and carminatives, as they are called : the relief thus afforded to the dis- 
tended stomach being so sudden, and for the time so complete, that the sufferer 
ascribes to the medicine mm carminis, the power of a charm. One of the most 
effectual and popular of these carminatives is peppermint water. A due regulation 
of the periods for taking food will often suffice to obviate the flatulence that belongs 
to emptiness. That which follows eating may, in many cases, be prevented, by 
swallowing, immediately before the meal, five or six grains of the extract of rhubarb, 
with or without a grain of cayenne pepper. If the ascending wind brings into the 
throat and mouth a portion of the solid contents of the stomach, the patient is said 
to ruminate. The regurgitated matters are often intensely acid ; and then an alkali 
may remedy the flatulence ; a teaspoonful of sal volatile, for example. 

Indigestion is, in many instances, attended with scarcely any pain; while in 
others the pain is very tormenting. Cullen speaks of it under the terms cardialgia ; 
and gastrodynia. Cardialgia is that less violent and more permanent uneasiness 
which in popular language is called heart-burn. Gastrodynia is that more severe, and 
usually more transient pain, which is commonly denominated spasm or cramp of 
the stomach. 

Dr. Abercrombie has some useful practical observations in respect to pain of the 
stomach. He speaks of it as occurring under four different forms, and I am able to 
bear witness to the reality of the distinctions that he has drawn. In the first place, 
some persons suffer pain, occasionally, when the stomach is empty, even when there 
is no flatulence ; and they are comforted and relieved by taking food. It is reason- 
able to suppose that this kind of pain depends upon some degree of acrimony of the 
fluids of the stomach itself. It is often removed at once by alkalies, or absorbent 
medicines. A teaspoonful of the aromatic spirit of ammonia, or a tablespoonful of 
the liquid magnesia, in a wineglass of camphor julep, will still the vs^hole uneasiness 
sometimes in a moment, as if by magic. 

A second form of pain in the stomach is when it occurs immediately after taking 
food, and continues during the whole process of digestion, or until vomiting ensues, 
which gives instant ease. In such cases we have reason to suspect the existence 
of chronic inflammation, or of some undue sensibihty of the mucous membrane of 
the stomach. The suitable remedies are such as I spoke of in the last lecture. I 
might have mentioned a form of medicine which Dr. James Johnson has found espe- 
cially serviceable against this morbid sensibility ; I mean the nitrate of silver, in 
small doses. 

In a third species of painful disorder of the stomach the pain does not begin till 
from two to four hours after a meal, but continues for several hours. This is a very 
common form of complaint. Dr. Abercrombie is of* opinion that the pain is seated 
in the duodenum, and connected with inflammatory action, or with morbid sensitive- 
ness of the mucous fining of that bowel. He says it is frequently accompanied by 
pain and tenderness of the right hypochondrium ; and that the fiver is often blamed 
when it really is not in fault. This last remark I well befieve ; but I am not so 
easily persuaded that the pain is duodenal. I befieve it depends upon acidity in the 
primse vise. It has been ascertained by several chemists, that the acid which is pre- 
sent in the gastric juice is the muriatic. Dr. Prout holds that the source of this 
muriatic acid is the common salt which exists in the blood, and that the decomposi- 
tion of this salt is owing to the immediate agency of some modification of electricity ; 
and he conceives that the principal digestive organs represent a kind of galvanic 
apparatus, of which the mucous membrane of the stomach and intestinal canal may be 
considered as the acid or positive pole, while the hepatic system is the alkaline or 
negative pole. However this may be, it is certain that the muriatic acid contained 
in the stomach is often in excess : other acids are also found there — the acetic, and 
more especially the lactic; and when the food, now converted into chyme, passes 
into the duodenum, the remaining superfluous acid teazes the stomach. I think this 
explanation of the cause of the pain is a more probable one than Dr. Abercrombie's, 
because you may generally mitigate or remove the pain by introducing an alkali into 
the stomach, whereby the acid is neutralized : even the swallowing a cup of 



DYSPEPSIA. 



779 



warm tea, by which the acid is diluted or washed away, often stops the pain. And 
I have in numerous instances succeeded in preventing the recurrence of this pain, 
by directing the patient to take a small quantity of alkah, in some aromatic water, 
immediately after his dinner. According to Dr. Abercrombie's theory, the pain 
ought not to be so immediately allayed by these remedies ; and, since the food is gra- 
dually propelled into the duodenum as it is digested, the pain should begin, I think 
(supposing him right), earlier than it does. Dr. Abercrombie has found nothing of 
more general utility in these cases than the sulphate of iron, combined with one 
grain of aloes, and five grains of aromatic powder, taken three times a day. He 
I praises lime-water, also, and small opiates, and a combination of bismuth and rhu- 
\ barb. What its modus operandi is I know not, but I am sure that bismuth is a very 
j effectual remedy for some kinds of gastric distress. 

I Cases now and then occur in which this pain, succeeding a meal, and the deposit 
of lithates in the urine, would seem to indicate the propriety of an alkaline treatment, 

I but which really are more benefited by the mineral acids. How to distinguish these 
exceptional cases, unless by trial, I have not yet learned. Any detected admixture 

j of phosphates might perhaps furnish the requisite clue. 

1 Pain in the stomach occurs in a fourth form, coming on at uncertain intervals in 
most violent paroxysms, and properly called gastrodynia. It is often accompanied 
■ by a sensation of distension, much anxiety, and extreme restlessness. In females it 
I is frequently combined with hysterical symptoms. This form Dr. Abercrombie 
I supposes to depend upon over distension of the stomach ; and it may be so ; certainly 
I great quantities of air are sometimes extricated ; and the pain is not confined to the 
stomach, but shoots through to the back and between the shoulders. I suspect that 
the pain is sometimes neuralgic. It is often very intractable ; occasionally it yields 
to carminatives. Dr. Abercrombie states that he has observed the most effectual 
relief in such cases to have been obtained from exciting a brisk action of the bowels by 
means of a strong purgative enema. He makes this practical remark, which is 
worth attending to. From the facilities with which such affections often yield to the 
remedy just mentioned, it appears not improbable that the pain may be sometimes 
situated in the arch of the colon. Wherever its seat may be, I know that it is fre- 
quently removed by a mustard poultice laid upon the epigastrium. Opium also is 
of eminent use in many of these cases ; and bismuth ; and cordials : but I have seen 
more rapid and decided rehef afforded by the prussic acid than by anything else ; 
and the cure so wrought is often permanent. It does not bring ease in all cases, nor 
is it a medicine that is any particular favourite of mine, yet its good effect is in some 
instances so striking, that if this were its only virtue I should esteem the hydrocyanic 
acid a most valuable remedy. 

You will meet sometimes with what is called spasm of the stomach (and I sup- 
pose it is such) in gouty people ; who are then said to have gout in the stomach. 
The pain comes on in sudden and severe paroxysms ; and is removable in general 
by laudanum and stimulants, brandy, for example ; or by the mustard poultice. 
On these cases, however, we look with jealousy and apprehension. In some in- 
stances the attack is really inflammatory, and would then be aggravated by a stimu- 
lant treatment. 

There is yet another modification of uneasiness and disorder of the stomach, of 
which the distinguishing characteristic is the vomiting, or rather the eructation of a 
thin watery liquid, sometimes sourish, but usually insipid and tasteless, and often 
described by the patients themselves as being cold. This is what CuUen calls 
pyrosis, the water-brash. It is a disorder much more frequent in the lower ranks 
of society than in others. It is particularly common in Scotland, and is there ascribed 
to the large employment of farinaceous substances as food, and especially of oat-meal. 
But it is said to be still more common in Lapland. Dr. Cullen, who saw a great 
deal of it, says that its paroxysms " usually come on in the morning and forenoon, 
when the stomach is empty. The first symptom of it is a pain at the pit of the 
stomach, v^ith a sense of constriction, as if the stomach was drawn towards the back. 
The pain is increased by raising the body into an erect posture, and therefore the 
body is bended forward. The pain is often very severe ; and after continuing for 



780 



DYSPEPSIA. 



some time, it brings on an eructation of a thin watery fluid in considerable quantity." 
Such is Cullen's description of pyrosis. He states that the complaint often occurs 
without other evidence of dyspepsia ; but this is not consistent with the experience 
of subsequent observers. It is a symptom sometimes of organic disease of the 
stomach. In one remarkable case of pyrosis which I saw, and in which not less 
than three pints of this thin tasteless liquid was brought up every day, the stomach, 
after death, was found to all appearance healthy ; but it had been pressed upon by 
an enormous Hver. I mention these facts that you may not suppose pyrosis to be 
always, as Cullen has described it, a substantive and idiopathic malady. 

When pyrosis is not caused by organic disease in the stomach or in the liver, it 
will yield in general to opium, and especially to opium in combination with astrin 
gents. The pulvis kino compositus of the Pharmacopoeia is an admirable remedy 
for it. But we often have to contend with this difficulty, that the bowels, in cases 
of pyrosis, are generally confined, and that the opium tends to aggravate this unna- 
tural condition; so that it becomes necessary to administer some aperient daily 
while the kino and opium are given : castor oil, or confection of senna, or cathartic 
extract. 

Costiveness is, in fact, a very frequent concomitant of dyspepsia, as Cullen's defi- 
nition affirms (plerumque cum alvo adstricta). And this sluggish state of the bowels 
often aggravates, if it does not produce, the dyspepsia. At any rate the defective 
powers and uneasy sensations of the stomach are rectified, in many instances, by 
measures which promote the regular and healthy evacuation of the intestines. 
Without professing to go into detail in this matter, I may state that, in our remedial 
attempts, we should imitate, as much as we can, the processes of nature. The 
mixed contents of tjae small intestines furnish the natural stimulus of their peristalic 
movements ; and the excrement excites the larger bowels. When this natural stimu- 
lus is insufficient, the want may be supplied by some substance which is involved in 
the food, and accompanies it in its progress — as the bran of brown bread, already 
mentioned, or a few grains of rhubarb or of aloes swallowed immediately before 
dinner. In adjusting the proper quantity of the drug the patient must assist the 
physician. It should be just so much as suffices to effect what nature neglects to 
do, and no more. With some persons an aperient pill acts more comfortably and 
opportunely if taken at bed-time. Sometimes diarrhcea is associated with indigestion. 
This is usualty connected with an excess of acid in the primse vise. The principle 
of treatment in such cases is obvious. 

There are innumerable sympathies of distant parts with a dyspeptic stomach, m 
respect to which I can do little more than barely enumerate a few. Thus indigestion 
is often accompanied by pain in the head, with some confusion of thought : or at all 
events, with a loss of mental energy and alertness. Together with a violent headache 
there are frequently nausea and vomiting ; and the complaint is popularly known by 
the name of the sick-headache : or, in the fashionable jargon of the day, as a bilious 
headache. I must refer you to a paper of Dr. Fothergill's, in the sixth volume of 
the Medical Observations and Inquiries, for a very good account of this troublesome 
complication. 

I shall hereafter have a good deal to say respecting certain morbid conditions 
of the urine, which take their rise sometimes from faulty digestion in the stomach, 
sometimes from faulty assimilation of the digested aliment in the more advanced 
stages of the process of nutrition. These conditions of the urine, indicating grave 
derangements of the whole system, furnish the characters and the names of several 
distinct maladies. 

I told you, in a former lecture, that certain affections of the viscera of the thorax 
are hable to be produced by mere indigestion. Palpitations of the heart, irregulari- 
ties of the pulse, fits of asthma, are no uncommon accompaniments of a disordered 
stomach. This is partly to be ascribed to that reflex sympathy between the parts 
concerned, which L have so frequently mentioned ; partly to the effect of flatulence, 
which, by resisting the descent of the diaphragm, impedes the free working of the 
lungs and of the heart. I told you, at the same time, that these symptoms torment 
many persons with the belief that they spring from organic disease. This notion is 



DYSPEPSIA. 



781 



particularly apt to infest the minds of medical students. I suppose most teachers in 
our profession partake of that sort of experience which Dr. James Gregory, of Edin- 
burgh, used to speak of in his lectures. He said that scarcely a winter passed over 
in which several of his pupils did not apply to him on account of palpitations sup- 
posed by them to depend upon structural disease of the heart: and in no single in- 
stance were their apprehensions well founded. They were all cases of mere dys- 
pepsia and hypochondriasis. 

Dyspepsia is often connected with phthisis, with leucorrhcea, with amenorrhosa 
and chlorosis : and some persons imagine that these diseases are caused by the 
dyspepsia. Indigestion may lead indirectly to the development of consumption, by 
producing debihty ; but the truer view of the matter seems to be that the dyspepsia 
is a consequence, rather than an exciting cause, of these complaints. When, for 
instance, leucorrhcea is cured by topical astringents, as it often may be, the indiges- 
tion frequently is cured too. 

One of the worst occasional concomitants of dyspepsia is that peculiar state of the 
mind to which I just now alluded under the term hypochondriasis. This is, in truth, 
a species of insanity : but it is so often connected with disorder of the digestive 
organs, that Cullen, whose descriptions of disease are admirably clear and true, 
however faulty many of his theories may be, defines hypochondriasis to be ^^Dys- 
pepsia — cum languore, msestitia, et rnetu, ex causis non eequis." In the following 
short paragraph he completes the picture. " In certain persons there is a state of 
mind distinguished by the concurrence of the following circumstances. A languor, 
listlessness, or want of resolution and activity with respect to all undertakings : a 
disposition to seriousness, sadness, and timidity : as to all future events, an appre- 
hension of the worst or most unhappy state of them ; and therefore, often upon 
slight grounds, an. apprehension of great evil. Such persons are particularly atten- 
tive to the state of their own health, to every the smallest change of feeHng in their 
bodies : and from any unusual feeling perhaps of the shghtest kind, they apprehend 
great danger, and even death itself. In respect to all these feelings and apprehen- 
sions, there is commonly the most obstinate belief and persuasion." 

Now when the attention of the hypochondriac is thus morbidly fixed upon the 
states and sensations of his digestive organs (as it is very apt to be) the patient be- 
comes a plague to his physicians as well as to himself. 

There are a few simple rules which ought always to be kept in mind in our treat- 
ment of dyspepsia ; although we can seldom enforce them, as they ought to be en- 
forced, upon our patients. What patients want, in general, is some medicine that 
will relieve them from their discomfort and uneasy feelings, and allow them, at the 
same time, to go on in the indulgence of those habits which have generated the dis- 
comfort. And such remedies have not yet been discovered. 

One great and indispensable principle in the treatment of indigestion, is that of 
restricting the quantity of food taken at any one time. The gastric juice is probably 
secreted in a tolerably uniform quantity. The muscular contractions of the stomach 
must needs be impaired or impeded by much distension of that organ. For both 
these reasons the amount of food introduced into the stomach should be kept within 
the limits of its capacity and powers. The great good which the late Mr. Abernethy 
unquestionably did to a host of dyspeptic patients, was owing much more, I am per- 
suaded, to the rules of diet, and the restrictions as to quantity, which he laid down, 
than to his eternal blue pill. 

Again, as Dr. Abercrombie has well remarked, and as Dr. Beaumont actually saw, 
various articles of food are soluble in the stomach with various degrees of readiness. 
Therefore, when the digestion is hable to be easily impaired, it is of great import- 
ance, not only to refrain from those substances which are known to be soluble with 
difficulty, but also to avoid mixing together in the stomach different substances which 
are of different degrees of solubility. Hence there are two reasons why it is salutary 
to dine off one dish. 1st. Because we avoid the injurious admixture just adverted 
to ; and, 2dly, because we escape that appetite, and desire to eat too large a quantity t 
which is provoked by new and various flavours. 

3(i 



782 



DYSPEPSIA. 



And another very important principle, greatly insisted on by Mr. Abernetliy, is, 
that the stomach should have time to perform one task before another is imposed 
upon it. He always made his patients (at least he always strongly exhorted them) 
to interpose not less than six hours between one meal and another. Allowing from 
three to five hours for the digestion of a meal, and one hour over for the stomach to 
rest in, Mr. Abernethy's rule seems as much founded in reason as it is justified by 
experience. But we preach in vain on these topics. Mr. Abernethy was in the 
habit of saying that no person could be persuaded to pay due attention to his digestive 
organs, till death, or the dread of death, was staring him in the face. I have now 
in my mind a family consisting of a mother and three grown-up daughters, who are 
continually ailing and valetudinary. They profess to have great respect for my pro- 
fessional advice : yet I never can induce them to think that their plan of eating is a 
bad orje. They are not early risers. The}^ get to breakfast about half after ten or 
eleven. At tvv^o they think it absolutely necessary to eat luncheon, which consists 
of a mutton chop or some hashed meat, with vegetables. At six they dine : and at 
eight they drink tea : and then they eat no more till the next breakfast. And this 
is just a picture of the habits of scores of famihes. They huddle all their food into 
the stomach, at four periods, within seven or eight hours ; and leave it idle for six- 
teen or seventeen. 

Dyspeptic patients are very importunate to know ivhat they may eat, and (more 
so still) what they may drink. It is of course impossible to lay down any general 
rules which will suit every case. The stomach has its idiosyncrasies. I remember 
seeing a publication some years ago, one section of which had this starthng title, — 
" Cases of poisoning by a Mutton Chop." Dr. Prout knew a person who could not 
eat mutton in any form. He was thought to be whimsical, and mutton was frequently 
served up to him under some other guise, without his knowing it ; but it invariably 
caused violent vomiting and diarrhoea. Yet, for the average of stomachs, mutton is 
probably the most digestible of all meats. And for the average of stomachs some 
useful general directions may doubtless be given. 

In fevers and inflammatory disorders, experience has taught us to forbid or limit 
the use of flesh meat on account of its stimulating qualities. And when the stomach 
itself is affected with chronic inflammation, or with morbid sensibihty, a diet restricted 
to farinaceous substances, and milk, is sometimes attended with the happiest conse- 
quences. I suspect that a false analogy has led some into the mistake of supposing 
that animal food ought to be refrained from, or taken in a scanty proportion, in merely 
dyspeptic complaints. Animal food is easier of digestion, in the human stomach, 
than vegetable food. It is nearer, in its composition, to the textures into which it is 
to be incorporated by assimilation. There is less of " conversion" requisite. Indeed 
we may look upon the appropriation of vegetable matter, by granivorous and grami- 
nivorous animals, as one stage of the process by which such vegetable matter is 
prepared for the sustenance of carnivorous animals : even as one great end of vege- 
table life seems to be that of generating or concocting matter for the nutrition of the 
former class, out of inorganic materials, not fitted for that purpose. A more elaborate 
digesting apparatus is provided for the vegetable eaters. Man, indeed, is omnivorous. 
But his organs of digestion are more hke those of the carnivorous than of the grani- 
vorous races. And it is notorious that vegetable food, when the stomach is w^ak, is 
followed by more flatulence, that is, is digested with more tardiness and difficulty, 
than animal food. Nevertheless, a mixture of the two, of well roasted or boiled flesh 
or fowl, with a mioderate portion of thoroughly cooked vegetables, is better suited, 
in my opinion, for a feeble stomach, than a rigid adhesion to either kind of aliment 
singly. Each of the four great classes of ahmentary principles specified by Dr. 
Prout should be represented ; the aqueous, the saccharine, the albuminous, and the 
oleaginous. All meats that have been hardened by culinary art, or b}^ condiments, 
should be avoided by him, who, as the vulgar express it, has "a bad digester;" all 
cured meats I mean—ham, tongue, sausages, and so forth. Mutton is thought to be 
more readily digestible than beef. Pork, its lean part at least, is much less so than 
either. All raw vegetables also must be eschewed ; salads, cucumbers, pickles. 
But if we press our prohibitions much more strictly than this, w^e incur the risk of 



/ 



DYSPEPSIA. 



783 



fixing the patient's attention too curiously upon his diet, and upon the sensations of 
his stomach ; and of rendering him hypochondriacally alive to the miserable subject 
of his feeding. 

Again, you will be continually asked whether you recommend malt hquor or 
wine, wine or brandy and water, white wine or port, sherry or madeira. Now it 
w^ould be very easy to propound some positive rules in this matter, but it would not 
be so easy to vindicate them. Some allowance must be made, no doubt, for custom. 
I beheve, however, that most dyspeptic persons would be better without any of these 
drinks. But it is very difficult to persuade them that the habitual use of strong 
liquors in small quantities can have any injurious effects. "It is not easy (says 
Cullen) to engage men to break in upon estabhshed habits, or to renounce the pur- 
suits of pleasure ; and particularly to persuade men that those practices are truly 
hurtful, which they have often practised with seeming impunity." They are too 
ready to believe that it is unsafe to abandon their accustomed indulgence. A friend 
of mine, who visited, some years since, many of the American prisons, tells me that 
the health of even the most inveterate spirit-drinkers improves, instead of suffering, 
upon the sudden and total abstinence from spirits, which the regulations of those 
prisons enforce. There certainly are cases in which the digestion seems to be helped 
by a moderate quantity of wine, or beer, or spirits ; yet no one can say before-hand 
— at least I cannot — which of them is to be preferred. Upon these points patients 
should interrogate their own sensations and experience, instead of seeking the oracu- 
lar counsel of a physician. Drinks which are followed by evident disturbance and 
discomfort are manifestly unfit. And even when a favourable effect, for the time, 
appears to be produced, there is always a risk of ultimate detriment to the powers of 
the stomach from this habitual excitement. 

There are states of mind and habits of hfe, which, having no direct relation to the 
organs of digestion, yet exercise a material influence over their functions. Mental 
distress; mental sohcitude ; mental toil ; over-much study ; want of exercise : these 
are all prohfic sources of dyspepsia. Sedentary habits, when their injurious effects 
are known, may be altered : excessive intellectual labour may be abandoned : but it 
is seldom that we can minister to a wounded or an anxious spirit. Our task is 
hardest of all when the patient's anxiety relates to his own complaints; when he is' 
morbidly engrossed by his bodily feelings, and despondent about its recovery. The 
management of the mind of a hypochondriac is peculiarly nice and difficult. It will 
not do to treat him as if his ailments were imaginary. He disbeUeves you, contemns 
your judgment, and deserts you: to be fleeced perhaps by some villanous quack. 
You. must hear what he has to say ; show an interest in his case ; and prescribe for 
him : assuring him that you understand his malady, that it is curable, and that he 
will be cured provided he follows your directions. If you can succeed in gaining 
his confidence, and in persuading him of this, the battle is half won. To tell such a 
person, however, not to think of his grievances would be worse than useless. The 
very effort to drive a* subject from our thoughts fixes it there more surely. But you 
j must endeavour to turn his attention to other things ; and to awaken in him some 
new interest. Prescribe change: change of air; change of place and of scenery; 
change of society. Get him to travel in search of health ; and the chances are in 
favour of his finding it. A tour, in fine weather, and through a pleasant country, 
combines almost all the ingredients which are, seperately even, desirable : the with- 
j drawal of the mind from its ordinary pursuits and cares ; the diversion of the atten- 
! tion from one's self, by new and varied objects ; exercise carried on in the open air ; 
i a holiday from intellectual toil. Six weeks among the mountains of Switzerland, or 
j upon the rivers of Germany, will often do more towards restoring a dyspeptic hypo- 
1 chondriac than a twelvemonth's regimen and physicking at home, 
j With these disjointed hints, gentlemen, I must request j'-ou to be satified in respect 
j to the principles upon which dyspepsia — and the hypochondriasis, which is in gene- 
I ral so closely hnked with dyspepsia — are to be managed. A full discussion of these 
j subjects in detail would furnish matter for several lectures. 



! 

! 



784 



ENTERITIS. 



LECTURE LXXI. 

Enteritis : its symptoms ; causes ; treatment. Mechanical occlusion of the Intes 
tinal Tube. Colic. Colica Pictonum : its symptoms, complications, treatment, 
and preventiori. 

Some of the diseased states of the intestinal canal, while they differ a good deal in 
their essential nature, have yet many characters in common. Colic ; ileus ; enteritis ; 
mechanical obstruction of the tube. It will be convenient, therefore, to consider these 
disorders in succession, and, in some degree, in connection with each other. 

In colic we have pain of the abdomen ; pain of a twisting or wringing kind, occu- 
pying generally the umbilical region ; vomiting ; and costive bowels. Similar pains 
are apt to occur in diarrhoea; but they are transitory, and are then termed gripings, 
or more learnedly, tormina. When they are violent, and more permanent, and 
above all, when attended with, constipation, they constitute cohc. 

You have not forgotten the symptoms of peritonitis. They are, briefly, pain in 
the abdomen, increased on pressure ; and fever. 

Now, if to the symptoms of colic, you add the symptoms of peritonitis, you have 
the symptoms of enteritis : by which word I desire to express the disease that is 
commonly called iiijtummation of the bowels. The term has lately been extended 
so as to signify any and every form of inflammation which any portion or tissue of 
the intestinal canal within the belly may suffer ; but I use it in the old-fashioned 
meaning. Cullen makes two species of enteritis. One of these consists in inflam- 
mation of the mucous membrane of the intestinal tube : he calls it enteritis erythe- 
matica. That is not the disorder I am about to speak of; but the other of his spe- 
cies, the enteritis phlegmonodea. I say that in cohc, we have abdominal pain, 
constipation, and vomiting. In peritonitis, the functions of the stomach and intestines 
are not, necessarily, affected : in enteritis they are. There is inflammation, not 
merely of the peritoneal coat, but of the areolar tissue uniting the several tunics, 
probably of the muscular tissue also, and often of the whole substance of the bowel 
at the inflamed part. 

When the intestinal channel is any how closed up, and a bar placed to the pass- 
age of its contents, the symptoms of cohc are very apt to ensue ; and at length, the 
obstacle continuing, fatal inflammation is set up. 

The term ileus is applied, I believe, to those cases, whether inflammatory or not, 
in which, by an inverted action of the intestines, their contents are carried, in a 
retrograde course, into the stomach, and thence out of the body by vomiting. 

Having made these explanations, I shall now address myself more especially to 
the consideration of enteritis. 

It is of much practical importance to discriminate between enteritis and the dis- 
orders that resemble it ; and particularly to distinguish it from colic. When it com- 
mences, as it sometimes does, with distinct rigors, and is attended by thirst, a hot skin, 
and a hard and frequent pulse, there is no room for doubt. But it often begins in- 
sidiously, with mere colicky symptoms ; the pain, at first, is not much augmented, 
it may even be somewhat eased, by steady pressure. If we mistake colic for enteritis, 
the error is of no great moment ; but the opposite mistake, which is more common, 
may be fatal. Blood-letting, and the other remedies of enteritis, will not aggra- 
vate the mere cohc ; they may even, though unnecessary, reheve the patient. — 
Some of the remedies of mere cohc are, however, highly dangerous when there is 
inflammation of the bowel. Physicians may faU into this error : patients who choose 
to prescribe for themselves, commonly do so. They take stimulants, cordials, car- 
minatives — the pleasantest and nearest at hand is a glass of brandy, or of gin. And 
in true colic these means are frequently of great service ; but they exasperate the 
symptoms, and increase the mischief when the disease is enteritis. Indeed, treat- 
ment of this kind will sometimes urge colic into enteritis. If the case be ambiguous, 



ENTERITIS. 



785 



you must act upon the most unfavourable supposition, and treat the complaint as if 
you were sure that inflammation was present. 

The pain of enteritis is increased by pressure. The pain of colic is not only not 
made worse, but it is actually mitigated often, by pressure ; and it usually intermits 
entirely. I know that when there is simply flatulent distension of the intestines, 
pressure does sometimes increase the patient's uneasiness ; but the uneasy sensation 
is very different from that acute sensibility which belongs to inflammation of their 
peritoneal covering. In enteritis there are also paroxysms of severe pain, determined, 
probably, by the peristaltic movements, or by the temporary distension of the inflamed 
parts of the bowel ; and the pain has frequently a twisting character : but there is 
not any thorough intermission. There is a duller abiding pain between the sharper 
fits. It is to be observed also, as a diagnostic circumstance, that, as in peritonitis, the 
patient lies on his back, with his knees drawn up, and is fixed in that position, and 
for the very same reasons. If, in his agony, he tosses about his arms, the trunk is 
kept motionless, and the respiration is thoracic : whereas in mere colic the mode of 
breathing is not altered, and the patient is apt to be turning and writhing in all pos- 
tures, and out of one posture into another. 

The nausea and vomiting are often most distressing. The patient not only rejects 
immediately whatever food, drink, or medicine he swallows, but he has fits of retch- 
ing when the stomach is empty. In some instances, matters are cast up having the 
appearance, and something of the odour, of liquid feces : or resembling, at any rate, 
the offensive fluids which are found in the small intestines after death in these cases. 
I cannot say that I have ever seen genuine excrement ejected, unequivocal ordure : 
5'-et this may well happen if it be true that clysters, introduced into the rectum, have 
been voided through the mouth. Such a phenomenon would show that the whole 
tube was pervious; that there was no mechanical obstruction. 

Although the fever, in the outset, may be high, and the pulse strong and hard, it 
soon becomes (as in ail acute abdominal inflammations) small and wiry ; or weak, 
and like a thread. In bad cases, as the disease proceeds, the abdomen begins to 
swell, becomes tympanitic ; hiccup sometimes comes on ; the pulse intermits or beats 
irregularly ; the extremities grow cold ; the features are sharpened and ghastly ; 
cold sweats break out; the pain ceases perhaps; and the sphincters relax. The 
head is generally unaffected. Now and then dehrium occurs late in the disease ; 
but much more frequently the intellect remains clear to the very last. Death begins 
at the heart, and takes place in the way of asthenia. 

You may probably have observed that the symptoms which I have been describ- 
ing are just the symptoms which the surgeon so frequently encounters in cases of 
strangulated hernia. The symptoms of that surgical complaint are, in truth, most 
commonly at least, the symptoms of enteritis, caused by the forcible closure of the 
bowel. Obstruction to the passage of the contents of the gut gives rise to its inflam- 
mation. And we often find, after death preceded by the signs of enteritis, an internal 
mechanical obstruction — an internal strangulated hernia. In some cases bands or 
strings of coagulable lymph, the products of bygone inflammation, have formed 
snares (so to speak) for the gut, which at length they catch and constrict. They do 
no harm till some coil of intestine gets beneath or beyond them ; and then they 
strangle it, as the phrase is. I have twice seen (as I think I formerly stated) the 
appendix vermiformis prove the immediate cause of fatal internal hernia. In one of 
these cases, the person had been a private patient of Dr. Macmichael ; and I went 
! with him to examine the body. The free end of the appendix had become adherent 
I to the mesocolon ; and so a loop was made, through which a portion of the gut had 
I passed. In the other instance, which I saw in Edinburgh, the appendix was lite- 
I rally tied round a piece of the intestine. Sometimes, again, there is intussusception : 
j the upper part of the tube slips into the lower, fills it up; obstructs it; and inflam- 
I mation fixes it there. Or it may be that a chronic thickening of the coats of the in- 
I lestine has narrowed its channel ; or a tumour presses upon the intestine from with- 
I out ; or some foreign substance, or morbid accumulation, plugs it up within ; in all 
which cases a chronic disorder passes at length into acute inflammation. A very 
small hernia at one of the usual orifices — not large enough to manifest itself exter- 
50 3(i3 



I 



786 



ENTERITIS. 



nally — is sometimes the cause of the obstruction ; even though only a portion of one 
side of the gut may be nipped in the aperture. 

Sometimes, but according to my experience less frequently, there is no mechanical 
impediment to account for the constipation. In all cases, whether there be mechanical 
obstruction or not, the inflamed portion of the gut is of a red or dark colour ; distended 
by its gaseous or liquid contents ; covered often, on its peritoneal surface, with co- 
agulable lymph ; or adherent to the contiguous organs. When the gut is mechani- 
cally closed, the part which lies on this side the obstacle, as we follow the natural 
course of the channel, is inflamed ; the part which lies beyond it is pale, contracted, 
and to all appearance, healthy. The line of demarcation is abrupt and strong ; and 
it is determined by the obstacle. And the distinction between the healthy and in- 
flamed portions is usually as sudden and decided, when there is no apparent obstacle. 
I mean that up to a certain spot the intestine is red like a cherry, or dark like a grape, 
large, and smeared (perhaps) with lymph or with pus ; while immediately beyond 
that point, and throughout the remainder of its course, it is white, empty, and shrunk 
up into the semblance of a cord. The pathology of these last forms of the disesise 
is full of difficulty. Some have held that the contracted part was the original seat 
of disease, namely, of spasm ; and that the upper adjoining portion of intestine be- 
came distended and inflamed in consequence of such spasm. "Without attempting 
to explain these phenomena, which are comparatively unfrequent, I content myself 
with observing that it is the distended part which is the really inflamed part, and 
that its muscular coat appears to have lost its natural contractile power — not (I fanc}^^) 
from over-stretching, as now and then happens to the urinary bladder — but from the 
effect of the inflammation. 

The inflamed portion of bowel is often of a very dark*colour, and even almost 
black, from the great congestion of blood in its tissues. Now this black colour has 
sometimes been erroneously set down as an evidence of gangrene. You must not 
trust to the mere colour, however. If the coats of the bowel be firm, and if the pe- 
culiar odour of gangrene be wanting, you are not to conclude that mortification has 
taken place, simply from the dark appearance of the intestine. 

Enteritis, not dependent upon any mechanical occlusion of the bowel, may arise 
under the operation of the ordinary causes of internal inflammation : cold and wet, 
for instance, applied externally, and especially to the feet and legs. Cold is thought 
to be particularly injurious in this way when the exposure happens soon after a 
meal: probably because at that time the digestive organs, being in activity, receive 
a more copious suppl}'- of blood. 

The mechanical impediments that occur within the bowel, are still more various 
in kind than those which constrict it from without. Hardened fecal matters: intestinal 
concretions. Some of these are curious, and I shall hereafter have a word or two 
to say respecting their composition. Persons who are in the habit of taking a good 
deal of magnesia, or of chalk, to reHeve acidity and heartburn, are liable to have 
these substances accumulate, and become indurated in the intestines. They generally 
begin to collect, I believe, around some accidental nucleus : and such a nucleus may 
very readily be supphed. A cherry-stone, a fish-bone, a gall-stone that has found 
its v\^ay into the bowel. Even a pill, prescribed to cure, may thus come to kill one's 
patient. Dr. Prout was asked to analyze certain odd-shaped, triangular bodies w^hich 
had been voided at stool, and were supposed to be gall-stones : but he found that 
they were specimens of Plummer's pill, which had defied the solvent action of the 
gastric juice, and had passed into, and hngered in, the bowels. Unbruised mustard- 
seed, and carbonate of iron, are other remedial substances which, injudiciously ad- 
ministered, have collected in hard masses, and caused intestinal disease. It is seldom 
that we can discover, during life, what is the exact nature of the mechanical obstacle: 
but I have observed this peculiarity in most of the cases in which I have known it 
produced by intussusception^ that after severe and sudden symptoms of obstruction 
and inflammation, blood has been passed by stool. Sometimes the included portion 
of bowel itself sloughs away, and is expelled per anum. 

Inflammation of the bowels requires ve.ry much the same kind of treatment as 
peritonitis : indeed, the disease is in most cases peritonitis and something more. The 



ENTERITIS. 



787 



patient must strictly abstain from every sort of stimulus, and confine himself as much 
as possible to the horizontal position. He must lose blood also from the arm, and 
the earlier the better. The lancet is not to be withheld merely because the pulse 
is small. If the artery becomes fuller, and its beating more distinct, under venesec- 
tion — nay, if the patient does not become faint — the hrst bleeding should be a large 
one. This is not only the safer plan, but in the long run it is the most economical 
of the blood and strength of the patient. As in simple peritonitis, the abdomen must 
be covered with leeches, and afterwards with fomentation cloths. Should one spot 
or region be more painful and tender than another, on that part the leeches are to be 
accumulated. It may be requisite to repeat the venesection and the leeching once, 
or twice, or many times ; the propriety of such repetition depending upon the 
urgency and obstinacy of the symptoms, and upon the age and state of the patient. 
I am speaking of idiopathic enteritis, and of its earlier stages. In the advanced 
periods, when feebleness of the pulse is associated with tympany of the belJy and 
coldness of the surface, it betokens weakness and sinking, and the tendency to death 
by asthenia; and, consequently, it then indicates support rather than depletion. So 
also when the enteritis is not idiopathic, but consecutive — when we have reason to 
believe that it arises out of a firm mechanical impediment — our employment of blood- 
letting must needs be modified by that circumstance. 

One point in the management of enteritis, requiring great caution and judgment, 
relates to the exhibition of purgative medicines. The costive state of the bowels is 
apt to be looked upon as the main evil, and their evacuation as the chief indication 
of treatment ; but great mischief, I apprehend, is likely to arise from the exclusive 
pursuit of that indication. I am still speaking of the idiopathic disease, where it is 
presumable that no mechanical obstacle exists to render the passage of the feces im- 
possible. Purgatives given by the mouth are often rejected by the stomach, with 
great distress to the patient. If they are retained, and fail to operate, they must do 
more harm than good. Certainly they should not precede the venesection. I well 
remember, though it is now many years ago, being myself badly treated for enteritis. 
Being ill, in a strange place, I sent for the nearest practitioner, who happened to be 
a very ignorant man. Finding that I was sick, and that my bowels did not act, he 
gave me, for two or three days in succession, strong drastic purges, with no other 
effect than that of increasing my sickness, and adding to the abdominal pain I suf- 
fered. I was then seen by a most intelligent physician (this was before I had paid 
any attention to physic myself), and the first thing he did was to have me copiously 
bled ; and the immediate effect of that bleeding was to send me to the night-chair. 
And I am persuaded that when evacuatioiTs follow the administration of purgatives in 
such cases, they are often owing to the blood-letting and other antiphlogistic measures 
that are employed at the same time. These are the opinions of Dr. Abercrombie 
also, who says, " I confess my own impression distinctly to be, that the use of pur- 
gatives makes no part of the treatment of the early stages of enteritis ; on the con- 
trary, that they are rather likely to be hurtful until the infla'mmation has been sub- 
dued." It is an instructive fact, that when, purgative medicines do operate during 
the height of the inflammation, the stools they produce are merely watery ; and it is 
only after the inflammation has been reduced that fe.ces are discharged, and then in 
such quantity sometimes as to show that they must have been shut up in the bowels 
during the period of active inflammation. 

You should wait, then, for the effect of other measures, blood-letting, leeching, 
fomentation, before you give active purgatives by the mouth ; and in ah stages of the 
disease, whatever laxatives are given should be of the mildest kind, such as are least 
likely to excite irritation of either the stomach or bowels. 

The same objections do not apply to enemata, which soothe while they evacuate 
the lower parts of the canal. You will read or hear of great service done by an 
infusion of tobacco, or by the smoke of tobacco, thrown into the bowels through the 
rectum. Dr. Abercrombie speaks of a weak infusion of the leaves as being a remedy 
of very general utility. It should, I apprehend, be a weak infusion to be at all safe; 
but, of my own knowledge, I can teU you little or nothing about it. I do know, 
however, that the injection of a large quantity of merely warm water is often of much 



788 MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 



use : from two to six pints, for example, thrown up gradually and gently. Indurated 
feces are softened and brought away in this manner, and the warm water acts as an 
internal fomentation. 

Of internal medicines I beheve the best 3^ou can give is a combination of calomel 
and opium, in such proportions as will restrain the purgative qualities of the calomel. 
The opium allays pain, and, perhaps, relaxes spasm ; mercury tends to arrest the 
inflammatory action ; and the more immediate effects of this combination are often 
found to be, a settling of the irritable stomach, a disposition to diaphoresis, and an 
improved pulse. 

To sum up, then, bleeding, and calomel and opium are to be resorted to for 
checking the inflammation : and when that is in great measure abated (and probably 
not before), it will be right to give some mild laxative to clear out the bowels. 
There can be none more suitable or convenient than castor oil. But before we ven- 
ture upon purgatives by the mouth it will be proper to wash out the bowels by 
lavements of tepid water. These injections may sometimes have mechanically a 
beneficial effect upon the parts concerned in the inflammation ; untwisting, for ex- 
ample, a twisted bowel ; or setting free the half-incarcerated intestine, it is often 
expedient to administer them through a long tube passed as far as possible into the 
rectum. 

There is one very important point in the treatment of enteritis that I have yet to 
mention. I have told you that in the advanced stage of the disease symptoms of 
sinking often come on ; a total cessation of pain, failure of the vital powers, and 
coldness of the body. These symptoms, this collapse and approach to syncope, are 
generally considered to denote grangrene, and, therefore, a hopeless state of disease. 
Yet in many cases which have proved fatal after similar symptoms, not a trace of 
gangrene has been discoverable. So that this unpromising change in the symptoms 
does not always indicate a morbid condition which is necessarily mortal. And if the 
patients are to be saved at all, ihey are to be saved by wine and support. We must 
combat the obvious tendency to death by asthenia. 

" A man, aged forty, was affected with enteritis in the usual form, for which he 
was treated in the most judicious manner by a respectable practitioner. On the fifth 
day the pain ceased: the pulse was 140, and extre me Ijr feeble and irregular; his 
face was pale, the features were collapsed, and his whole body was covered with 
cold perspiration ; his bowels had been moved. In this condition (says Dr. Aber- 
crombie, from whom I quote the case) I saw him for the first time. Wine was then 
given him, at first in large quantities, and upon the whole, to the extent of from two 
to three bottles during the next twenty-four hours. On the following day his ap- 
pearance was improved; his pulse 120, and regular; the wine was continued in 
diminished quantity. On the third day his pulse was 1 12, and of good strength, and 
in a few days more he was well." 

Dr. Abercrombie relates other cases to the same effect ; and most physicians, I 
suppose, have occasionally seen such. They teach us that we must not abandon our 
patients in despair, even under the most adverse circumstances. If diarrhosa should 
supervene with this state of collapse, opiates must be joined with the wine. External 
warmth is also a powerful auxiliary. 

I know of no cases of disease more painful to witness or to treat than those which 
result from invincible obstruction of the intestinal tube. They are usually attended, 
at length, with enteritis ; but they differ much in some respects from what I have 
called idiopathic enteritis. The inflammation is an accident or consequence of the 
obstruction ; or of the means used to overcome it. They happen usually somewhat 
in this manner. A person thinks it expedient to take some aperient medicine. It 
has no effect. He repeats the dose. It causes pain and gripings, and probably sick- 
ness also ; but still the bowels are not moved. Eneraata are employed. They 
bring away, perhaps, some hardened feces, but there is no further relief. Mean- 
while the patient may have a clean tongue, a quiet pulse, a cool and soft skin, and a 
supple and painless abdomen. Purgatives of a more drastic kind are tried, but tried 
in vain ; and the physician is summoned. 



MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 789 



Now the first thing which you have to do, when called to a case of " obstruction 
of the bowels," is to search narrowly whether there be not some unsuspected exter- 
nal hernia. All delicacy must be waived ; and every part of the body, where hernia 
may possibly show itself, must be submitted to inspection. If none be found, the 
rectum, and in women the vagina, must be severally explored. Stricture, or a 
quarry of impacted feces, may possibly be detected in the one : a uterine or other 
tumour, pressing upon the bowel, may perchance be felt through the other. I shall 
never forget the shock I once experienced on being sent for to see a woman, of mid- 
dle age, who was in articulo mortis, and who, as I was told, had for some days been 
labouring under sickness, pain in the abdomen, and constipation. In her left groin 
there was a large palpable strangulated hernia, which had not been detected by the 
practitioner in attendance, simply because it had not been looked for ; and which was 
discovered only when it was too late. 

Remember, therefore, that in every case of obstinate costiveness, with signs of 
inflammation within the abdomen, it is absolutely necessary, for your own credit and 
subsequent comfort, as well as for your patient's safety, to make dihgent and thorough 
inquiry after such hernia as may be recognized externally. 

But often you find nothing of the sort, and then you are at liberty to prosecute 
with more energy and decision the purgative plan of treatment. You prescribe 
strong doses of jalap and calomel; black draughts. The stomach being irritable, 
you give pills of cathartic extract, and repeat them at short intervals ; or large doses 
of calomel, ten grains or a scruple, three or four times in succession. You inject 
stimulating clysters. Then you are driven to croton oil : and at last, in some vague 
hope of relaxing spasm, to opiates. If symptoms of inflammation spring up, you 
put fairly in force the remedies of inflammation; and especially blood-letting. But 
all is in vain. The medicines are vomited ; or, if retained, they serve but to aug- 
ment the patient's distress, producing or renewing the pain and the nausea. It is 
extraordinary how comfortable the patient sometimes becomes upon the intermission 
of these active attempts. Now and then he suffers tormina, or has fits of retching; 
but in the intervening periods his sensations and outward condition may be those of 
perfect heakh ; only there is no alvine discharge. 

Now, under these afflicting circumstances, the question will force itself upon you 
— how long am I to pursue the purgative system? Common sense, and common 
humanity, answer — you must stop it the instant you are convinced that there is a 
mechanical obstacle, which cannot be overcome. To persist in the use of drastic 
purgatives after that conviction, is to inflict wanton and needless torture upon the 
patient. But how are you to know this ? That is one difficulty. And how are 
you, beheving that it is so, to satisfy the patient's friends that his disorder is irreme- 
diable ; and to resist their importunity to try this and that : how persuade them to 
look passively on, while their relative is slowly perhaps, but surely, perishing? 
These are great and terrible difficulties. 

You will be urged by all imaginable suggestions : even the most absurd. Crude 
mercury may perhaps be one. Pounds of this metal have been swallowed in such 
cases ; in the hope, I suppose, that it would force a passage by its vi'eight. But the 
obstacle may be in an ascending coil of intestine. And if not, experience does not 
teach us to put any faith in this rude mechanical remedy. It has often done mis- 
chief, and seldom or never done any good. The metal is apt to become oxidized in 
the body, and then to produce very distressing salivation. This is an evil which I 
have known to occur, and to trouble the patient greatly, some time after the ineffect- 
ual exhibition of large doses of calomel. 

Dashing cold water over the abdomen, and the lower extremities, is another rouo^h 
expedient, which is sometimes successful in producing evacuations. It was adopted, 
after various other measures had failed, in the case in which the bowel was tied 
down by the adherent appendix vermiformis ; and it caused the emptying of that part 
of the canal which lay beyond or below the internal hernia. It is plain that this 
partial success can be of little or no use ; certainly of none that can compensate for 
the shock and annoyance of the cold aff'usion. 

Let me not, however, be misunderstood. I do not say that you are to abandon all 



790 MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 



hope when purgatives (and, if need be, blood-letting) have failed, after a few trials, 
to obtain evacuations from the bowels. Nor even that you are necessarily, for that 
reason, to give up the use of purgatives. The intestines may be torpid and insen- 
sible to ordinary stimuli, and really require strong rousing. Dr. Abercrombie men- 
tions the case of a gentleman whose bowels were locked up by an accumulation, as 
the result showed, of black hardened feces. The obstruction, which had resisted 
the m.ost active purgatives, and was accompanied by an evident and painful disten- 
sion of a part of the abdomen, yielded at once to the repeated application of galva- 
nism to that part : each application being immediately followed by a copious evacua- 
tion. Here the flagging muscular action was restored apparently by the galvanic 
stimulus. Very lately I attended an elderly lady, who from Wednesday morning 
to the next Monda}^ noon, had had no alvine relief, notwithstanding the employment 
of the most active cathartics. She suffered frequent paroxysms of pain and vomiting : 
but the abdomen was scarcely, if at all, distended ; nor was it tender. At length she 
complained that what she vomited was stercoraceous — to use her own w^ords, "what 
came upwards ought to have passed the other way." It was a thin, brown-coloured, 
ill-smelling fluid. Dr. Mayo and Mr. Arnolt were now associated with me in this 
case, and they touched and felt the abdomen as I had previously done. The lady 
observed that their hands were heavy ; and she fancied that the pressure they made 
had displaced something within. . And I believe that it was so : for before our consul- 
tation in the next room was over, word was brought us that the bowels had acted. 
She had passed a liquid motion precisely resembling the stuff she had last vomited. 
The next day, with one of several similar stools, a hard lump was voided, which 
proved to be a gall-stone, as big as a small walnut. 

As large quantities of w^arm water had without difficulty been injected, I infer that 
the concretion had been impacted high up in the bowel, probably at the valve of the 
coecum. Some years previously the lady had suffered severe abdominal pains, 
which at the time were ascribed to the passage of a bihary calculus through the 
gall-ducts. 

In this instance there was no evidence of any strong contractile efforts of the bowel 
above the place of obstruction. 

Large enemata — as much as the intestines will patiently receive — graduall}'- and 
gently introduced, and repeated three or four times a day, may sometimes succeed 
in breaking down and w^ashing away masses of hardened excrement. And if these 
enemata are composed of milk or beef-tea, and are suffered to remain as long as they 
W'ill, they may answer another important purpose ; they may contribute sensibly to 
the nourishment of a patient who cannot retain food in his stomach. They are 
generally very soothing and comfortable ; alla3^ing tormina, and abating sickness : 
and they are adapted to every stage and variety of the complaint. 

There are, however, cases in w4iich we arriv^e at the melancholy but sure convic- 
tion that some mechanical impediment has rendered the bowel absolutely and hope- 
lessly impassable. We fear this when, the constipation being obstinate, we discover 
a tumour, or hardness, in some part of the belly : or Vv-hen we receive a history of 
some former inflammatorj^ attack, since which the bowels have been habitually diffi- 
cult to regulate. Our fears are strengthened when the patient feels that the injec- 
tions reach a certain spot, and there always stop ; and that the intestines rumble, 
and roll, and propel their contents downwards to the same spot, and no further. 
And this is the distinctive symptom upon which I desire to fix your attention. The 
abdomen gradually enlarges, especially if the patient is able to retain food. The 
intestines fill up alDOve the obstacle ; and then throes of pain occur, spasms the suf- 
ferers usually call them, attended with sickness ; and during these pangs you may 
feel, and if the abdomen be uncov^ered, you may see. immense coils of intestine, as 
big perhaps as one's arm, rise and roll over, like some huge snake, with loud roar- 
ings and flatulence. When this takes place, the time for giving purgatives is cer- 
tainly over. The distended bowel requires no stimulus ; it acts, and strives with all 
its power, but strives in vain, to overcome the opposing barrier. If you would con- 
sult your patient's ease, if you would not embitter and abbreviates his slender rem- 
nant of hfe, harass him no further with active remedies. In some cases violent 



COLIC. 



791 



inflammation quickly supervenes, and death arrives in a few da3^s : in others, the 
patient survives, vi^ithout any evacuation from his bowels, but with long intervals 
of ease and comfort, for four, or five, or six weeks. Even a brief respite may be of 
infinite value ; giving time for the arrival of distant friends — for the settlement of 
worldly concerns — and for preparation of the spirit against the inevitable hour. 

It is to these circumstances of irremediable disease that opiates are eminently 
adapted. Even when the symptoms are less desperate, they are not without their 
use. I cannot better express Avhat I think upon this point than in the words of the 
first Fleberden, who says : " The probability of advantage from anodynes has deter- 
mined me to recommend them; and experience has strongly confirmed this judg- 
ment. Under the protection of an opiate I have successfully given more and stronger 
purges than would have stayed without its help. The patient's strength has been 
kept up by some refreshing sleeps : and even in hopeless cases, in v^hich the dying 
person is harassed by unspeakable inquietude, he may be lulled into some compo- 
sure ; and without dying at all sooner, may be well enabled to die more easily. 
Lord Verulam blames ph37sicians for not making the euthanasia a part of their 
studies: and surely, though the recovery of the patient be the grand aim of their 
profession, yet, where that cannot be obtained, they should try to disarm death of 
some of its terror: and if they cannot make him quit his prey, and the life must 
be lost, they may still prevail to have it taken away in the most merciful manner." 

1 have spoken of these cases as being irremediable : but perhaps I have spoken 
somewhat too absolutely. Life may sometimes be saved by a surgical operation. 
The gut may be punctured above the seat of obstruction, and suffered to discharge 
its contents through what is called an artificial anus. This expedient is feasible, 
however, in those cases only in v/hich the obstacle is situated near the termination 
of the large intestine ; i. e., in the rectum, or in the lower part of the descending 
colon : for here only can we ascertain, with any thing like certainty, the exact place 
of the impediment, and here only may the colon be pierced, from behind, without 
injury to the peritoneum. Under no other circumstances, in my opinion, would an 
attempt to reheve the patient, by cutting down upon and opening the bowel, be justi- 
fiable. An artificial outlet in the loin would probably be less disgusting to the pa- 
tient, and less offensive to others, than if it were in front of the body. I am not 
aware that the operation has ever been done in this country. It has been practised 
successfully in France. The mode of performing it I am not competent to teach 
you. In an appropriate case I should think it right to mention, though 1 should be 
slow to recommend, this anceps remedium. The risk of failure, and the penalty of 
success, should both be set fairly before the patient. The choice between certain 
death, on the one hand, and the chance of living with a very loathsome bodily 
infirmity, on the other, must be made b}^ himself. 

For further information upon this subject, I would refer you to an interesting essay, 
by Mr. Erichsen, published in the 2Sth volume of the Medical Gazette. 

It remains that I should say something more respecting co/ic which may exist 
independently of enteritis, and of mechanical occlusion of the bowel; although the 
three are very often combined and intermixed in the course of the same disease. 

In colic there is pain in the abdomen, constipation of the bowels, vomiting often : 
and these are symptoms which occur also in enteritis. The pain is a twisting or 
wringing pain generally, round the navel ; and such is the character of the exacer- 
bations of pain experienced when the bowels are inflamed. These are the points 
of resemblance between the two maladies : and it is of much importance, as 1 told 
you before, to observe their differences ; and to note the marks by which the one 
may be distinguished from the other. It is, then, an essential ditference that enteritis 
is attended with fever, and with tenderness of the belly. The pain is increased by 
all kinds and every degree of pressure ; and the patient, fixed in the supine position, 
breathes with the intercostal muscles only, and carefully avoids any movenient which 
would call the abdominal muscles into action, and so compress the inflamed bowel. 
In colic, on the other hand, the circulation is tranquil ; there is no fever ; and the 
pain is even mitigated by pressure. The patient will he on his belly for ease : nay. 



792 



COLICA PICTONUM. 



he will press it, with the whole weight of his body, across the back of a chair, and 
obtain comfort by that mancsuvre. During the paroxysms the pain is often most 
violent : what the old writers call dolor atrox — atrocious pain : but there are inter- 
vals of complete ease. Even when the pain is worst, the patient tosses and shifts 
from one posture to another in search of relief: and he does not wear that anxious 
and apprehensive aspect which we see in those who are labouring under enteritis. 
The pain arises, I imagine, from the distension of the bowel, here and there, by gas ; 
or, it may be, from spasm ; or from both these states at once. At any rate, it is 
often associated with audible flatulence, and with evident outward spasm. The 
abdomen is hard, and drawn spasmodically inwards towards the vertebral column ; 
and its muscles are partially and strongly contracted, gathered up into lumps and 
knots. None of these circumstances belong to enteritis. 

However, there is good reason for beheving that, even in mere colic, the pain may 
sometimes be augmented by pressure. When a portion of the gut has become 
rapidly distended, considerable uneasiness may result from its forcible compression; 
although, as Dr. Abercrombie states, the kind of pain can generally, by attention, 
be distinguished from the sensitive tenderness of an inflamed peritoneum. 
Luckily, if such pain on pressure should lead us to mistake a case of pure colic for 
a case of enteritis, the error is on the safe side : and we must always bear in mind 
the tendency remarked in colic, when the complaint is neglected, or badly treated, 
to run into actual inflammation. In fact, as any obstacle to the passage of the ah- 
mentary matters through the bowels may give rise to colic, cohc is sometimes merely 
the first step towards acute inflammation arising out of a continuance of the obstruc- 
tion. And having told 5^ou that colic may be thus produced, I have at once intro- 
duced you to a large class of its causes which have already been spoken of in the 
present lecture as frequent causes of inflammation also. 

But colic, hke inflammation of the bowels, sometimes arises without any appa- 
rent or detectable obstruction, of a mechanical kind, to the free transit of the contents 
of the alimentary tube. And there is one particular form of colic that requires a 
separate notice. The cohca Plctormm — so called from its great frequency, hereto- 
fore, among the Pictones, or inhabitants of Poictou — is produced by the slow intro- 
duction of the poison of lead into the system. 

Now, the colic which has this origin is not to be distinguished, in its ordinary 
symptoms, from any other kind of colic. But the abdominal pain is usually, in such 
cases, a part only of more general disease. It has received, in different places, a 
variety of names — cohca Pictonum, the painter's cohc, the Devonshire colic, the 
bellain of Derbyshire, the dry belly-ache of the West Indies. In all cases it acknow- 
ledges the same cause — the gradual entrance of lead into the body. 

In this country, we see the disease more often in painters than in any other per- 
sons. They use, as you know, white lead in the preparation of their colours ; and 
they are perfectly familiar with this terrible cohc. We see it, also, in all workmen 
whose occupations bring them habitually into contact with preparations of lead. No 
doubt there are very great differences in the suscepiibility of this effect of the poison 
of lead. Persons have been known to suffer cohca Pictonum, in consequence of 
their sleeping for a night or two in a recentlj^ painted room. On the other hand, I 
have myself seen a patient who became affected with the disease, for the first time, 
after working with white lead for nineteen years. Generally the first attacks of colic 
are well recovered from. The obstinate constipation of the bowels is at length over- 
come ; the patient obtains ease, and forthwith recurs to his previous habits ; and after 
a period, which varies in different individuals, he is again laid up with the colic. 
Even the primary attacks are usually attended with pains in the head, and in the 
limbs ; sometimes with cramps ; sometimes even with epilepsy and coma. At 
length, in one of these attacks of colic, or after one of them, when the violence of 
the pain and the costiveness have yielded to treatment, the patient finds that he has 
lost the full power of using one or both of his hands. The wrists, as the patients 
express it, drop. You see at once what is the matter, by the characteristic state of 
the arms and hands. The extensor muscles of the hands and fingers are palsied ; 
so that, when the arms are stretched out, the hands hang dangling down by their 



COLICA PICTONUM. 



793 



own weight, and the patient is unable, by any effort of his will, to raise them. The 
palsy is local ; it does not proceed from any diseased condition of the nervous cen- 
tres. The affected muscles waste, and the atrophy is very remarkably seen in the 
bundle of muscles composing the ball of the thumb. Even from this condition, the 
patients often are capable of complete recovery. But if they persist in following their 
former calling — or if, without knowing it, they continue to be habitually exposed to 
the exciting cause of the disease — they become miserable cripples, fall into a state 
of general cachexia, and sink at length under some visceral disease. The poison 
accumulates in the body, and saps the powers of life. Francis Citois, a native of 
Poictou, who pubhshed an excellent and one of the earliest accounts of the disease, 
in the year 1617, has drawn the following graphic picture of its effects. Its cause 
was not at that time suspected. Speaking of the wretched sufferers, he says, "Per 
vices, veluti larvse, aut arte progredientes statuae, pallidi, squalidi, macilenti conspici- 
untur ; manibus incurvis, et suo pondere pendulis, nec nisi arte ad os et cseteras 
supernas partes sublatis, et pedibus non suis sed crurum musculis, ad ridiculum ni 
miserandum incassum compositis, voce clangosa ct strepera." 

The course of the disease is usually such as I have just described it. The colic 
happens first, perhaps several times, and then arrives the palsy. But in a few 
instances I have known this order reversed. The wrists have dropped, when there 
had been no preceding colic. 

The great cause of this fearful malady was first made out by our distinguished 
countryman. Sir George Baker. He set on foot an inquiry into the origin of what 
was called the Devonshire colic, so common was it in that county. He found, first, 
that it occurred chiefly in persons who drank the cidei' manufactured there ; and, by 
degrees, he traced the source of the malady to the admixture of lead with the cider; 
either designedly, for the purpose of sweetening it, or by the inadvertent employment 
of lead in the construction of the cider-mills and vats. It was under circumstances 
of the same kind that the cohc of Poictou originated. Preparations of lead were 
used— not fraudulently, but openly and honestly — to prevent the wines of the coun^ 
try from turning sour; the injurious influence of lead upon the human body not 
having then been ascertained. So, also, equally convincing proofs of the adultera- 
tion of rum by means of lead, giving rise to ifrequent attacks of dry belly-ache, in 
the West Indies, are given by Dr. John Hunter, in the Medical Transactions. I 
inyite your attention to his papers, and to Sir George Baker's, on this subject. They 
afford a capital specimen of medical research and reasoning. Various causes, as you 
may suppose, had been assigned for this disorder. These are one by one investi- 
gated and set aside, until, by this method of exclusion, the real source of all the mis- 
thief is detected. Sir George Baker's papers contain a great deal of curious and 
useful information in respect to the various modes in which this poison of lead may 
find its way, without being suspected, into the animal economy. The subject is one 
of vast importance in its relation to medical police; but my limits will not allow me 
to follow it beyond the point where it ceases to be directly connected with the prac- 
tice of physic. 

Colica Pictonum is seldom fatal as colic, or during the persistence of the abdomi- 
nal symptoms ; yet instances enough of death occurring while the colic was present, 
but from other accidental causes, have now been collected, to enable us to say, that 
no appearances have been met with in the intestinal canal, calculated to explain the 
pain or the constipation. Andral relates five cases, in which the body was carefully 
examined after death preceded by the painter's cohc. He found neither inflamma- 
tion, nor any remaining trace of spasm. The intestines were neither dilated nor 
contracted, but of their natural texture and appearance. Merat, who has written a 
good treatise on this form of colic, gives the dissections in four fatal cases : fatal, as I 
mentioned that they sometimes are, by the supervention of coma. There was no 
discoverable mark of disease ; the ahmentary canal was empty, and the large bowels 
contracted; as they were also found to bejn rabbits which had died of lead colic. 
For animals are susceptible of the disease, and it may be produced in them by the 
slow impregnation of their bodies with the specific poison. Dogs, cats and rats, that 
inhabit houses and manufactories wherein lead is much used or prepared, are known 

3r 



794 



COLICA PICTONUM. 



to be attacked both with colic and with palsy. With respect to the contraction of tLe 
large intestines in these cases, we must not be too ready to attribute it to spasm; for 
the bowel, when empty, is apt to be contracted. 

When the palsy has been of any continuance, the affected muscles not only shrink 
and waste, but undergo a structural change, which is obvious to the sight. They 
become pale, almost white, dry. John Hunter examined the muscles of the hand 
and arm of a house-painter, who died, while thus paralytic, in St. George's Hospital. 
He found them of a cream colour, and opaque, instead of being of a purplish red, 
and semi-transparent. And, since his time, lead has been detected in the palsied 
muscles, and in the brain, by chemical analysis. It is doubtless conveyed by the 
blood to all parts of the body. Why it fastens solely or chiefly on particular mus- 
cles or particular nerves, nobody knows. The pain it occasions, whether in the 
abdomen or in the hmbs, is generally thought to be neuralgic. Tt is one of the poi- 
sons that do not appear to find a ready exit from the body. Very recently, a most 
curious symptom, pathognom.onic, I believe, of the presence of lead in the system, has 
been pointed out by Dr. Burton ; and now that it has been pointed out, one can 
hardly understand how it escaped discovery so long. It is a blue or purplish line 
running along the edges of the gums, just where they meet the teeth. Dr. Burton 
first noticed this six years ago, but wisely refrained from making his observations 
public until he had, had time and opportunity enough to satisfy his mind that he was 
not mistaken. A paper of his on the subject was read at the Medical and Chirur- 
,gical Society last January (1840). I cannot resist the temptation to read to you the 
notes of a case which has subsequently occurred to me in the hospital. Mary Anne 
Davis, a middle-aged woman, presented herself with dropped wrists. It was an 
exquisite example of palsy of the extensor muscles of the hands and fingers. She 
could raise her arms, but her hands hung down hke the talons of a bird, or like the 
fore paws of an erect kangaroo. This began nine weeks before. She complained 
of pain, beginning under the nails, stretching up the backs of her hands, and reach- 
ing sometimes to the elbows. The bottoms of her feet had also been tender, and at ^ 
night were burning hot. _ 

Seeing the dropped wrists, we thought immediately of the poison of lead. But 
the patient was a female. We do not often see these effects of that poison in women ; 
for obvious reasons. At first we could get no clue to the mode in which lead could 
have found its way into her system. Her husband was a broker. She had not 
been living in a newly-painted house : and had (she said) no concern with lead in 
any way. Lead often creeps in, however, through undetected channels, and I could 
not help suspecting it here. Mr. Pyper, my clinical assistant, soon elicited another 
part of her history, Vv^hich added to our suspicions ; namely, that before the palsy 
occurred, she had had pains in the abdomen, and costive bowels, for five days toge- 
ther. Nay, she had a recurrence of colic after her admission. This was a strongly 
corroborating fact ; but what clenched the proof was the discovery of a decided blue 
rim along the edges of nearly all her gums. This conclusive evidence led to further i 
cross-examination ; and at last it came out that some of her sons (she had seven) had 
occupied their leisure time in the preceding summer with making bird-cages, and 
painting them green, in the one room in which she habitually lived. The case alto- ! 
gether was a very neat one. ' 

Mr. Tomes pointed out to me some interesting circumstances, which led him, at ; 
one time, to think it probable that the colour might be produced by some chemical 
action between the tartar that forms on the teeth, where they meet the gums, and 
the lead which pervades the sj^stem. This woman's teeth, like those of many in ' 
her rank of hfe, were loaded with tartar. In one place was visible a stump, level 
with the gum, and surrounded by a ring of tartar; and there was also a correspond- 
ing border of blue. In other places there were gaps, where teeth once were ; here 
there was, of course, no tartar; and here there was no blue line on the edge of the 
gum. The blueness may however appear when there is no tartar at all. I do not 
know exactly in what manner the chemical union arises, but the colour depends, I 
believe, upon a sulphur et of lead, formed somehow by the action of sulphuretted 
hydrogen upon, the metal. It is curious that the edge of the gum should always be 



COLICA PICTONUM. 



795 



the part thus marked ; that very part which first exhibits the influence of another 
metal, mercury, when ptyahsm is about to ensue. 

This discovery of Dr. Burton's is not a mere piece of curiosity, but is likely to 
be of use in various w^ays. In the first place, it may settle the nature and cause of 
many doubtful cases; as it did, indeed, of the one just narrated. The poison of 
lead produces pains which resemble, and no doubt are sometimes mistaken for, the 
pains of rheumatism; it has other obscure consequences too: and an inspection of 
the gums may often greatly elucidate such cases. Dr. Burton finds that small 
quantities of lead given as a medicine will produce the phenomenon. In two in- 
stances it occurred within two days. One of these patients had taken fifteen grains 
of the acetate of lead in that time ; the other twenty-four grains. A correspondent 
of his produced the blue rim in twenty -four hours ; viz., by four doses, of five grains 
each, exhibited every six hours. He finds too that the line remains distinct after 
death; even more so than during life. It may afford valuable information therefore 
to the medical jurist in cases of suspected poisoning with the sails of lead. It is, I 
say, an early consequence of the absorpiion of lead. It will teach us, as the mercu- 
rial affection of the gums teaches us, that the medicine is pervading the system ; and 
admonish us to look out for, and guard against, colic. It may apprise workers in 
lead that their caution has been insufficient ; that the poison has entered ; and that 
they are in peril of belly-aches and palsy. It is a capital diagnostic sign also be- 
tween colic so arising, and colic from other causes ; and between colica Pictonum, 
and the pain of inflammation of the bowels. 

[The symptoms of colica pictonum. or lead colic, are in some respects diiferent from those 
of ordinary colic. There is usually, at first, a loss of appetite, with some degree, more or 
less in diiTerQii^t cases, of nausea, and very commonly an increased discharge of saliva. The 
patient's sleep is disturbed, or more frequently, there is an inability to sleep; according to 
M. Ranque, of Orleans, he exhibits various other symptoms of a disordered condition of the 
nervous system. The attack of colic usually commences with vomiting ; the matter dis- 
charged being, at first, whatever has been taken into the stomach mixed with bile and the 
gastric secretions, very generally changed from their healthy condition; if the vomiting con- 
tinue, these latter are alone discharged. Pain of the abdomen is next complained of; it is 
most severe about the navel, the epigastrium, the hypochondria, the loins, and above the crest 
of the ileum. The pain, in general, commences at the hypogastric region, or, as a cramp, at 
the pit of the stomach, and from thence extends, in a short time, over the rest of the abdo' 
men. The pain is at first paroxysmal, with intervals of ease ; these intervals being the 
longest at the commencement of the attack. More commonly there occur remissions rather 
than intermissions of the pain; and it is remarked, that both the remissions and exacerba- 
tions are much longer than those of ordinary colic. As the disease advances the pain is 
almost constant, but is usually most severe at night. It is not increased by pressure ; on the 
contrary, jiressure very generally, but not invariably^ affords relief, provided it be not made 
upon the epigastrium ; according to Merat, patients have been known to bear, with relief to 
the paroxysms, the weight of two or three persons standing on the belly. The abdomen is 
almost invariably hard and flat from a contraction of its muscles ; the navel is sometimes 
drawn in so as almost to approach the spine; in a few instances there exists some fullness of 
the abdomen, and occasionally it has an irregular, knotty feel. There generally occur, within 
the first day or two, sometimes within the first few hours of the attack, headache, and a dull, 
anxious, or depressed expression of the countenance ; to these symptoms are soon added, 
pains of the limbs, especially of the inside of the thighs, calves of the legs, ankles, and soles 
of the feet; these pains are worst at night; tbey are often accompanied with cramps, and 
according to Tanquerel, are relieved by pressure. The disease is seldom attended with febrile 
excitement. The skin is of a dull, dirty cadaverous appearance; it is frequently hot. and 
almost invariably bedewed with irregular, clammy, and often cold, perspiration. The pulse, 
according to MM. Ranque and Merat, is rarely accelerated, but often below 00° in a minute ; 
others, however, notice a considerable acceleration of the pulse, which we have remarked iu 
many cases, the pulse being at the same time hard, and communicating to the finger a pecu- 
liar thrill. Obstinate constipation of the bowels is an almost invariable symptom ; although 
it does not always occur at the very commencement of the attack; in a few instances, it is 
said that the attack has been attended with diarrhoea ; such an occurrence, however, we have 
never observed. On the contrary, in all the cases that have fallen under our notice, either 
no dischai-ge has taken place from the bowels, or a scanty stool has occurred composed of a 
few lumps of dry, hardened feces, passed with much straining and pain. The urine, 
though generally natural in appearance, is often diminished in quantity. 

From an attack of colica pictonum, particularly a first attack, the patient may, under a 



796 



COLICA PICTONUM. 



judicious and timely treatment, recover perfectly ; and with a careful avoidance of any oi 
its exciting causes, and of the poison of lead, he may remain ever after free from a recur- 
rence of the disease. When the disease, however, is neglected, or badly managed, or the 
patient is constantly or repeatedly exposed to the influence of lead, be becomes affected either 
with a peculiar form of partial palsy, which is well described by Dr. Watson in the text; or, 
instead of this gradual loss of voluntary motion in the muscles of the extremities, there occur 
another set of symptoms, which very generally terminate speedily in death. The patient 
after a few days becomes affected with giddiness, great debility, torpor, and sometimes deli- 
rium : as the torpor advances, the pains in the abdomen and extremities abate ; at length 
convulsions, and a comatose condition ensue, from which very few recover. Cases are 
recorded by Louis and others, in which death suddenly occurred during the first stage of the 
disease, without the occurrence of any symptoms that would cause such a result to be sus- 
pected. Drs. Elliotson and Copland each relate a case in which death was caused by per- 
foration of the stomach. To a paralytic afiection of the muscles of the extremities, as a 
very common effect of repeated attacks of colica pictonura, we have already referred ; and 
two cases are related by Dr. Alderson, of Hull, England, in which the disease was attended 
with paralysis of the nerves of vision ; Tanquerel states that this is not uncommon in Paris, 
the paralysis being attended with dilated and immovable pupils ; he met, also, with one in- 
stance in which deafness was present, no doubt from paralysis of the auditory nerve. — C] 

In the treatment of colic — and especially of the lead colic — the great indication is 
to get the bowels to act. If the pain of the belly be increased on pressure, if the 
pulse be at all accelerated, if the face be flushed, and there be the shghtest approach, 
to fever, it will be right to take blood from the arm. It is a measure of safety as 
regards the possible existence of inflammation : and if there be no inflammation pre- 
sent or impending, it will tend to remove the spasmodic state of the muscles which 
goes along with, and perhaps chiefly constitutes, the disease. External warmth 
should also be applied ; diligent friction, with some stimulating liniment ; or, what 
is much better, a mustard poultice, or a turpentine stupe. My colleague, Dr. Wil- 
son, has been very successful in relieving these patients, by putting them into a hot 
bath, and having a large quantity of the water in which they are immersed, thrown 
gradually into their bowels by means of a proper syringe. The bath presently be- 
comes polluted, to the great satisfaction and refreshment of the patient. It will 
generally be expedient to give a full dose of calomel and opium ; ten grains of the 
one with two of the other. Sometimes the effect of the opiate is to suffer the bowels 
to empty themselves ; showing that the previous difficulty was probably spasmodic. 
Usually the calomel and opium will soothe the vomiting, the restlessness and the 
pain ; and then a full dose of neutral salts, or of castor oil ; or (if these do not suc- 
ceed) of the -last named remedy, castor oil, quickened by one or two drops of the oil 
of croton, will produce free evacuations from the bowels ; and the patient soon re- 
turns to his ordinary state of health. It is sometimes necessary to repeat this prac- 
tice, this alternation of purgatives and anodynes : but when once the bowels have 
been freely moved, the disease, in general, becomes very tractable. 

At La Charite, in Paris, there is what is called a specific mode of treatment fol- 
lowed. It is complicated and rough, but not a whit more successful than the simpler 
plan which is universally adopted in this country. You may see it described, if 
you are curious on the subject, in most of the French books. I think it is given in 
detail in Ratier's Formulary of Hospital Practice. 

Some have recommended salivation for the cure of the painter's colic, on the 
principle, I conjecture, of driving out one metaUic poison by another. But the two 
may combine, for aught I know, to plague the patient. The practice is quite unne- 
cessary. 

You will be consulted about the palsy which arises from lead, and especially to 
remedy the dropped wrists, which render the patient incapable of earning his liveli- 
hood. Now in the early stages of the palsy, and in its primary attacks, you may 
often succeed in effecting a cure. Electricity has long been thought useful, applied 
in the way of sparks at first, and of shght shocks afterwards, along the muscular 
parts of the extensors of the fingers. It accelerates the recovery to give ,the hand 
and fingers the mechanical support of a sphnt, made for that express purpose, and 
so contrived that the hand and fingers are kept extended through the greater part of 
the day. Patients labouring under this kind of palsy resort to the Bath waters for 



COLICA PICTO.YUM. 



797 



a cure : and I learn from a gentleman who once held the office of house-surgeon to 
the hospital there, that the physicians have much more faith in the use of the baths, 
with shampooing, and in sphnts and blisters to the palsied muscles, than in electricity. 
The warm douche is a promising expedient : the electro-magnetic apparatus, per- 
haps, still more so. 

According to Andral and others, who have had more experience of that drug than 
I have, there is no form of palsy so Hkely to be benefited by strychnine as this which 
proceeds from the poison of lead. T should recommend you to try the safer methods 
of binding the hand to a splint, and stimulating the muscles by friction, shampooing, 
or electricity, before you resort to that active poison. 

It is observable o? this disease, as of many, and, indeed, of most others, except 
certain contagious febrile diseases, that when once it has occurred, it is much more 
liable to occur again, upon a repetition of the exciting cause, than before. It is of 
very great moment, therefore, that they who are necessarily exposed to the poison 
of lead — as painters, plumbers, printers (who handle leaden types), colour-grinders, 
potters, and glass-blowers (who use the oxide of lead in their respective manufacto- 
ries), shot-makers, workers in lead mines, and so on — it is of great importance that 
these persons should be made aware of the means which are best adapted for their 
protection against the injurious agency of the poison : and we ought to be able to 
give them advice in that matter. The rules for their guidance are short and simple ; 
and, if carefully observed, I beHeve they will generally prove successful. They 
resolve themselves into cautions against the admission of the metal or its compounds 
into the body through any channel. 

1. To prevent its introduction through the skin minute attention to cleanliness is 
necessary. The face and hands should be washed, the mouth rinsed, and the hair 
combed, several times in the clay ; and bathing and ablution of the whole body should 
be frequently performed: also, the working-clothes should not be made of woolen, 
but of strong compact linen ; and they should be washed once or twice a week at 
least ; and they should be worn as little as possible out of the workshop : and some 
light impervious cap might protect the head while the person is at work. 

2. Care should be taken that none of the poison be admitted into the system with 
the food. The workmen, therefore, should not take their meals in the workroom, 
and should be scrupulous in cleansing their hands and lips before eating. 

3. The entrance of the poison into the air-passages during respiration should be 
guarded against as much as possible. Masks have been recommended for this pur- 
pose : none, probably, would be more convenient or more effectual, than Mr. Jeffrey's 
orinasal respirator. 

There is a notion prevalent in some places, which apparently has some founda- 
tion, that the free use of fat, and of oily substances, as food, is a preservative against 
the colic. A physician, near Breda, informed Sir George Baker that the village in 
which he lived contained a great number of potters, among whom he did not witness 
a single case of lead colic in the course of fifteen years ; and he attributed their 
immunity to their having lived very much on butter and bacon, and other fat kinds 
of food. De Haen also was told by a physician, the proprietor of a lead mine in 
Styria, that the labourers there were once very subject to colic and palsy; but that 
after they were exhoried by a quack doctor to eat a good deal of fat, especially at 
breakfast, they were exempt from these disorders for three years. This is a kind 
of prophylaxis that is very easily adopted. 

More recently Liebig has asserted that " the disease called painter's colic is un- 
known in all manufactories of white lead in which the workmen are accustomed to 
take, as a preservative, sulphuric acid lemonade, a solution of sugar rendered acid 
by sulphuric acid." 

If this be so, the lemonade must protect the system by converting any other salt 
of lead, which might find entrance, into an insoluble sulphate : solubility being 
requisite to give efficacy to any poisonous substance. 
4 Mr. Benson, the manager of the British white-lead works, in Birmingham, states 
(in the Lancet) that he has tried this method of prevention. Under his direction 
sulphuric acid was first added to the treacle-beer, used as a beverage by the work* 

3r2 



798 



DIARRHCEA. 



I 



men, in the summer of 1841. Lead colic, wiiich had prevailed before " to a dis- 
tressing- extent," soon began to diminish in frequency : and from October in the 
same 3^ear, up to the date of Mr. Benson's communication in December, 1842 — a 
period of fifteen months — not a single instance of the disorder had occurred amongst 
them. This is very encouraging. 



LECTURE LXXII. j 

JDiarrhcea. Sporadic Cholera. Epidemic Cholera. \ 

The morbid fluxes which proceed from the long tract of mucous membrane that 
lies between the stomach and the anus are many in number: and they vary much' 
both in kind and in cause. Hemorrhages are not uncommon. I have already de- I 
scribed the disease called melmna, which is characterized by the discharge of black | 
semifluid matters, resembling tar, from the bowels, and in most instances from the 
stomach also by vomiting. The matters vomited, and the matters passed by stools, ; 
are composed principally of blood, which has been rendered black, and otherwise 
modified in appearance, during its progress onwards in the one direction and in the 
other. Again, hemorrhage from the bowels is apt to occur in continued fever ^ as I 
shall show you when we come to that disease. Hemorrhage takes place also from 
the rectum in hasmorrhois, or bleeding piles : a malady that falls chiefly to the care 
of the surgeon. Blood comes away, too, mixed with a greater or less quantity of ! 
mucus, in dysentery. ' 

The remaining forms of profluvia from the intestinal canal I shall proceed to con- 1 
sider seriatim ^ at least the most important of them. 

There are several very different affections classed together under the head of [ 
diarrhcea: by which term is usually signified the occurrence of frequent, loose or i 
liquid alvine ev^acuations. Thus diarrhcea is a very common symptom of pulmo- | 
nary phthisis ; and this form of the disorder has been already mentioned. It is very ! 
oiten met with also in continued fever, and during the decline of the febrile exanthe- 
mata, of which I have yet to speak. But diarrhoea is not unfrequently the main 
symptom of the illness under which the patient labours ; and constitutes, at any rate, 
the chief object of our treatment. I shall touch briefly on some of its varieties. 

In the first place, there is that common form of the complaint which proceeds 
from over-repletion of the stomach ; or from the ingestion of food that is not whole- 
some : food that disagrees (as the phrase is) with the patient's stomach and bowels 
at that particular time. We may call it, with Cullen, by way of distinction, diarrhoea 
crapulosa: in which feces are discharged in a more liquid state, and more copiously, 
and more often, than is natural. These cases are in truth slight cases of irritant 
poisoning. The ingesta irritate the mucous surface, and probably the muscular coat 
also ; the secretions of the inner membrane are poured forth in unusual abundance, 
and the peristaltic motions of the intestines become m.ore strong and active ; the ob- 
ject of these changes being that of getting rid of the offending substances: a salutary 
and conservative effort, which we assist and imitate in our treatment of this form of 
diarrhoea. 

The symptoms by which this species of diarrhcEa is marked, must be well known 
lo us all. There are often nausea; flatulence; griping pains in the bowels, suc- 
ceeded by stools of unnatural appearance and odour, and of fluid or watery consist- 
ence. There are often, also, a furred tongue and a foul breath : but the disorder is 
attended with little or no fever ; the pulse remains of the ordinary frequency ; and 
the temperature of the body does not rise. 

There are certain things which, more than others, tend, when taken into the sto- ^ 
mach, to cause this crapulous diarrhoea : and there are certain circumstances which \ 
increase the disposition to be affected by the ordinary exciting causes. \ 



DIARRHCEA. 



799 



We frequently see this disorder supervene upon a debauch, in which case the 
mixture of various articles of food, and of drink, each of which in itself might have 
been perfectly innocent — and the actual quantity of the mixed ingesta— have occa- 
sioned the irritation and disturbance. But where there has been no intemperance in 
eating or drinking, some kinds of food are more likely than others, cxteris paribus, 
to provoke diarrhoea. I do not speak of idiosyncrasies, which show the truth of the 
old proverb, that what is one man's meat is another man's poison, and which cannot 
be reckoned upon beforehand ; but I refer to the average of systems and stomachs. 
And among these indigestible and irritating substances we may place raw vege- 
tables of many kinds ; such as cucumbers and salads, sundry kinds of fruit, espe- 
cially if they be hard, immature and acid ; plums, melons, pine-apples, nuts, and so 
forth. Mushrooms may be added to the hst, even when they are cooked. Putrid 
food, or food which, in the more refined phraseology of gastronomers, is termed 
high, has the same effect upon some persons : and so, in a particular manner, have 
some kinds of fish ; shell-fish, crabs and muscles, for instance, in this country ; and 
in other countries, in the West Indies, there are several species of fish which are 
actually poisonous, and cannot be safely eaten at all. And similar disorder is fre- 
quently produced in children by any sort of food, other than the natural sustenance 
furnished by the mother. The new kind of nutriment disagrees with them : and the 
very same thing is apt to occur in adult persons. An article of diet which is per- 
fectly v/holesome and digestible, and which the stomach bears well after a little habit, 
will sometimes cause griping and purging, when it is taken for the first time. It is 
upon this principle that the diarrhoea to which Englishmen are subject upon first 
visiting the towns upon the continent, is to be explained. I do not know that it is 
so, but I think it very likely that Frenchmen, and Germans, and Italians, suffer 
in the same way when they first come to this country, and adopt our habits and 
regimen. 

Another curious exciting cause is to be found in certain mental emotions, and 
especially the depressing passions ; grief, and above all, fear. A sudden panic will 
operate on the bowels of some persons as surely as a black dose, and much more 
speedily. Among the circumstances which predispose most persons to this kind of 
malady, we may particularly specify season — the hot weather of summer and au- 
tumn. And it is probably consistent with the experience of most of you, that the 
atmosphere of the dissecting-room has a similar tendency. 

Now this diarrhoea, from occasional irritation, produced by the presence of sub- 
stances that offend the stomach or bowels, will generally cease of itself. The purging 
is the natural way of getting rid of the irritant cause. We may favour the recovery 
by diluent drinks, and by making the patient abstain from all further use of food 
which is not perfectly easy of digestion ; and we may often accelerate the recovery 
by sweeping out the alimentary canal by some safe purgative, and then soothing it 
by an opiate. Or we may give the aperient and the anodyne together, and the one 
will not interfere with the operation of the other. A table-spoonful of castor-oil, 
with six or eight minims of laudanum dropped upon it : or from fifteen grains to a 
scruple of pov/dered rhubarb, with half as much of the pulvis cretse compositus cum 
opio. By some such medication as this, emptying the bowels, and quieting them, 
the cure is generally accomplished with ease, and speedily : tuto, cito, et jucunde. 

We sometimes, however, meet with cases in which diarrhcEa runs on; the stools 
being composed of fecal matter in an unnaturally fluid state ; and the precise condi- 
tion on which this disposition to an over-loose state of the bowels depends, escaping 
detection. If the disorder be slight, it will often yield to the astringent and bitter 
medicines. The infusion of cusparia, with the tincture of cinnamon, supplies a con- 
venient formula. If it be more severe, or obstinate, we have recourse to a chalk 
mixture, which neutralizes acidity ; combined with catechu, which is a direct astrin- 
gent of the tissues; and with laudanum, which calms irritation. And in extreme 
cases the sulphate of copper has been found to have a powerful effect in restraining 
the flux. It is apt to gripe, and should be combined therefore with opium. A quar- 
ter of a grain of each, in a pill, given three or four times a day, I have frequently 
found successful, when previous attempts to remove the diarrhoea had failed. 



800 



DIARRHOEA. 



[A much more effectual remedy is the acetate of lead, combined with opium and ipecacu- 
anha; one grain of the first, from a fourth to the half of a grain of the second, and from 

half a grain to a grain oT the latter, combined in the form of a pill, or in a powder, mixed ] 

with a little simple syrup, may be given to an adult and repeated every three or four hours ; 

according to circumstances, j 

Diarrhoea in a chronic form is that which the practitioner will be the most frequently ' 

called upon to treat in the adult; and it, in general, requires for its complete removal a cau- j 

tious and judicious course of treatment persevered in for a length of time. The slightest | 

deviation from the strict diet and regimen required in each case, will often very considerably i 

protract the cure ; while a too early abandonment of the appropriate remedies will fre- I 

quently be quickly followed by a return of all the worst symptoms of the disease. j 

In chronic diarrhoea there exists a morbid excitability of the intestinal canal, so that almost | 
everything taken into the stomach, as food or drink, brings on quickly repeated discharges by- ' 
stool consisting of the ordinary secretions of the digestive tube, more or less changed in cha- ; 
racter, mixed with portions of half digested aliment; and the looseness continues, often un- j 
attended with griping, or any other uneasy sensation save those connected with the debility | 
and emaciation produced by the interruption to the digestive and nutritive functions generally, | 
which the rapid passage of the aliment through the bowels occasions. There is no doubt, | 
that frequently the morbid excitability of the digestive canal is due to a chronic inflamma- i 
tion, often follicular, and attended with ulceration of some portion of its mucous membrane; 1 
when this is the case, we have repeated discharges by stool without apparently any exciting I 
cause other than the morbid secretions of the liver, pancreas, or of the stomach and intes- | 
tines themselves. The discharges are, in general, dark-coloured and offensive, very fluid, and ^ 
small in quantity, and are often preceded and accompanied by griping pains more or less | 
severe. There is, very commonly, some degree of nausea, and occasionally vomiting, the ' 
appetite for food is generally destroyed, though in many cases it continues unimpaired. The 
patient becomes more and more emaciated and debilitated; his skin assumes a dirty sallow 
hue and a dry harsh feel; the palms of the hands become hot and dry; the countenance has, 
in many cases, a dull, desponding expression; the features acquire considerable sharpness, 
and the eyes become sunken and surrounded by a broad leaden-coloured ring. The abdo- 
men is frequently flaccid, and exhibits no tenderness upon moderate pressure; occasionally, «i 
however, it becomes swollen and tympanitic, and is now and then decidedly tender to the j 
touch. We have known in cases of chronic diarrhoea, an effusion of serum to occur within 
the peritoneal cavity, and to produce a very decided intumescence of the abdomen. In pro- ' 
tracted cases, the body exhales a peculiar sickly odour, the tongue becomes of a dark maho- I 
gany hue, and often, together with the parietes of the mouth, is covered with aphtha;. The 
pulse is usually small and feeble, often quick and frequent. Febrile symptoms are not gene- | 
rally present; in many cases, however, there is observed some degree of febrile excitement i 
towards evening — very protracted cases we have repeatedly known to be accompanied with ' 
well-marked hectic gymptoms — more or less puffiness of the face, and oedematous swelling ' 
of the extremities, very commonly occur in the course of the disease. The discharges by j 
stool, while they are always fluid and vitiated, exhibit considerable variety in their appear- i 
ance ; most generally they are dark-coloured, and exhale a rancid or fetid odour ; occasion- i 
ally, however, they have a jelly-like consistence, and very little smell ; at other times they j 
consist of a small quantity of a dirty yellow fluid, and when they contain solid matter this j 
will generally be found to consist of portions of half-digested aliment. All these changes in the , 
character of the discharges may present themselves in the same case, and often within a very j 
short period. In protracted cases, the discharges would appear to acquire an acrid property, pro- j 
ducing an erythematous inflammation of the verge of the anus, and often of the nates. The \ 
frequency of the stools varies very much in different cases, and at diflerent periods in the 
same case. Occasionally, the diarrhoea takes place only after the ingestion of food or drinks, , 
or of -particular kinds of food, and the discharges from the bowels continue to recur at short j 
intervals until the offending matters are got rid of ; in many cases, repeated stools occur in 
the course of the day, whether food is taken or not, and are suspended during the night ; in i 
other instances the evacuations from the bowels often cease for a day. or even longer, and 
then return, and for a short period with increased frequency. 

The duration of chronic diarrhoea is very various ; unless arrested by a proper course of i 

treatment — its spontaneous cessation being a thing of very rare occurrence — it will run on I 

for weeks, often for months, and the patient finally sinks from extreme exhaustion. Occa- ; 

sionally perforation of the intestines occurs from ulceration or softening, and the fatal event • 

is preceded by peritonitis. ' ' 

The causes of chronic diarrhcEa are the same as those of the acute or simple form of the 
disease; frequent attacks, within a short period, of an ordinary bowel complaint, will very j: 
commonly induce a chronic affection. — Improper articles of diet, and acescent drinks, habit- 
ually indulged in ; exposure to a cold, and, at the same time, humid atmosphere ; the abuse ! 
of purgatives, and intemperate habits generally, are among the most common causes of , 



DIARRHCEA. 801 

chronic diarrhoea. It is an affection much more readily induced in those of a lax, and feeble, 
excitable and broken-down constitution, than in those of an opposite condition. 

The state of the intestinal tube in those who have fallen victims to the disease is very- 
various. In some cases, the mucous coat, particularly of the large intestines, is somewhat 
thickened, spongy, and pale — in others its anatomical characters are entirely changed, large 
portions of it presenting a smooth, glassy, mottled appearance, as though its surface had been 
covered with a thin coating of dirty varnish. Occasionally large patches of the mucous mem- 
brane of the colon or rectum are of a dark mahogany or of a slate colour — ■ the traces of 
follicular inflammation, or of ulcerations, more or less extensive, are not unfrequently met 
with, especially in the ileum and colon. Dr. Stokes notices a form of chronic diarrhoea as 
of common occurrence, dependent upon ulcers situated close to the verge of the anus ; these 
ulcers occur chiefly in persons of a broken-down constitution, and those who have taken a 
great deal of mercury ; we have repeatedly observed them, also, in individuals, who have 
been in the habit of using almost daily the various pills composed chiefly of aloes, soaj), and 
scammony, or gamboge, vast quantities of which are vended in the United States as a popu- 
lar remedy for almost every ailment. The ulcers situated just within the anus produce irri- 
tation in the colon, tenesmus, griping, frequent discharges by stool, and most comm.only dur- 
ing the straining a little blood is passed. Th^ presence of the ulcers may be at once detected 
by an examination of the rectum ; which examination, as Dr. Stokes very correctly remarks, 
should invariably be made in all cases where the diarrhoea has been of long standing, and 
has resisted a great variety of treatment ; where it is attended with tenesmus, and a desire 
of sitting on the night chair after a stool has been passed ; and, finally, where the patient's 
health does not appear to be so much affected as it naturally would be from long-continued 
disease of a large portion of the great intestine. 

In the treatment of chronic diarrhoea our leading indications are, to control the morbid 
irritability or excitability of the intestinal mucous membrane, and restore it as quickly as 
possible to its healthy condition and functions. To effect these objects is not always, how- 
ever, a very easy task, and always demands considerable judgment on the part of the prac- 
titioner, and considerable patience, and an implicit obedience on the part of the patient to 
the medicinal directions and dietetic rules laid down. The first and all-important considera- 
tion is that of diet — so that, while the patient is supplied with aliment calculated for his 
support, as little irritation as possible of the intestines shall be excited by it. The food taken, 
by an individual labouring under chronic diarrhoea should be easy of digestion, of the mildest 
quality, and such as leaves, after undergoing digestion, but a small quantity of excrementi- 
tious matter ; and even of such food but a small portion should be taken at a time. Rice is 
probably the best article of diet in the generality of cases of chronic diarrhoea ; wdien well 
boiled, with the addition of a little salt, while it is sufficiently nourishing it is extremely mild 
and unirritating, by no means difficult of digestion, and scarcely affords any excrementitious 
matter to be transmitted along the intestines. It may, generally, be eaten mixed with a 
very moderate quantity of plain beef or mutton broth ; plain meat broths prepared with the 
addition of a large amount of rice, will often furnish a very suitable food in chronic diarrhoea, 
and are to many stomachs more palatable ; rice, also, boiled with milk and sweetened, but 
not too heavily, with the best of loaf sugar, or fresh milk thickened with rice flour, may be 
occasionally given. Should either preparation, how^ever, be found to disagree with the 
patient, or to augment or keep up the diarrhoea, it should be at once relinquished. We have 
indeed, in numerous instances, found plain broths, when well prepared, or the juice of 
roasted meats with a portion of stale bread or cracker broken into it, agree better than any 
preparation of rice. Tapioca, sago, or arrow-root, we have seldom found an appropriate ali- 
ment for persons labouring under the chronic form of diarrhoea. As soon as it can be borne, 
and this can only be ascertained by a cautious trial, a small portion of tender chicken, tur- 
key, or mutton, plainly boiled or roasted, may be eaten with rice. Pure water, toast water, 
or rice water, taken cold and in very moderate quantities at a time, should be the only drink 
allowed. 

Next, or more properly perhaps, equal in importance to a well-regulated diet, is an atten 
tion to the clothing and regimen of the; patient. Individuals affected with chronic diarrhcsa 
are particularly susceptible to the influence of a cold and damp atmosphere — a slight ex- 
posure to which will often increase their disease, or when we have succeeded in diminish- 
ing the frequency of the discharges, causes them to return as before. It is essential, there- 
fore, that independent of cautiously avoiding every species of exposure, the patient should be 
suitably lodged and clothed. The chamber he occupies at night, as well as daring the day, 
should be dry. of a comfortable and equable temperature, perfectly clean, and well ventilated : 
his clothing should be adapted to the season and state of the weather — flannel next the skin 
should always be worn ; a belt of flannel around the abdomen, or enveloping this part with 
a flannel roller nicely adjusted, and renewed daily, will always be found advantageous. In 
obstinate and protracted cases, the removal of the patient from a cold, damp, and changeable, 
to a more equable, warmer, and drier climate, whenever practicable, is a measure froiT> 
51 



802 



DIARRHCEA. 



which the very best results are to be anticipated; it has, in numerous instances, been known 
to effect a speedy cure, when all other means have failed. 

In regard to exercise, even the gentlest kind, whether passive or active, cannot sometimes 
be undertaken, from the frequent and pressing calls to evacuate the bowels which occasion- 
ally are found to be excited by motion of every kind : in other cases, short walks in the open 
air, in suitable weather, or a gentle ride in an open carriage, or sailing in a boat, are advan- 
tageous, and should be repeated daily if the patient's strength will admit of it. 

The warm bath, followed by brisk friction of the surface, is a remedy from which the best 
effects are to be anticipated in most cases of chronic diarrhoea; it maybe repeated daily, the 
temperature of the water being carefully graduated by the condition of the patient's surface ; 
when this is dry and warm, a tepid bath should be preferred, but if the surface is cool, or 
its heat is not well sustained, the water should be decided IJr warm. The temperature of 
the bath should never be so low as to cause the patient when immersed in it the slightest 
sensation of chilliness on the one hand, nor so high on the other, nor the continuance in it 
so long, as to produce profuse perspiration. 

By a few physicians the effects of leeches to the abdomen or to the anus, in cases of chro- 
nic diarrhcea, are spoken of in the highest terms of commendation. Drs. Crampton and 
Forbes, in their very excellent essay on the disease under consideration, contained in the 
Cyclopaedia of Practical Medicine, (^Philadelphia Edition, vol. i., p. 640,) spealc of leeches ap- 
plied to the anus, as a remedy " possessed of remarkable powers — often working,'' according 
to the common expression, " like a charm, even in cases of diarrhoea of very long standing, 
and of different external characters. Combined with proper diet, indeed, we are per- 
suaded," they remark, "that the greater number of diarrhoeas, both acute and chronic, will 
yield to this method, with little or no aid from other medicine." — "Although, in our prac- 
tice, we always," they add, ''combine with the use of leeches, in the cases where they are 
indicated, a proper diet, yet we have had ample evidence of their unassisted powers in 
checking or removing diarrhcea of great severity and obstinacy." 

It is certain that many of the most obstinate cases of chronic diarrhcea are kept up by a 
subacute inflammation of some portion of mucous membrane of the large intestines, and in f 
such cases a well-timed application of leeches to the anus will be productive of the best j 
effects. In such cases, the earlier the leeches are applied the better. In detecting the cases j 
in which leeching is indicated, will demand a good deal of tact, and close habits of observa- 
tion on the part of the practitioner — his judgment must be made up from an inquiry into the 
history, and a careful analysis of all the circumstances of each case, for we know of no lead- 
ing phenomena by which those cases where leeches are calculated to do good can be distin- | 
guished from those to which they are not adapted ; as a general rule, however, we are per- ' 
suaded that in well-marked cases of chronic diarrhcea, particularly when the disease has j 
existed for any length of time, leeches are at best a doubtful, if not an improper remedy. ' 

Blisters to the abdomen will, we apprehend, be found more generally advantageous than I 
leeches; we have found them to produce a speedy, marked, and prompt amelioration in the j 
prominent symptoms of the case ; the frequency of the stools, under their use, being speedily i 
diminished, and the discharges assuming a more natural appearance. In many instances, j 
however, we confess tliat no benefit whatever has resulted from repeated blisters. They are { 
a remedy, nevertheless, which so generally do good that they should not be overlooked. j 
Keeping on the blister for a few hours, and then replacing it by a soft emollient poultice ; 
repeating it as soon as the vesicated surface has healed, is a preferable plan to allowing the 
blister to remain on until complete vesication is produced, and keeping up the irritation thus j 
produced by stimulating dressings. j 

The principal internal remedies from which any good effects are to be anticipated are, 
opiates and astringents. Opium, either by the mouth, or introduced into the rectum, in the ' 
form of an injection, acts beneficially by quieting the pain and other uneasy sensations under | 
which the patient labours, as well as by allaying the irritability of the bowels, and thus sus- 
pending the frequency of the stools ; it aids in this manner the efficacy of whatever astringent j 
is r/wade use of. The Dover's powder will frequently be the best form in which the opium i 
can be administered ; or, if this be found to disagree with the stomach, as will sometimes 
be the case, the opium may be given in the form of a pill; combining it with a small por- j 
tion of ipecacuanha, we have generally found advantageous : or the opium may be given as j 
an enema rubbed up with starch. The dose of the opium, and the period of its repetition, | 
must be left to the judgment of the practitioner. — We have not derived the same advantage 
in cases of chronic diarrhoea, from the salts of morphium as from the opium itself. i 

Of astringents, nearly the whole list, both vegetable cflid mineral, has been recommended, j 
and each one is praised by different practitioners as particularly efficacious in the disease •, 
under consideration. The vegetable astringents most deserving of attention are, the catechu, \ 
kino, galls, logwood, blackberry root, and the root of the geranium maculatum. The first |: 
may be given in the form of the infus. catechu comp. Dr. Pemberton prefers the kino to all • 
other astringents, in chronic diarrhoea; he gave it in doses cf a scruple made in a bolus with ; 
opiate confection (on Diseases of Abdom. Viscera). More recently, an extensive series of ex j 



DIARRHCEA. 



803 



periments on the effects of kino in diarrhoea were made in the hospital La Pitie, in Paris, by 
M. Bally. In chronic diarrhoea, unaccompanied by fever or marks of inflammation in the 
mucous membrane, the continued use of the remedy, even for a short time, was found almost 
invariably to be effectual in stopping the diarrhoea. In one case of three years standing it 
effected a cure. But the most remarkable result of M. Bally"s experiments is the alleged 
fact — that the kino, given in doses of twelve or fifteen grains, for several days in succession, 
succeeded in curing diarrhoea attended by febrile and inflammatory symptoms. (Crampton 
and Forbes, from Med. Gazette, v. 700.) We have repeatedly employed both the catechu and 
kino in cases of chronic diarrhoea where astringents were evidently indicated, and although 
their beneficial effects were often promptly exhibited, they have, nevertheless, repeatedly 
failed in diminishing the frequency of the discharges ; we have found the galls, either in 
powder — combined with camphor or opium, and not unfrequently with both — or in decoc- 
tion, a much more effective astringent in protracted and obstinate cases of diarrhoea, than 
either the kino or catechu. The logwood in decoction is a favourite remedy with many prac- 
titioners ; we have, however, been disappointed in its effects ; it may serve as a useful vehi- 
cle for more active remedies. The dewberry-root is unquestionably a very powerful astrin- 
gent, and well adapted to the disease under consideration; in infusion or decoction it is 
extensively employed by the physicians of the United States, as is also the root of the gera- 
nium maculatum, the effects of which latter, in chronic discharges from the bowels, are very 
highly spoken of by many practitioners. 

Of the mineral astringents, we know of none superior, in cases of chronic diarrhoea, to the 
acetate of lead ; in the dose of one grain, combined with a quarter of a grain of opium and 
the same quantity of ipecacuanha, repeated every three hours, it will, in a large number of 
cases, promptly arrest the disease. The alum will, also, be found a good astringent in chro- 
nic diarrhoea; it may be administered in the form of alum whey, or in substance, combined 
with opium. We have given it in conjunction with powdered galls and with the best effects. 
The sulphate of copper, which has been employed in combination with opium by Dr. Elliot- 
son with the most decided success, has repeatedly succeeded in our hands in arresting the 
disease under circumstances the most unpromising. The mode in which we have generally 
employed it, has been in a quarter or one-third of a grain doses combined with two grains 
of extract of quina and a fourth of a grain of opium every three hours. The protocarbonate 
of iron, the tincture of the chloride of iron, and the solution of the persesquinitrate of iron, 
we have repeatedly employed, and in cases of long standing have found them, especially the 
first two, very efficacious. They are particularly well adapted to protracted cases of the dis- 
ease, attended with great prostration, and more or less infiltration of the subcutaneous cellu- 
lar tissue. 

The balsam copaiba and spirits of turpentine are among the remedies from which, in nu- 
merous cases of chronic diarrhoea, the very best effects may be anticipated. When the dis- 
charges from the bowels are small in quantity, and resemble in consistence thin starch or 
mucilage, or when they are dark-coloured and of a rank offensive odour, we are acquainted 
with no remedies from which the same amount of good may be anticipated. They may be 
combined with opiates and astringents where these are considered necessary. The spirits 
of turpentine we employ more frequently than the copaiba ; it is, we believe, equally effica- 
cious, while it is more easily taken by the patient, and agrees better with the stomach; it 
may be combined with siinple syrup and water, by adding a few grains of magnesia. 

A variety of other remedies are recommended by different writers, the efficacy of which 
is highly extolled. The most prominent are Hope's Mixture, which is a mixture of nitrous 
acid, camphor water and laudanum — the nux vomica and its active principle; the ferrocya- 
nuret of iron ; the nitrate of silver, and the resinous extract of the artemisia vulgaris. Of the 
effects of these we have had no experience. 

In those cases in which the diarrhoea appeal^ to be kept up by ulceration seated just 
within the verge of the anus, very speedy and permanent relief will always be obtained by 
touching the u leers with nitrate of silver. 

We have given above an outline of the treatment demanded in the chronic form of diar- 
rhoea ; in conclusion, we would remark, that the management of this disease always requires 
the exercise of great judgment and discretion on the part of the practitioner. Nothing would' 
appear more easy than by opiates and astringent remedies to arrest the inordinate discharges 
from the bowels, and thus to effect the cure of the patient, but it will be found that, in many 
cases, when astringents are too early resorted to, the disease, instead of being removed, is 
aggravated ; or if by our astringents we do succeed in suspending the discharges from the 
bowels, a swollen and painful state of the abdomen quickly succeeds, producing greater dis- 
tress to the patient, and terminating more promptly in death, than had the diarrhoea been 
allowed to run its course. In numerous instances, chronic diarrhoea may be very effectually 
cured by a proper regulation of diet and regimen, the warm bath, blisters to the abdomeuj 
and internally the blue pill or calomel combined with opium and ipecacuanha, and, perhaps, 
the use, at the same time, of moderate doses of copaiba or turpentine, without astringents. 
There are, however, unquestionably, many cases, in the course of which astringents, and of 



804 



SPORADIC CHOLERA. 



the most powerful kind, are demanded in order to effect a removal of the disease, and otheFSj 
in which mild astringents, early administered, Mali very materially shorten its duration; and 
it is in rightly determining the cases and period of the disease, in which astringents are in- 
dicated, that the success of the practitioner in effecting its cure will frequently depend. — C] 

I have alluded to the influence of hot weather in predisposing the system to be 
affected by the exciting causes of diarrhoea. And there is a complaint of which 
diarrhoea is one prominent symptom, but which is something more than mere diar- 
rhoea — that shows itself in this country more or less, every autumn, and prevails 
extensively in some years, as a m.inor epidemic. It is rightly enough named cho- 
lera; for it is attended with, and consists mainly of, a remarkable flux Oi bile. Sy- 
denham held that the disease is hmited to the month of August ; and that bowel affec- 
tions, with vomiting, occurring at other times, are not genuine cases of cholera. But 
this was one of that great man's crotchets. The symptoms that mark this complaint 
are vomiting and purging of liquid matter, deeply tinged with, and principally com- 
posed of, bile ; violent pains in the stomach and bowels ; cramps of the legs and of 
the abdominal muscles ; a great depression of the vital powers, and a tendency to 
syncope or collapse. 

The attack is generally sudden. At first the contents of the alimentary canal are 
evacuated; and then a quantity, an enormous quantity sometimes, of a turbid, yel- 
lowish, acrid fluid, is expelled with violence both from the bowels, and by vomiting. 
The patients complain of a burning sensation in the epigastrium. As the vomiting 
and purging go on, clonic spasms of the lower extremities, and especially of the 
gastrocnemii, occur ; the surface of the belly is drawn up into knots : and after a 
while, the patient, exhausted by the pain and the spasms, and still more so by the 
copious discharges, grows cold and faint. Sometimes actual syncope happens ; and 
sometimes death. 

Death, however, is an uncommon event of this form of cholera, in this country. 

The chief cause of cholera, such as has now been described, appears to be casual 
exposure to cold, after a continued high temperature of the atmosphere: and the 
great irritation of the stomach and bowels evinced by the symptoms, proceeds 
from the presence of bile in the intestines in undue quantity, and rendered more 
acrid than usual by some morbid alteration of its quality. The attack seems to 
be often deiermined by some of those causes of irritation which I just now men- 
tioned when speaking of simple diarrhoea; and particularly by imprudence in eating 
and drinking. 

I believe that no better treatment can be followed in this disease than that long 
ago laid down by Sydenham. He observes that any attempt to stop the purging and 
vomiting by strong drastic aperients, under the notion of expeUing the irritant matter, 
Vvould be like endeavouring to extinguish fire by pouring oil upon it ; and that to 
try to lock up the acrid discharges in the alimentary canal by means of narcotics or 
astringents, would be equally hurtful. He therefore was accustomed to dilute the 
contents of the stomach and bowels by emollient drinks, and injections, especially by 
chicken broth ; and so to favour their expulsion ; and when any faintness or sign of 
sinking began to show itself, to administer laudanum in full doses. We are seldom 
summoned to these cases in the outset. Generally the vomiting and diarrhoea have 
continued for some hours before we see the patient: so that it is expedient to give 
the opiate as soon as we can. If the stomach be very irritable, solid opium in the 
form of pill may be preferable to laudanum ; or an opiate clyster — or an opiate sup- 
pository — may be introduced into the rectum. 

[In such cases we know of no remedy more effectual than a pill composed of opium, 
camphor and acetate of lead, in the proportion of one grain each. When the stomach is so 
irritable that the pill is quickly rejected, a solution of acetate of lead, eight grains to 
two ounces of water, with the addition of one grain of the acetate of morphia, in the dose 
of a teaspoonihl, repeated at proper intervals, will very generally be retained. — C] 

When the skin is cold, and the pulse sinking or irregular, carbonate of ammonia, 
or brandy and water, may be given by the mouth ; and a mustard poultice, or a bag 
of hot salt, or a moist and hot flannel sprinkled with oil of turpentine, should be 
applied to the abdomen. The cramps of the extremities may be reheved by dili- 



• 



\ 



EPIDEMIC CHOLERA. 805 

gent friction with the hand ; or some stimulating liniment may be rubbed upon the 
affected muscles. When the collapse is great, the patient should not be allowed to 
raise himself out of the horizontal posture, lest fatal syncope should follov/. Opium, 
however, is our sheet-anehor in this complaint : it sustains the flagging powers, while 
it quiets the gastro-intestinal irritation. 

After an attack of severe cholera, the patient is apt to be left extremely feeble ; 
with soreness of the muscles of the trunk and limbs : and sometimes, symptoms of 
inflammation of the mucous membranes will supervene ; pain and tenderness of the 
belly, a white tongue, thirst, and fever. And these symptoms may require some of 
the remedies of inflammation. 

Such is the disease which has long been famihar to English practitioners, as cho- 
lera: but about twelve or thirteen years ago, this country was visited by a severe 
epidemic disorder, which was also called cholera ; or by way of emphasis, the cho- 
lera ; or sometimes spasmodic cholera ; or Asiatic cholera ; or malignant cholera. 
The symptoms of this new disease resembled, in some points, those of the old- 
fashioned cholera: but differed from them in more, and in more important, particu- 
lars. So that the apphcation of the term cholera, or cholera morbus, to both these 
morbid affections, is very much to be regretted, for it has produced a great deal of 
confusion and inconvenience. 

I scarcely know how to name the newer and severer disorder. I have no right 
to alter the received nomenclature ; and choosing from among the many appella- 
tions which have been given to the complaint, that epithet which seems the least 
objectionable, I may call it epidemic cholera: although this term is objectionable, 
since the other malady, the English or sporadic cholera, is sometimes also epi- 
demic. 

The epidemic cholera so far resembled the sporadic, that it was attended by pro- 
fuse vomiting and purging, by extreme prostration of strength, and by cramps. But 
it differed remarkably in these respects; in the circumstance that the matters ejected 
from the stomach and bowels contained no bile (and this alone is a good reason 
against calling the disease cholera) ; in the early supervention of the symptoms of 
collapse ; and in the great mortality of the disorder. 

The amount of the fluid matters thrown up from the stomach and discharged by 
the bowels, was really in many cases wonderful. At first, perhaps, the patient would 
have so copious a stool — a consistent dejection it might be, but so large in quantity — 
as to lead him to conclude that the whole contents of the intestines had been evacu- 
ated at once. Yet soon afterwards a turbid whitish liquid would again and again 
pour from his bowels in streams ; and be spouted from his mouth as if from a punip : 
not in general with much effort, but easily and abundantly. The matters thus dis- 
charged were thin, and for the most part of a whitish colour, like water in which rice 
has been boiled ; without fecal smell ; and containing small white albuminous flakes. 
There were some varieties in the evacuations, but the kind I have mentioned, resem- 
bling rice-water, was the most common and the most characteristic : and however 
else their sensible qualities might vary, this circumstance was universal, that they 
contained no bile. 

With all this there was early sinking, and collapse, as it was called. This term 
collapse expressed a general condition, made up, in the most exquisite cases, of the 
following particulars: — A remarkable change took place in the circulation, and a 
striking alteration in the appearance of the patient. The pulse became frequent, 
very small and feeble, and at last, even for hours, sometimes, extinct at the wrists. 
The surface grew cold ; and in most, or in many instances, blue as well as cold. The 
lips were purple; the tongue was of the colour of lead, and sensibly and unplea- 
santly cold to the touch, like a frog's belly; and the breath could be felt to be cold. 
With this coldness and blueness there were a manifest shrinking and diminution of 
the bulk of the body. The eyes appeared sunk deep in their sockets ; the cheeks 
fallen : in short, the countenance became as withered and ghastly as that of a corpse. 
The cadaverous aspect that sometimes precedes death in long-standing diseases, . 
would come on in the course of an hour or two, in this complaint. If the physi- 

3s 



806 



EPIDEMIC CHOLERA. 



cian left his patient for half an hour, he found him visibly thinner on his return. 
The finger nails became blue ; the hands and fingers shriveled, white, corrugated, 
and sodden, like those of a washerwoman after a long day's work. The skin was 
bathed in a cold sweat. The voice becam.e husky and faint. So pecuhar was this 
change, that ihe sound was spoken of as the vox cholerica. These are the symp- 
toms which the single word collapse was meant to express. 

Another very striking feature of the disorder was the muscular cramp ; affecting 
the muscles of the thighs and calves of the legs, rendering them as hard and rigid 
as wood ; and drawing up into knots the muscles of the abdomen. These spasmodic 
contractions were attended with severe pain, and constituted the greater part of the 
patient's suffering. During the continuance of the symptoms that I have been en- 
deavouring to describe, not a drop of urine was passed or secreted. One man, who 
was under my own observation and care, and who recovered, did not void a drop of 
M^ater from Sunday morning till the afternoon of the following Wednesday. 

Even in the extreme state of collapse the intellect remained quite clear: the 
patients would continue to talk rationally to the last moment of their lives ; and, 
for the most part, they seemed singularly indifferent and apathetic about their 
condition. 

In the fatal cases — and a very fearful proportion of the whole number wei^e fatal — 
death took place sometimes in the course of two or three hours ; and it was seldom 
delayed beyond twelve or fifteen. In those that recovered, the favourable symptoms 
Vv^ere the cessation of the vomiting, purging, and cramp ; the return of the pulse, and 
of warmth to the surface ; the disappearance of tlie blueness of the skin, and of the 
hippocratic countenance ; the re-appearance of bile in the alvine evacuations ; and 
the restoration of the secretion of urine. 

The course of the symptoms varied a good deal in different persons. Sometimes 
the vomiting and purging soon ceased, and sometimes there w^as neither sickness nor 
diarrhcea at all, but rapid collapse and sinking. These were thought the most formi- 
dable cases. However, the pecuhar secretions were poured forth, in some, at least, 
of the instances in which none of them were ejected from the body. A patient died 
of cholera in the Middlesex Hospital without any vomiting or purging : but on ex- 
amining the dead body, we found the intestines quite full of the rice-water serous 
fluid. Sometimes the cramps were not very troublesome. The cutaneous bluen;-ss 
was not a universal phenomenon. The patients were in general tormented by thirst: 
and when attempts were made to bleed them, the blood was found dark and thick, 
like treacle, and scarcely moving, if moving at all, in the veins : in some cases it 
could not be made to flow out. Considerable hurry and anxiety of the breathing 
were also symptoms that I omitted to mention before. 

Examination of the dead bodies threw no light, that I know of, upon the nature 
of this frightful disease. The alimentary canal generally was found to contain a 
white hquid, having whiter flakes in it; such as had previously issued from the 
bowels : and the mucous glands of the intestines, both the solitary and the agmi- 
nated, were usually large and conspicuous. The veins were loaded with thick, black, 
tar-like blood ; and the urinary bladder was always found empty, and contracted into 
the size of a wahiut. Even when the blue colour had existed in a marked degree 
during life, it often quickly disappeared after death. And another most singular 
phenomenon was occasionally remarked in the dead body. A quarter or half an 
hour, or even longer, after the breathing had ceased, and all other signs of animation 
had departed, slight, tremulous, spasmodic twitchings and quiverings, and vermicular 
motions of the muscles would take place ; and even distinct movements of the hmbs, 
in consequence of these spasms. 

The disease, of which I have drawn but a faint outline, was not known in this 
country till the autumn of the year 1831. There are persons, 1 am aware, who hold 
that it has always existed among us ; only not in such numerous instances as at that 
period ; and they appeal to Morton, and other early writers on the diseases of this 
country, in support of their opinion. But the malady was too striking to be over- 
looked, or ever forgotten, by any one who had once seen it. Certainly, tiU that year 
I never saw anything hke it. To be sure, I had not at that time been very many 



EPIDEMIC CHOLERA. 



807 



years in practice here. The late Dr. Bahington, however, told me that it was quite 
new to hira. He had, for a very long period, been in extensive practice, in those 
parts of the metropolis and its vicinity where the epidemic cholera raged most ; and 
when it first came among us he had the curiosity to ask every medical man whom 
he met, whether he had seen any case of the cholera ; and if the answer was " yes," 
he went on to inquire, whether, before that year, the person had ever met with the 
same complaint ; and the reply was always, without a single exception, "no." Yet 
I say there were, and are, a few practitioners who denied, and deny, that it was any- 
thing more than the common and well-known English complaint, raging with unusual 
frequency and violence. 

But we have evidence of a different kind of the nevvmess of the epidemic cholera 
to these kingdorps. Its approach was discerned afar off, as distinctly as a storm is 
foreseen by the rising of the clouds from the horizon in the direction of the w-ind. 
The disorder began to rage wdth terrible severity, in India, in the year 1817. I do 
not mean that it then broke out there for the first time. It had visited those regions 
again and again before. But from its eruption in the year I have mentioned, when 
it committed frightful devastation in the armies in the north-eastern districts of India, 
its course can be distinctly traced to our own shores; towards which it approached 
with slow and halting, but with sure steps, in a north-western direction. From India 
it spread to Persia ; and thence to Russia ; and across through Poland to Germany : 
and at length it was found at Hamburgh. It was predicted before that time, that the 
distemper would at length reach Great Britain. Our government had even sent two 
physicians into Russia to investigate its nature, in the fearful anticipation that its 
march across the earth would continue progressive ; and accordingly, at the expira- 
tion of fourteen years, it made its appearance on the eastern coast of this country ; 
in Sunderland : and in due time extended over every part of these islands. I say 
its arrival had been foreseen and foretold ; and it is absurd to suppose that a vast 
number of persons would fall sick and die, with symptoms quite strange to the great 
mass of practitioners here, merely to fulfil this prediction. 

The progress of the disorder did not end here., Crossing the Atlantic, it invaded 
America ; turning, at the same time, in a south-easterly direction, it ravaged France 
and Spain, and the north coast of Africa, and Italy. 

Moving thus onward, as it did, in defiance of all natural or artificial barriers, 
under opposite extremes of temperature and climate, in the teeth of adverse winds, 
over lofty mountain chains, across wide seas, through "hot, cold, moist, and dry" — 
in what manner, you will probably ask, was this wasting pestilence propagated ? 

Upon this point various and discordant opinions are entertained. Many persons 
believe that the complaint spread by contagion ; more, however, that it was not con- 
tagious at all, but arose from some deleterious cause with which the general atmo- 
sphere of the place was pregnant. Now 1 cannot reconcile the phenomena of the 
appearance and extension of the malady with either of these hypotheses exclusively. 
It must, 1 think, be granted that the complaint, in every instance, was excited by the 
application of some noxious material to the body, some positive poison. It is certain, 
also, whichever hypothesis may be chosen, thai many more individuals were exposed 
to the agency of this poison, than were injuriously affected by it. This exemption 
from the disease no more invalidates the doctrine of contagion, than it invalidates the 
doctrine of some diffused atmospheric influence ; nay, it is more explicable upon the 
former than upon the latter supposition ; for while many may avoid a specific conta- 
gion, all are immersed in, and all breathe, the common atmosphere. But the ex- 
emption shows this : that the exciting cause, to be effective, required a fit recipient: 
that the susceptibility of being hurt by the poison in its ordinary dose and intensity 
varied much in different persons; and in the majority was very faint, or wanting. 
It is clear that the poison travelled. It is equally clear to my mind, that it was 
portable; and therefore communicable from person to person. I even believe that 
it was capable of being conveyed, and was actually conveyed, from one spot to 
another, by persons who were themselves proof against its effects. The innumerable 
authentic instances of coincidence, in point of time, between the first outbreak of the 
disorder in a particular place, and the arrival at that place of some person or persons 



EPIDEMIC CHOLERA. 



from an infected locality, prove that the poison could be thus carried. Of this direct 
importation of the disorder into new and distant places, by infected individuals, and 
of its subsequent extension from those individuals to others who had intercourse with 
them, you may see a vast number of examples, collected by Dr. James Simpson, in 
the 49th voJume of the Edinburgh Medical and Surgical Journal. The evidence 
there adduced of the portability of the poison is abundant, and to rpy mind, irresist- 
ible. Whether the malady was contagious in the same sense in which small-pox is 
contagious — whether, I mean, the cholera poison had the power of multiplying and 
reproducing itself in the human body, as yeast multiplies itself during the fermenta- 
tion of beer — is a different and a much more doubtful question. A disorder may be 
contagious, without this property of reproduction in the animal fluids. The itch is 
contagious. The itch is produced by a minute parasitic animalcule, whose existence 
has, of late years only, been assured to us by the microscope. Suppose that these 
itch insects could fly, or were capable of being wafted through the air — they would 
then represent what is conceivable enough of the subtle exciting cause of cholera. 
Between the two epidemic distempers, influenza and cholera, there were numerous 
and striking points of similitude or analogy. They have observed the same, or very 
nearly the same, geographical route. Both, issuing from their cradle in the east, 
have traversed the northern countries of Europe, till, arriving at its western boundary, 
they have divided into two great branches ; the one proceeding onwards, across the 
Atlantic, the other turning in a retrograde direction, towards the south and east. 
The main differences between them have been, that whereas the poison of influenza 
spared very few of the commmiity, inflicting a disease which, of itself, was seldom 
fatal — the poison of cholera, on the contrary, smote very few, but with so deadly a 
stroke that as many sank beneath it, probably, as recovered. Both were general 
disorders, affecting the whole system, but in both the most prominent of the symp- 
toms had reference, in the majority of cases, to the mucous membranes ; to those of 
the air-passages in the influenza ; to those of the alimentary passages in the cholera. 

Now this strong analogy has been made use of as an argument that the cholera 
was not contagious. " The influenza (say the objectors) had no contagious proper- 
ties ; therefore it is, d priori, likely that the cholera had none." But i demur to the 
major proposition. Cullen thought the influenza was contagious, and I adverted, in 
a former lecture, to some facts which favour that belief. Supposing it, however, to 
be so, the proof of its contagious property must, from the very nature of the case, be 
extremely difficult. Its visitations are so rapid, widely spread, and multitudinous, 
that there is no time for its transference from house to house, or from person to per- 
son ; yet it may be nevertheless transferable. Its inherent rate of locomotion outstrips 
and precludes the tardier conveyance of the poison by man. Its contagious qualities 
(granting them to exist) are hidden in its universality, and can seldom be traced but 
by accident. I therefore esteem this argument from analogy as worthless ; and my 
own creed respecting the cholera is, that it 7i;as contagious, in the limited sense 
already explained ; but that its contagious power was not very great : that a com- 
paratively small part of the population, of this country at least, v;as susceptible of its 
operation ; and that few were in much danger of suffering from exposure to the 
physical cause of the disease, except under circumstances of predisposition. At the 
same time I believe that a great majority of the cases of cholera were not attributable 
to direct contagion, but to the poison diffused through the atmosphere. There is no- 
thing inconsistent in the supposition that this noxious matter travelled sometimes by 
its own peculiar powers, sometimes made use of vehicles. 

[During the prevalence of the cholera in Philadelphia, in 1832, we closely investigated 
every fact calculated to throw light upon the question of its contagious or non-contagious 
character, and for this investigation, our position in the Board of Health and as chief of a 
large hospital, alforded us ample opportunities — but we were unable to discover the slightest 
evidence of the disease having been in any one instance communicated from the sick to the 
well.— C] 

This, I say, is my creed upon the vexed question of contagion. Respecting the 
special nature of the poison I can only guess ; and my guessing, as you may have 
perceived, takes the same direction as before. I adveirted, when speaking of the 



EPIDEMIC CHOLERA. 



809 



influenza, to what Dr. Holland has called "the hypothesis of insect life as a cause 
of disease." I shall not repeat the observations I then made ; but I would refer you, 
for much curious thought and information upon the subject, to Dr. Holland's very 
interesting essay. The hypothesis in question squares more readily than any other 
that I know of, with the ascertained history of the disorder: with its origin, after an 
unusually wet season, in the low marshy country, and hot atmosphere of Bengal: 
with its, irregular but continuous migrations : with its dying away after a while, and 
its occasional and partial revivals. But still, remember that we are deahng merely 
with an hypothesis. 

Whatever obscurity may overhang the exciting causes of the epidemic cholera, 
we are quite sure that certain circumstances exercised a strong predisposing influence 
upon the human body, to render it more than usually susceptible of the disease. 
The predisposing causes, as might well be imagined, were such as tended to debili- 
tate the system : and therefore poverty, which implies scanty nourishment, and 
frequently also the confinement of several persons to a narrow space, and want of 
fresh air; poverty, which includes these and other evils, was found to predispose the 
body to a ready reception of the malady. But to infepiperance, more than to any 
other single cause, may the pi'oclivity to become affected by this species of cholera 
be ascribed ; and especially to the intemperate and habitual use of distilled spirits. 
This fact was peculiarly manifested in the selection, by the disease, of its victims in 
this country ; and it has been remarked almost everywhere else. 

I have all along spoken of the visitation of epidemic cholera in the past tense, 
because, for the last eleven or twelve years, we have heard but little of it. Yet we 
can scarcely venture to hope that the stranger pest has altoirether forsaken us, for we 
have had slight sprinklings of the disease in and near London, every summer, I be- 
lieve, since 1832; but it has never again been extensively prevalent or epidemic. 
Certainly it dealt lightly, upon the whole, wath our country. It was much more 
general, and more widely fatal, in France, wdiich it visited subsequently to its arriving 
here : it was very destructive also in its subsequent course, both westward and to- 
ward the south-east. 

The epidemic cholera made its attack in two different modes. In one it seized 
upon the patient suddenly, and without warning. This was comparatively rare. 
Much more commonly the specific symptoms were preceded, for some iitde time, 
even for some days perhaps, by diarrhoea. And this I take to be the most important 
practical fact that was ascertained during its prevalence among us. When the dis- 
ease Avas once fairly formed, medicine had very little powder over it ; but in the pre- 
liminary stage of diarrhoa it was easily manageable. Unfortunately people are 
inclined (especially those classes of the community among whom the cholera most 
raged), to regard a loose state of the bowels as salutary ; and to make no complaint 
of it, and to do nothing for it: or, in other cases, they conceive it to proceed from 
some peccant matter within, which requires to be carried off, and they take purgative 
medicines to get rid of it. Both of these are serious and often fatal mistakes. M&re 
neglect of the diarrhosa frequendy permitted it to run into well-marked and uncon- 
trollable cholera; and the employment of purgatives hastened or insured that cata- 
strophe. The proper plan of proceeding, I am convinced, was, to arrest the diarrhoea 
as soon as possible after its commencement, by astringents, aromatics, and opiates. 
You may object, perhaps, that the cases that were cured in this way were not cases 
of cholera at all, and never would have been ; but simple ordinary diarrhcea. It is 
impossible to prove the contrary, no doubt; but the presumption is strong that the 
diarrhea would in many, and, perhaps, in most instances, have run on, if not check- 
ed, into the more perilous form of the disease. In many places, when, taught by 
experience, the authorities established diarrhcea dispensaries, to which those attacked 
by looseness of the bowels were warned and invited to apply, that the looseness 
nriight forthwith be corrected ; in many such places the cholera, which had before 
been cutting the inhabitants off by scores, and hundreds, began instantly to decline 
in frequency. I venture to advise you, supposing the disease should reappear, or 
whenever in the autumn a suspicion arises that this form of cholera is present in the 

3s2 



810 



EPIDEMIC CHOLERA. 



community, not to try, in cases of diarrhosa, to carry off the presumed offending 
matter, but to quiet the irritation, and stop the flux as soon as you can. 

But when the regular symptoms, peculiar to the severe form of cholera, had set 
in, medicine, I repeat, had very little influence upon it : and accordinglj^ as might 
have been expected, a hundred different cures of the disease vs^ere announced, most 
of them all but infallible. Some persons held that timely bleeding would save the 
patient ; others relied confidently upon mustard emetics. Hot air baths were manu- 
factured, and sold to a great extent, to meet the apprehended attack in that manner 
without delay. Certain practitioners maintained that the disease was to be remedied 
by introducing into the system a large quantity of neutral salts, which were to liquefy 
and redden the blood, and to restore the functions of the circulation. But of this 
practice it was said in a sorry but true jest, that however it might be with pigs or 
herrings, saliing a patient in cholera Avas not always the same thing as curing h\m. 
In a great number of the sick the blood was mechanically diluted by pouring warm 
water, or salt and water, into their veins. Some physicians put their trust in brandy, 
some in opium, some in cajeput oil, which rose to I know not what price in the 
market ; some again, in calomel alone. 

Now, I would not willingly mislead or deceive you on this point, by speaking 
with a confidence which I really have no warrant for, of the success or propriety bi 
any of these expedients. I believe that each in some cases did good, or seemed to do 
so ; but I cannot doubt that some of them did sometimes also harm. I had not more 
than six severe cases under my own charge: and I congratulated myself that the 
mortality among them was not greater than the average mortality. Three died, and 
three (I will not say were cured, but) recovered. The three that died I was called 
in to see when the disorder was at its height : and in each case it went on with 
frightful rapidity, in spite of all the means adopted, and proved fatal a few hours 
afterwards. The three that recovered I saw somewhat earlier, but still not till the 
specific symptoms were present : one was a girl in the hospital. They all recovered 
under large and repeated doses of calomel. Yet (as I said before) I do not venture 
to affirm that the calomel cured them. In the first case which was treated in that 
way, I merely followed up the plan that had been begun by Dr. Latham, who had- 
visited the patient for me when I was accidentally absent. I found that he had felt 
better, less sick and less faint, after taking half a drachm of calomel at a dose ; and I 
repeated the same dose many times, for after every dose his pulse rose somewhat, 
and he appeared to rally. This was the same man whom I mentioned before as 
having made no urine from the Sunday to the Wednesday: all that time he kept 
discharging rice-water stools. At last, on the fourth day he passed a little water, 
and his alvine evacuations became rather more consistent, and began to look green : 
and from that time he gradually got well. Afterwards I treated my hospital patient 
in the same way, and with the same event. Yet I will not pretend to say that these 
persons might not have done quite as well if they had been left entirely to them 
selves. 

[^oon after the appearance of the cholera in Philadelphia, we were persuaded that had 
we a remedy capable of arresting the inordinate serous discharge, which in this disease is 
poured out by the mucous membrane of the alimentary canal, we should very readily suc- 
ceed in its cure. We were, therefore, induced to try the eflects of the acetate of lead, with 
the remedial powers of which in a somewhat analogous disease, the cholera of infants, we 
were familiar. We administered it in pills, combined with opium and camphor, or when 
the stomach rejected it in this form, in solution with the acetate of morphia, and at the same 
time, by the rectum, in injections composed of a strong solution with the addition of lauda- 
num. Under this plan of treatment, the discharges were in numerous instances promptly 
arrested, and tlie patients recovered, even after the stage of collapse had ensued. From our 
subsequent experience with this plan of treatment, we are convinced, that had the remedy 
been generally resorted to from the commencement of the epidemic, the mortality of the 
disease would have been materially reduced. Since 1832 many cases of the cholera have 
occurred every year; all that have fallen under our notice were treated by the acetate of 
lead, and we have lost none. — Dr. Graves has subsequently recommended the same remedy, 
and speaks of its effects in the highest terms. — We usually administer the acetate of lead in 
the dose of one grain, combined with one of opium and the same quantity of camphor, 
^.very hour, or two, or three, according to the violence of the attack. The thirst of the 



CHOLERA INFANTUM. 



811 



patient was assuaged by small portions of ice held in the mouth and allowed slowly to dis- 
solve — large and frequent draughts of cold water we always found to be injurious. — Cups to 
the abdomen were frequently employed, and we have reason to believe always with advan- 
tage. — From warm bathing, dry heat to the surface, sinapisms, stimulating pediluvia, we 
never saw any good effects result. — C] 

Some of the expedients recommended had certainly a very marked and immediate 
effect upon the condition of the patients, especially the injection of warm water into 
the veins. Many instances of this were related at the time. One I myself saw. 
The patient was a young man, who was nearly moribund apparently. His pulse 
had almost, if not quite disappeared from the wrist ; he was very blue, and his visage 
was ghastly and cadaverous : in one word, he was in an extreme state of collapse. 
Out of this he was brought in a few minutes by injecting warm water into one of 
the veins in the arm. The pulse again became distinct and full ; and he sat up, and 
looked once more like one alive, and spoke in a strong voice. But he soon relapsed ; 
and a repetition of the injection again rallied him, but not so thoroughly : and in the 
end he sunk irretrievably. Dr. Babington told.me of a patient whom he saw speech- 
less, and all but dead, and whose veins were injected. He then recovered so as to 
sit up, and talk, and even joke, with the bystanders : but this amendment did not 
last either. Yet even this temporary recovery might sometimes be of great import- 
ance : might allow a dying man to execute a will for example. And some of the 
persons thus revived got ultimately well. We had for some time a woman in the 
Middlesex Hospital acting as nurse, who had been rescued, when at the verge of 
death in cholera, by the injection of warm water into her veins. 

It was remarked of those who recovered that some got well rapidly, and at once ; 
while others fell into a state of continued fever, which frequently proved fatal some 
time after the violent and peculiar symptoms had ceased. Some, after the vomiting 
and purging and cramps had departed, died comatose ; oi^er-drugged sometimes, it 
is to be feared, by opium. The rude disciphne to which they were subjected might 
account for some of the cases of fever. And the process of artificially replenishing 
the veins was certainly attended with much danger. The injection of air with the 
water — inflammation of the vein from the violence done to it — an over-repletion and 
distension of the vessels by the liquid — might, any one of them, and sometimes, I 
suppose, did, occasion the death of the patient. Never, certainly, was the artillery 
of medicine more vigorously phed — never were her troops, regular and volunteer, 
more meritoriously active. To many patients, no doubt, this busy interference made 
all the difference between life and death. But if the balance could be fairly struck, 
and the exact truth ascertained, I question whether we should find that the aggregate 
mortality from cholera in this country, was any way disturbed by our craft. Except- 
ing always the cases in which preliminary diarrhoea was checked, just as many, 
though not, perhaps, the very same individuals, would, probably, have survived had 
no medication whatever been practised. 

1 do not know that I have any thing more to say that could be of any use to you, 
in respect to the epidemic cholera. 

[Of the diseases to which children are liable in the mifldle and southern portions of the 
United States, few produce a greater amount of mortality than Cholera Infantum, or 
the Summer Complaint. It is an endemic of all our larger cities, during the season of the 
greatest heat; attacking children between four and twenty months of age, or at the period of the 
first dentition. So generally is it confined to this period, that an infant's second summer is 
considered by mothers as one of unusual peril, and should it escape an attack at this period, 
or pass sat^ely through the disease, it is considered to have a fair chance of surviving the 
period of infancy. 

The first symptom of the disease is usually a profuse diarrhoea, the stool being very fluid, 
generally of a very light colour, though often of a pale yellow or green ; to the diarrhcea is 
soon added an extreme irritability of the stomach, everything taken into it being rejected 
immediately, and with violence. The irritability of stomach, in most cases, continues through 
out the attack, and in many frequent spontaneous vomiting is a prominent symptom. 

After the disease has continued for a short time, the discharges from the bowels are ordi- 
narily composed entirely of a perfectly colourless and inodorous fluid, containing often minute 
mucous flocculi, and are discharged without the least eftbrt. They are occasionally, howevf^r, 



CHOLERA INFANTUM. 

very small in quantity, and squirted, as it were, from the anus. In' these cases, there is usually 
more or less tormina and tenesmus. 

Very frequently the vomiting becomxes suspended, even at an early period of the attack, 
M^hile the discharges from the bovi^els continue, or augment in frequency and in quantity, 
the irritability of the intestinal canal being often such, as to cause whatever food or drink 
is taken to pass ofi' rapidly, without having undergone the slightest change. 

The infant becomes quickly affected with extreme langour and prostration, and is rapidly 
emaciated — being reduced in a few days, often hours, to an extent that would scarcely be 
credited by those unacquainted with the disease. 

The pulse, from the very commencement of the attack, is usually quick, frequent, small, 
and often tense. The skin is dry and harsh, the head and abdomen are often hot, while the 1 
extremities retain their natural temperature, or are even decidedly cold. The tongue is ] 
moist, and covered with a white slimy mucus. There is always intense thirst — whatever | 
fluid is taken being almost immediately ejected from the stomach. The child suffers more 
or less pain in the abdomen, as indicated by its fretful ness, low moaning cries, frequent 
change of posture, the drawing up of its knees, and its occasional acute screams. The abdo- 
men is sometimes tumid, and generally tender to the touch. Towards evening, there occurs, 
in most cases, a decided febrile reaction. 

In many cases, some degree of delirium, with an injected and wild appearance of the 
eyes, and a tossing of the head backwards and forwards, is early manifested. When this is the 
case, we have frequently seen the patient attempt to bite or scratch his attendants. 

The disease usually runs a protracted course. The discharges from the bowels continue | 
to be frequent and profuse, but dark-coloured, like dirty water, or the washings of stale meat, . i 
and often very offensive. They not unfrequently, however, are small in quantity, and composed | 
entirely of a dark-coloured mucus, mixed with the food and drinks that have been taken. 
The emaciation of the patient becomes extreme; his eyes are languid, hollow, and glassy; his i 
countenance pale and shrunken; his nose sharp and pointed: and the lips thin, dry and 
shrivelled. The surface of the body becomes cool and clammy, of a dirty brownish hue, and j 
often covered with petechise. The tongue is dark-coloured, smooth and shining, or covered, | 
as well as the parieties of the mouth, with aphthse. In many cases the child lies constantly r 
in an imperfect doze, with half-closed eyelids, and so insensible to external impressions, that i 
flies will frequently light upon the half-closed eyeballs without the patient exhibiting the | 
least consciousness of their presence. The abdomen becomes more or less tympanitic, and j 
die hands and feet of a leaden hue, or pallid and oedematous. The fauces, becoming dry, ■ 
causes a sense of uneasiness, which induces the patient to thrust his hand deep in the mouth, j 
as if to remove some offending substance. I 

In many of the protracted cases, an eruption of very minute white vesicles occurs upon j 
ihe neck and breast. This Dr. Dewees considered to be invariably a fatal symptom ; but we j 
have seen many patients recover, even when this eruption has been the most extensive and | 
distinct. j 

The patient, unless relieved from his suffering by a judicious treatment, becomes daily i 
more and more exhausted, rolls his head about when awake, and utters constantly short, } 
plaintive, scarcely audible cries. He falls at length into a state of complete coma, death being 
frequently preceded by a convulsive attack. Not unfrequently, at a much earlier period of j 
the disease, the brain becomes affected, and the child dies with all the symptoms of acute | 
meningitis. 

Cholera infantum is of very variable duration. In violent attacks, the prostration which i 
suddenly ensues is occasionally so extreme, that the patient is destroyed within the first i 
twenty-four hours. Usually, however, the disease is of many days, or even weeks' con- i 
tinuance, and the patient generally sinks, apparently from a total cessation of the nutrition I 
of the system. j 

The lesions exhibited by the post-mortem examination of those who have died from cholera j 
infantum, vary according to the period of the disease when death takes place. When the dis- i 
ease has been of short continuance, the mucous membrane of the alimentary canal presents ' 
often an abnormal paleness, and the liver is more or less congested. When the case has been i 
of a more protracted character, increased redness in points or patches, in different parts of the | 
stomach and intestines, is often present. The red points are sometimes very minute and I 
isolated, and spread over a considerable portion of the stomach and duodenum, or over the I 
small intestines only. They have the appearance, generally, of minute extravasations of | 
blood. In the lower intestines the points occur in clusters, so as to form patches of redness, i 
varying in size, though never of any great extent, and often slightly elevated, from a thick- I 
ening of the mucous tissue at the parts occupied by thein. Occasionally, portions of the 
mucous membrane are more or less softened — often without the slightest inflammation. In 
other instances, increased redness of some portion of the intestines exists, with contractions, \ 
often extreme, of its calibre. j' 

The mucous follicles of the intestines are very generally enlarged, often in a state of j 
inflammation, and occasionally of ulceration. Dr. Horner describes the appearance of the 



812 



CHOLERA INFANTUM. 813 

enlarged follicles, as resembling a sprinkling of white sand upon the surface of the raucous 
membrane. The intestines are generally empty, or contain merely a small amount of thick 
tenacious mucus, Drs. Page and Lindsly describe an appearance of dark spots upon the 
mucous membrane of the stomach, above its i)yloric orifice. We have never detected it. 

The liver is almost invariably enlarged, and more or less congested ; while the gall-bladder 
is filled with dark-green bile, or a pale and almost colourless fluid. Dr. Page describes 
the liver as being in some cases large, soft, and spongy; and Dr. Horner, as being usually of 
a light yellow or mottled colour. 

In the more protracted cases, indications of inflammation of the meninges of the brain are 
very frequently present. 

The prognosis in cholera infantum will depend very much upon our ability to remove the 
patient from the influence of the impure and heated air by which the disease has been pro- 
duced and is kept up, as well as upon the period of the attack at which the treatment is com- 
menced. Without this removal, it is scarcely possible to efl^ect, in any case, a permanent cure ; 
while in most cases — in their commencement, at least — little else is required to arrest the dis- 
ease: even at a later period, its effects are oTten strikingly evinced in the rapid improvement 
of the patient, from almost the very moment the removal takes place. In cases where the dis- 
ease has continued for many days, and reduced the patient to a state in which a fatal termina- 
tion would seem inevitable, by removal to the free open air of the country, and an appropriate 
course of treatment, a very rapid recovery is often effected. 

Cholera infantum is evidently produced by the action of a heated, impure, and stagnant 
atmosphere, directly upon the skin, and indirectly upon the digestive raucous surface, at an 
age when the latter is strongly predisposed to disease from the effects of dentition, and from 
the increased development and activity of the muciparous follicles which takes place at that 
period. 

The dependence of cholera infantum upon a high degree of atmospheric temperature is 
shown by the fact, that its prevalence is always in proportion to the heat of the summer; 
the disease increasing and becoming more fatal with the rise of the thermometer, and 
declining with the first appearance of cool weather in the autumn. That, however, the dis- 
ease is not produced by heat alone, in its more aggravated forms, is proved by its occurring 
almost exclusively in the larger and more crowded cities of the Middle and Southern States, 
and by its especially prevailing, and being most destructive to life, among the children of the 
poorer classes, inhabiting small, ill-ventilated houses, situated in narrow, confined lanes, 
courts, and alleys, or in situations abounding with accumulations of filth. When it occurs in 
the country, which is rarely the case, it is almost exclusively in low, damp, and otherwise 
unhealthy situations. 

The process of dentition is unquestionably a predisposing cause of the disease ; while 
premature weaning and errors in diet act often as exciting causes. 

In regard to the treatment of the disease, this is very simple, and generally successful, 
whenever we are able to remove the patient from the heated, confined, and impure atmo- 
sphere by which the disease has been generated, to a situation where he may enjoy the 
advantages of a cool air and free ventilation. 

The infant should be confined to the breast, or, if weaned, to a diet of fresh rennet-whey, 
With the addition of gum acacia, rice-water, tapioca, or plain meat broths, with some cool, 
perfectly bland, and slightly mucilaginous fluid for drink. He should be immersed daily in 
a bath, warm or tepid, according as the temperature of the skin is deficient or increased. 

If the removal of the patient is impracticable, he should be placed in as pure, cool, and 
free an atmosphere as possible, and carried frequently abroad in any open and healthy situa- 
tion in the neighbourhood of his residence, in a carriage, or in the arms — or where his resi- 
dence is near a large river, he should be taken on the water in a boat. His clothing should 
be perfectly clean and dry, and sufficient to guard against the influence of sudden changes 
of temperature, but not so warm as to overheat the patient ; fine soft flannel, or soft, coarse 
muslin, worn next the skin, will be proffer in all cases. His sleeping apartment should be, 
if possible, large and airy. He should sleep upon a mattrass, or on a blanket folded and 
laid upon the sacking-bottom of the bedstead, or upon the floor of the crib, his body being 
defended by a light, loose covering. 

The gums should be carefully examined, and if they are hot, swollen and inflamed, they 
should be freely lanced. 

When the disease commences as a simple diarrhoea, the warm bath, repeated daily, or 
even night and morning, and followed by gentle friction over the surface of the body, with 
a hand or soft dry cloth ; cold mucilaginous drinks, and a combination of a sixth of a grain 
of calomel, about four grains of prepared chalk, and a half a grain of acetate of lead, 
repeated every three or four hours, will ordinarily arrest it. 

To subdue the irritability of the stomach, from a sixth to a fourth of a grain of calomel, 
rubbed up with a little dry loaf-sugar, and sprinkled upon the tongue, will very generally be 
found sufficient. When, however, this fails, a few drops of the spirits of turpentine, or a 
solution of camphor in sulphuric sether, repeated at short intervals, will usually succeed. 



814 



DYSENTERY. 



When the vomiting is violent and frequent, particularly if there is any pain or tenderness 
of the abdomen, a few leeches to the epigastrium, followed by a light emollient cataplasm 
or warm fomentations, will be found decidedly beneficial. The effects of fomentations to 
the abdomen, with a strong decoction of hops, have been spoken of by many practitioners as 
peculiarly soothing. 

A teaspoonful of cold water may be allowed every fifteen or twenty minutes ; it is grate- 
ful to the patient, and will assist in allaying the gastric irritability. 

When the irritability of the stomach is so far quieted as to allow of the remedy being 
yetained, the disordered action of the bowels will in most cases be promptly restrained by a 
combination of a fourth of a grain of calomel, three grains of prepared chalk, one grain of 
acetate of lead, and a fourth of a grain of ipecacuanha, given every three hours. Under the 
use of this prescription, the inordinate discharges will be quickly suspended, and replaced 
by regular, natural stools. The acetate of lead should be omitted as soon as the watery dis- 
charges are arrested, and the calomel, prepared chalk, and ipecacuanha, in the same pro- 
portion as above, continued until regular and healthy stools are procured. The use of some 
one of the light vegetable astringents will complete the cure. The full restoration of the 
patient to strength will be greatly promoted by a mild unirritating diet, daily exercise in the 
open air, and the most scrupulous cleanliness of person and clothing. 

In cases where much heat of the head, a wild injected state of the eyes, aversion from 
light, with delirium, or other symptoms of cerebral disease ensue, leeches should be applied 
to the temples or behind the ears, cold lotions to the scalp, and warm sinapisms, pediluvia, or 
some stimulating embrocation to the lower extremities. In these cases, blisters behind the 
ears, kept open by the use of some irritating ointment, will often be found beneficial. 

In the chronic stage of cholera infantum, ihe most efficacious remedies are the warm bath, 
repeated daily ; blisters to the abdomen, kept on until the skin is reddened and then removed, 
the part being covered with a soft emollient poultice; injections composed of starch and a 
few drops of laudanum ; small doses of Dover's powder at night, with light astringents, as 
kino, decoction of dewberry-root or of the geranium maculatum, with change of air, and a 
diet of boiled milk thickened with rice-flour, or of plain meat broths with the addition of 
rice. A solution of the tartrate of iron, twenty grains to the ounce of water, with the addi- 
tion of a drachm or two of ginger syrup, or the persesquinitrate of iron, maybe administered 
with good effects. In many cases the sulphate of quinia in solution, besides exerting a bene- 
ficial influence upon the disordered condition of the bowels, will be found useful in restoring 
strength to the patient, who is always in a state of extreme jirostration. 

When the stools are thin, small in quantity, dark-coloured, and highly offensive, with flatu- 
lence, and a tendency to a tympanitic condition of the abdomen, or when frequent griping 
pains are experienced, the best effects will be derived from the use of turpentine. It may 
be given in the following mixture: — K.. Mucil. g. acacise '^nj.; sacch. alb. pur. 5ij. ; spir. 
tether nit. JJiij. ; spir. terebinth.^ij. ; magnes. calc. gr. xiij. ; lavend. spir. comp. 3ij- — M. The 
dose of which is a teaspoonful three times a day — or oftener, when the child is over two 
years of age. The addition of 3"]- of the tincture of kino, and the same quantity of the 
camphorated tincture of opium, will be proper in cases attended with great irritability of the 
bowels. 

When the discharges are acrid, offensive, and dark-coloured, we have administered with 
advantage pulverized charcoal, two to eight grains, in combination with two or three grains 
of powdered rhubarb, a fourth to a half a grain of ipecacuanha, and a grain of extract of I 
hyosciamus every three or four hours. | 

The umost attention must be paid to the diet of the patient ; he should be confined to meat I 
broths — the juice of roasted meats, with boiled rice — rice milk and tapioca in moderate ' 
quantities at a time — with toast or rice water, or rennet-whey, with the addition of a portion ' 
of gum acacia, for drink.- — C] , 



LECTURE LXXIII. 

Dysentery. Diarrhoea Miposa. Intestinal Concretions. Worms, 

Another of the morbid fluxes from the alimentary tube, of which I have yet to ! 
speak, is dysentery. 

Its characteristic symptoms are, griping pains in the abdomen, followed by fre- j- 
quent, mucous or bloody stools, straining and tenesmus. In chronic cases pus is 
sometimes discharged from the bowels. The acute form or stage of the disease is j 
attended with fever. 



DYSENTERY. 



815 



The differences between dysentery and diarrhoea are obvious enough. Both of 
them may be accompanied by griping pains : in both the stools are frequent and 
loose : but in diarrhoea they are fecal ; in dysentery there is retention of the natural 
feces, or they are expelled from time to time, in small, hard, separate lumps, termed 
scybala. Again, straining, and tenesmus, and the excretion of mucus, which is often 
tinged with blood, form no necessary features in diarrhoea ; whereas in dysentery 
these symptoms are prominent and constant. These nosological distinctions are true 
and useful, although in our actual intercourse with the sick, we do not find them 
always or strictly observed. Some of the worst forms of dysentery commence with 
the ordinary symptoms of diarrhoea. 

Dysentery consists, essentially, in inflammation of the mucous membrane of the 
large intestines ; yet not, I apprehend, of the whole of that long surface indiscrimi- 
nately. Observation of the course of the disorder, during life, and of the morbid 
appearances visible after death, leads to the conclusion that in simple dysentery, 
marked by tormina and tenesmus, and frequent dejections of sanguinolent mucus 
without fecal matter, the inflammation chiefly affects the rectum and the descending 
colon. When the earlier portions of the large intestines are involved in the diseased 
process, the stools at the outset are often composed, in great measure, of excrement 
in an unnaturally fluid state, and mingled with blood and slime. We generally 
speak of these circumstances as constituting dysenteric diarrhoea. 

SUght and simple dysentery may occur and run its course with very httle or no 
disturbance of the circulation. When it is acute and severe, it is attended with more 
or less pyrexia. The acute disease may terminate in recovery ; or in early death ; 
or in chronic dysentery, which usually, in the end, is fatal. 

The wards of our metropolitan hospitals place frequently under our notice severe 
cases of chronic dysentery in the persons of soldiers and sailors, who bring the dis- 
ease home with them from hot chmates. With these exceptions, dysentery is, now- 
a-days, neither a very common, nor a ver}'- serious disorder in this country. I say 
now-a-days, for the time was when it raged in London like a plague. The present 
Dr. Heberden, in his valuable essay, On the Increase and Decrease of different 
Diseases, shows, that in the seventeenth century the number of deaths set down, in 
the weekly bills of mortahty, under the titles bloody flux, and griping in the guts, 
was never less than 1000 annually, and in some years exceeded 4000. For five- 
and-twenty years together, viz., from 1667 to 1692, they every year amounted fo 
above 2000. During the last century, the number gradually dwindled down to 
twenty. Dysentery is one of the pests of hot cHmates. In aU tropical regions, at 
certain seasons of the year, it is very prevalent and destructive. But it is in fleets 
and armies, and especially among troops in actual service, that the distemper most 
displays its terrible power. There is no single malady which is so crippling to an 
army in the field as this. Sir James M'Grigor, to whom was entrusted the superin- 
tendence of the medical department of the army, on " the two greatest services on 
which the military force of this country has, of late years, been employed, namely, 
that in Walcheren, and that in the Peninsula," calls dysentery "the scourge of 
arimes," and the " most fatal of all" their diseases. In two years and a half, the 
British army in Spain lost no less than 4717 men by this complaint. 

How are these facts to be explamed ? Wherefore is dysentery, which was so 
familiar to our ancestors, so happily rare among us ? Why does it thus wait upon 
and affiict the march of armies ? Upon what depends its frequency in hot climates ? 
We may expect to obtain some answer to these questions by searching into the 
causes of the disorder. 

It has been ascribed to exposure to wet and cold ; to the use of unwholesome 
food ; to the agency of malaria ; to contagion. 

Weather and season have a manifest influence in the production of dysentery. In 
temperate climates, like our own, it is an autumnal disorder. In tropical countries 
it is observed to be more common and more severe when rains succeed to long- 
continued drought. In respect to this, as to other bowel affections, a high diurnal 
temperature of the air appears to be the predisposing, and exposure to cold the ex- 
citing cause. I stated, on a former occasion, that great vicissitudes of temperature 



\ 



816 DYSENTERY. 

are very frequent and very pernicious, even under the torrid zone. Scorching days 
are followed by extremely cold nights. The dysentery which arises under these 
circumstances is apt to run on into the ensuing winter. Soldiers in the field against 
an enemy are peculiarly obnoxious to the agencies which favour or generate the 
complaint. Marching, or engaged in actual conflict, during the day ; bivouacking 
at night, often in the open air, and under every variety of weather; ill-provided, too 
often, with clothes and bedding; their food scanty, precarious, or of bad quality; 
seizing the many opportunities which their dreadful trade supplies of hcense and 
intemperance ; depressed, it may be, by disaster or defeat ; we need not wonder 
either at the prevalence of dysentery among them, or at its untractableness while 
they remain subject to the same morbid influences. Neither can the causes be 
warded off from the patient, nor, in general, can the patient be removed from the 
causes. Yet occasions do arise which show distinctly enough this alleged relation 
of cause and effect. Prxsens morbum facit — siihluta toUit. Take, on the one 
side, the following facts from Sir John Pringle's book Oyi the Diseases of the Army. 
The men who had fought at Dettingen lay that night on the field of battle, without 
tents, exposed to a heavy rain. For the next night or two they encamped on better, 
but still wet ground; and they wanted straw. Nearly half of these troops were 
soon after affected with dysentery ; while three companies which had not been engaged 
in the battle, nor exposed to rain, nor lain wet, escaped the complaint entirely. 
Take this converse fact, related by Desgenettes. Four hundred of the French 
"army of Egypt," reduced to a state of extreme weakness and emaciation by dysen- 
tery there contracted, embarked at Alexandria on their return towards France; were 
carried away, in short, from the alleged causes of their disorder. Nineteen died at 
the very outset of the voyage ; which, had, however, so good an effect, upon all the 
rest, that before they reached Malta they were thoroughly convalescent. 

The very frequent coincidence or aliernation, in some places, of dysentery with 
intermittent poison, has given rise to the opinion that both these diseases are alike 
attributable to the malarious poison. But dysentery prevails where there is no other 
evidence of the presence of malaria. You may recollect that when we were upon 
the subject of ague, I showed you that its repeated paroxysms were attended with 
extreme and increasing congestion of blood in the internal organs ; of which conges- 
tion the tumid spleen, the ague-cake, was an effect and a token. Noav, whatever 
gorges the splenic vein, gorges its tributary, the inferior mesenteric, which carries 
the blood from the rectum and the descending colon. Upon such congestion of the 
mucous membrane, inflammation is readily engrafted ; and, in this indirect way, 
dysentery may be said to result from the marsh effluvia. Ague is an effect of ma- 
laria, and dysentery is sometimes a sequela of ague. In precisely the same manner, 
dysentery is apt to supervene, in hot chmates especially, upon hepatic congestion 
and disease. 

That dysentery is, in itself, a contagious malady, we have no satisfactory evi- 
dence. In its sporadic form, in this country, we never see it spread from person to 
person. But it is a prominent symptom in some epidemic visitations of continued 
fever, which undoubtedly is contagious. To this fact I am inclined to attribute the 
notion, formerly much more common than it now is, that simple dysentery is 
catching. 

The remarkable decline of dysentery in this metropolis has been cotemporary with 
that of other disorders, and is due to the same combination of causes. For nearly 
two centuries we have had no plague among us. Agues, formerly very rife in Lon- 
don, have almost disappeared. Coyitinued fevers, which used to break out annually 
in hot weather, are comparatively unfrequent. I beheve that we may trace these 
great blessings to an event which was regarded, at the time, as a national judgment; 
I mean the great fire that, in 1666, consumed everything betw^een Temple Bar and 
the Tower. The streets and houses thus destroyed had been filthy in the extreme, 
close, densely crowded, and consequently most unhealth}^ The impurity of the air 
excited, perhaps, some maladies ; and it certainly predisposed those who dwelt in it 
to various kinds of diseases, "the seeds of which (says Dr. Heberden) like those of 
vegetables, will only spring up and thrive when they faU upon a soil convenient fol 



DYSENTERY. 



817 



their growth." To the better construction of the houses and of the streets in the 
rebuilt city ; to the increased means of ventilation ; to the general formation of drains 
and sewers ; to the more copious supply of water ; and to the more temperate and 
cleanly habits of the people ; w^e may fairly ascribe our present exemption from 
dysentery, from ague and continued fever, which are often the parents of dysentery, 
and from the plague itself. In too many parts of this overgrown place, there is still 
much room for improvement. 

The pyrexia that accompanies dysentery sometimes begins before the local symp- 
toms declare themselves ; more frequently it succeeds their manifestation. Occa- 
sionally the fever runs high, the pulse is hard and frequent, the skin hot, the face 
flushed, and the tongue furred ; and the patient complains of headache and thirst. 
But in this, as in other abdominal diseases, the pulse soon becomes small and weak, 
the strength rapidly declines, and the temperature of the body sinks. 

In acute cases, the pain is often severe ; but it is subject to remissions and exacer- 
bations. It occupies the hypogastrium, or some part of the course of the colon, 
where there is usually more or less tenderness on pressure. The patient is tormented 
by a sensation as if there were some excrement ready to be dislodged, goes perpe- 
tually to the night-chair, and is irresistibly impelled to strain violently to get rid of 
the irritation. But the efforts are ineffectual ; he discharges but little ; and what is 
voided is either altogether a jelly-Hke mucus (in which case the complaint has been 
called the dysenteria alba, and the morbus mucosus), or more commonly it is mucous 
and bloody (the bloody flux of our old authors), mixed with films, and membranous 
shreds, and morsels that resemble flesh. In many of the dejections there is no 
genuine fecal matter at all; or the small indurated balls which I just now mentioned 
come away occasionally. Frequently the ejected mucus is variegated in colour, 
green, or black, or reddish, like the washings of meat, and horribly fetid. Some- 
times pain and difficulty in making water are added ; there is dysuria, the irritation 
of the rectum being reflected upon the bladder through the lower portion of the 
spinal cord. Sometimes the stomach sympathizes, and nausea and vomiting ensue. 
With all this local suffering there is a continuance of febrile distress ; the patient 
passes sleepless, or dreamy and disturbed nights, and is low-spirited and desponding. 
In the fatal cases, the pulse becomes very small and rapid, the features sharpen, and 
the surface grows cold. Death begins at the heart. 

Inspection of the dead body discloses more or less ulceration, chiefly of the large 
intestine. The glands that are scattered over its surface are enlarged and prominent, 
looking somewhat hke small-pox pustules, for which indeed they have been mis- 
taken. They probably form the foci of most of the ulcers, which are sometimes 
narrow and oblong, lying across the gut ; sometimes very large and irregular, with 
here and there islands or ridges of thickened mucous membrane. In the worst 
cases, the whole extent and circumference of the bowel present, internally, one irre- 
gular, confused, and tattered mass of disorganization. 

[In the ordinary cases of dysentery, the morbid appearances detected after death are, in- 
flammation with thickening of the mucous membrane of the colon and rectum ; occasionally, 
mortification and sloughing of this membrane, but more generally, in protracted cases, deep 
and extensive ulcerations, in the course of the transverse bands of the colon, or enlargement 
and ulceration of the follicles of the large intestines. In the more violent forms of the dis- 
ease, especially those which occur in hot and intertropical climates, in addition to the inflam- 
mation, ulceration, mortification, or sloughing of the inner coat of the large intestines, there / 
is often morbid vascularity of the mesocolon, mesentery and omentum, with adhesions of the 
omentum to the adjacent viscera, and of contiguous portions of the intestines to each other. 
The latter usually happen only when ulcers have perforated nearly all the coats of the 
bowels. The glands of the mesocolon and mesentery are often enlarged, sometimes in- 
flamed, and more rarely in a state of suppuration ; the corresponding prjrtion of the intestine 
being usually the seat of a deep and extensive ulcer. The omentum occasionally adheres to 
these diseased glands, forming a band by which a portion of intestine may become strangu- 
lated and be the cause of death. 

The ulcerations of the large intestines are commonly most numerous and extensive in the 
cseeum and upper portion of the colon. The ileo-csecal valve has, in some cases, been found 
entirely destroyed by the ulceration ; the lower portion of the ileum forming then an intus- 
susception into the caecum, and becoming there strangulated has caused death. In a few 

52 3t 



818 



DYSENTERY. 



more fortunate instances, the strangulated portion of the ileum sloughs off, after adhesion has \ 

taken place between the adjacent parts, so as to maintain the continuity of the canal, when I 

the patient may recover. The right portion of the omentum is not unfrequently found ad- I, 

hering to the cascum, and this morbid attachment gives rise to symptoms which may be mis- j 

taken for hepatic abscess. Sometimes, in the whole course of the colon, we find not more i 
than eight or ten deep ulcerations, with sloughing, thick, abrupt, raised edges, surrounded by 

an extensive thickened base, into which sinuses and undermining cavities are seen to pene- j 

trate. These appearances, Mr. Twining states, {opera citat.) have reminded him of the foul | 

ulceration at the centre of a small carbuncle ; he has seen several patients die with only six | 

or eight of these ulcers in the colon. The patients had a flushed face, restlessness, and I 

symptoms of continued fever, which were with ditHculty controlled by any course of treat- j 

ment. | 

The last three or four inches of the ileum are generally studded with superficial ulcera- I 

tions, and have a rough appearance from the enlarged follicles and glandular bodies ; with. : 

this exception, we rarely meet with any traces of disease in the small intestines in those j 

who die of dysentery — excepting in those cases in which the dysenteric symptoms occur | 

towards the termination of protracted fevers. | 

In a few instances the coats of the colon are so much thickened, that, when a transverse | 

section is made, its canal stands open like a thick leathern tube, the interior of the intestine i 

being covered with numerous large ragged ulcers, in the intervals of which the mucous j 

membrane is partly destroyed, and hangs in shreds. In several of these cases, Mr. Twining | 

(on the Diseases of Bengal), has observed the Caecum, and lower portion of the ascending i 

colon, to be nearly covered with a thick layer of coagulable lymph, deposited beneath the ' 

peritoneal coat, and extending a considerable distance along the iliacus muscle ; in some in- j 

stances an imusual amount of fat is found at the same part mixed with the lymph. In other i 
cases, when the disease has been more protracted, the whole of the great intestines are con- 
tracted in diameter, resembling a cord, their mucous coat being at the same time covered 
with rmmerous small superficial ulcers. In such cases, also, the internal surface of the 

ceecum, and of four or five inches of the colon, will now and then be of a livid red colour j 

inclining to brown, having a fieshy appearance, as if from a growth of granulations. Mr. I 

Twining (opera citat.) has met with this condition but seldom, but when it has existed, he j 
has found it to extend also to a small part of the sigmoid flexure of the colon. The patients 
in these cases had become much emaciated, with flat contracted abdomen, dry skin, tongue 
of a slate colour, glossy and morbidly clean, as if skinned ; the stools consisted of an opaque 

dirty-bfown water. I 

When death takes place after protracted sufiering from dysentery, we often find the eel- ! 

lular structure at the root of the mesentery and mesocolon, and across the bodies of the | 

lower lumbar vertebra:', deprived of its usual elasticity and pliability, and to a certain degree | 

indurated ; and in many cases entirely devoid of fat. This change is probably the result i 

of a previous inflammation at this part — giving rise to an exudation of coagulable lymph into ! 

the interstices of the cellular substance. — C] j 

When submitted to early treatment, and when its exciting causes can be averted, j 
or avoided, dji^sentery is not an intractable disorder. Sir James M'Grigor remarks 
of the camp dysentery in the Peninsula, that it had two stages, which it was of con- j 
sequence to note, because they required different and almost opposite modes of treat- 
ment : the inflammatory stage, and the stage of ulceration. A plan proposed by Dr. 
Somers appeared to Sir James so judicious, and proved so successful, in the first at- 
tacks of the pure unmixed disease, that he recommended its general adoption in the \ 
army. It was this : j 

First, the patient was freely bled. Immediately afterwards twelve grains of Do- 
ver's powder were administered. This dose was repeated three times, at intervals i 
of one hour. Plenty of warm barley-water was at the same time given, and profuse ' 
sweating encouraged for six or eight hours. A pill, containing three grains of calomel j 
and one of opium, was exhibited every second night ; and in the intervening days j 
two drachms of Epsom salts dissolved in a quart of hght broth. The venesection i 
was repeated, while the strength and the pulse permitted it, until the stools were 
free or nearly free from blood ; and Dover's powder as a sudorific, was always given 
after the blood-letting. When the pains were great, and attended with much tones- ' 
mus, the warm bath gave instantaneous relief. " This plan being steadily persevered 
in for a few days, the inflammatory diathesis of the intestinal canal, which had ex- j' 
cited symptomatic fever throughout the general system, was found gradually to yield, \ 
and make way for returning health." j 

If the disease was not cut short by this method, but advanced into the second 



DYSENTERY. 



819 



stage, and became chronic, the most effectual remedies appeared to be laxatives, and 
opiates, given alternately ; and combined with such medicines as promote perspira- 
tion. The abdomen should be swathed with flannel, or covered by a warm adhesive 
plaster. Much benefit maybe obtained from the employment of clysters, if there be 
not too much tenesmus to admit of the introduction of the pipe of the injecting syringe. 
Warm starch, with laudanum in it — not exceeding in quantity a couple of ounces, 
lest the irritable bowel should expel it again — will sometimes afford signal relief. 
Or if the pain and tenesmus are so great that a clyster-pipe cannot be used — or the 
enema is not retained — a grain or two of solid opium inserted into the rectum beyond 
the sphincter ani, will often allay the distress. The food should be farinaceous and 
simple ; and great care must be taken during the convalescence to prevent a return 
to improper diet, and a fresh exposure to cold. 

There is one important point in the treatment of dysentery, concerning which a 
striking discrepancy of opinion exists, even amongst practitioners who have had large 
experience of the disease : I allude to the employment of mercury as a remedy. I 
have no data for settling the question : but the amount of evidence appears to be 
against its indiscriminate use. It seems (as we might expect) to be powerful both 
for good and for evil. Sir James M'Grigor has probably hit the distinction which 
should guide us to prescribe or to withhold this drug. It was, he tells us, when the 
dysentery was complicated with disease or disorder of the liver, that mercury proved 
so highly useful : when along with the dysenteric symptoms there were present a 
dull pain in the hepatic region, and in the right shoulder, a yellowish-brown colour 
of the skin, and of the conjunctiva, and uneasiness when the patient lay in any other 
posture than on the right side. He adds : " In the early stage of the acute and un- 
mixed disease, and before venesection has been performed, mercury will aggravate 
the symptoms. In the more advanced stage of the disease, particularly when there 
is hectic fever, with extensive erosion or ulceration of the intestine, it is invariably 
found to hurry it on to a fatal termination." 

The sporadic dysentery which we chiefly see in this country seldom requires the 
lancet. Leeches, however, are to be applied, in the track of the colon, w^herever 
there is much tenderness or pressure. A full dose of castor oil may then be given ; 
and after that an opiate. It is the practice of some physicians to prescribe laxatives 
and opium together ; but in this complaint it is better to alternate them. Opiate 
enemata are of service for relieving tenesmus. These remedies will be much as- 
sisted by the warm bath ; by hot fomentations to the abdomen ; and by such means 
as promote the natural secretions of the skin. If there be any reason to suspect that 
the portal system is gorged with blood, complete relief to the dysenteric symptoms 
may often be obtained by the practice which I recommended as proper in metena ; 
viz., the exhibition of five grains of calomel at bed-time, and of a senna draught the 
next morning, for two or three days in succession. Should the symptoms still drag 
on, it may be necessary to give mercury, even to the extent of making the gums 
tender; but it should be introduced gradually. Equal parts of hydrargyrum cum 
cretd and of Bover\s powder, constitute a very good combination either in pill or 
powder for such forms of the complaint. But in the milder cases of simple sporadic 
dysentery there is no occasion, I had almost said there is no excuse, for giving your 
patient a sore mouth by the lavish employment of mercurial remedies. 

[There are few cases of dysentery in which the lancet, or the application of leeches Of 
cups to the abdomen can be dispensed with, without endangering ulceration, thickening, or 
other structural changes in the mucous membrane of the intestines — by which the sufferings 
of the patient are prolonged and his life endangered. When we consider that the disease 
consists in fact in an inflammation of the lining membrane of the great intestines, proceed- 
ing on, more or less rapidly, to ulceration, and in the more violent cases to gangrene and 
sloughing, but little doubt can be entertained of the propriety of blood-letting in its early 
stage ; even in the mildest cases, the application of leeches or cups to the abdomen will very 
generally be attended with marked relief, and will materially shorten the duration of the 
attack. The more violent forms of the disease can be successfully managed only by the 
prompt, free, and even repeated use of the lancet, and the application at the same time of 
leeches upon that portion of the abdomen where pressure causes the most pain ; and this 
system of active depletion must be continued, so long as fever or tenderness of the abdomen 



DYSENTERY. | 

continues, more especially if the stools continue to be bloody. The use of the warm bath, j 
in a few hours after the bleeding, and its daily repetition, will always be attended with 
benefit; or when there is no convenience for the employment of the warm bath, the abdo- I, 
men may be enveloped with cloths wrung out of warm water, and repeated as they lose, j 
their heat, or covered with a ligbt, soft and warm poultice. A large number of cases, if i 
treated at their commencement by bleeding, and the warm bath or fomentations, with per- 
haps a dose of Dover's powder at night, to ensure repose, will be very readily and speedily 
cured by these means alone. I 

There exists much discrepancy of opinion in regard to the employment of purgatives in , 
dysentery. — Some practitioners insisting that they should be early commenced with and re- ' 
peated at short intervals until natural stools are procured. While we cannot perceive any | 
indication that purgatives are calculated to fulfil, which cannot be as efiectually met by ] 
other less exceptionable remedies, we are convinced that the operation of purgatives cannot ,' 
fail to increase, in most cases, the irritation of the bowels, and to augment considerably the ' 
sufl^erings of the patient. In cases where ulceration of the intestines is suspected to exist, j 
we consider that purgatives are altogether inadmissible. j 

Subsequent to bleeding, the internal remedy from which we have derived the most ad- j 
vantage in nearly all the forms of dysentery that have fallen under our notice, is the ipe- | 
cacuanha; we usually administer it in doses of half a grain, combined with the blue mass ! 
and extract of hyoscyamus, of each one grain, repeated every three hours — ten grains of the I 
Dover's powder being given at night. After the discharges from the bowels have lost in 
some measure their slimy, bloody appearance, and though still small, liquid, and frequent, | 
have acquired more of a fecal character, combining the ipecacuanha with acetate of lead 
and a small j)ortion of opium, will be found in general to quickly diminish the tormina and 
tenesmus, and to afford marked and often very great relief to the patient. ' 

Blisters are not a remedy from which any advantage can be anticipated until after the more 
acute symptoms of the disease have been reduced by bleeding — previously they will often 
do harm, but at this period they will be often serviceable. We have repeatedly observed 
very great relief to follow their application. , 

To remove the painful affection of the bladder, with suppression of urine, that so frequently !; 
attends violent cases of dysentery, Mr. Twining recommends injections of cold water into | 
the rectum as a remedy the most prompt and certain in its effects. These injections will also ! 
be found an excellent remedy for the copious discharges of blood which frequently occur ; j 
these discharges will in general, however, be promptly arrested by an injection often grains ' 
of acetate of lead in six ounces of water. 

In cases where the tenesmus is severe during the night, an injection of sixty drops of lau- ! 
dan am in two ounces of cold water will usually remain in the rectum until morning, and | 
promote greatly the comfort of the patient. I 

The intense sufferings which the patients often experience from the severe tormina and 
almost constant and distressing tenesmus attendant upon many cases of the disease, tempt the ! 
inexperienced practitioner to resort at once to opiates for their relief. But the use of opium j 
in dysentery requires the utmost caution ; until the violence of the inflammation, in the more i 
severe forms of the disease, is reduced by active depletion, they are, in general, inadmis- I 
sible ; they are apt to mask the more prominent symptoms, and by the calm they thus pro- 
duce may lead the physician into a false security as to the condition of his patient while a , 
fatal disorganization is taking place in the intestines. After, however, bleeding, either gene- 
ral or local, or both, according to the violence of the case, has been carried to a proper extent, I 
an opiate at night in the form of Dover's powder, or during the day time opium combined j 
with ipecacuanha and the blue mass, will often be demanded to quiet the tormina and , 
tenesmus, and in this manner will give great relief to the patient and contribute materially , 
in shortening the duration of the most distressing symptoms of the disease. Opiate injec- i 
tions are certainly one of the most prompt and efficacious means we possess of relieving the 
distressing tenesmus, which often continues to torment the patient after the violence of the i 
attack has been reduced. As an injection, we prefer the solid opium rubbed up with olive j 
oil, flaxseed tea or thin starch. The tenesmus is usually dependent on ulcerations low down . 
in the rectum ; and may frequently be relieved by introducing within the anus, three times 
a day, a portion of the size of an hazelnut of an ointment composed of thirty grains of acetate j 
of lead, mixed with an ounce and a half of fresh lard. When tenesmus remains after the j i 
more prominent symptoms of the disease have been removed, an injection of one drachm of ; 
acetate of lead dissolved in eight ounces of tepid water was a favourite prescription with j 
Mosely, and in many cases it will afford prompt relief. j 

The utmost caution should be observed in regard to the nature and amount of the food and j' 
drinks allowed to the patient as well during the disease, as in the stage of convalescence. It i, 
is all important to keep the colon as nearly as possible empty so long as any degree of in- \ 
fiammation exists. — The practice followed by some practitioners of exhibiting to the patient |, 
large quantities, daily, of flaxseed tea and other mucilaginous fluids, under the notion that by ; 
so doing we soothe the inflamed intestine, is productive of far more injury than good. Whilst 



820 



DYSENTERY. 



821 



the disease continues the mildest diluents only should be allowed, and these only in moderate 
portions at a time. Even after convalescence has been fully established, the patient should 
be restricted to the blandest and most unirritating food, and this in very moderate quantity. 
Errors in diet, as Mr. Twining very properly remarks, are among the principal causes of a 
tardy recovery and frequent relapses. 

In describing the post-mortem appearances in fatal cases of dysentery, we noticed various 
morbid conditions of the caecum as of occasional occurrence; to these Mr. Twining, in his 
work on the Diseases of Bengal, (page 69,) directs especial attention. No particular change 
in the general treatment of the case, however, is demanded. All that is necessary is for the 
practitioner to bear in mind the possibility of the occurrence of more or less violent inflam- 
mation of the caecum, and by the most undeviating perseverance in the employment of the 
remedies demanded for its reinoval, especially the local application of leeches, to prevent 
the disorganization of the intestine, and the death of the patient. "When," remarks Mr. T., 
"a considerable enlargement of the caecum takes place, during dysentery, it is usually first 
noticed about ten or fourteen days after the commencement of the attack. There is not 
usually so much pain as to make the patient complain, particularly of the part affected; and 
unless the practitioner habitually examines the abdomen of those he is treating for dysen- 
tery, he will be occasionally told of the swelling at a period of the disease when the patient 
is past recovery: or he will find, upon dissection, such a mass of disease and inflammation, 
with induration, in the right iliac region, that he will be surprised how it could have escaped 
his notice during life. Excepting in fat persons, the rounded, doughy, inelastic tumefaction 
of the caecum is easily detected by examination with the hand ; and, in fact, is often visible 
on inspection. 

The inflammation of the caecum is to be treated by the daily application of leeches to the 
right iliac region ; the discharge of blood being promoted by warm fomentations or poultices. 
When by this means the morbid sensibility is removed, and the tumefaction considerably 
reduced, a blister should be applied and kept open by some stimulating dressing. Mr. 
Twining recommends as a means of reducing the remaining induration, "a course of Plum- 
mer's pill, and extract of coloc}'-nth, at night, followed by the compound powder of jalap in 
the morning." "We must remember," he adds, "'that no part of the disease can be left 
unsubdued without hazard to the patient's life." 

In chronic dysentery, there is frequent watery purging, attended often with tormina, and 
very generally with tenesmus, by which the patients are much distressed and soon greatly 
exhausted. The discharges are mostly of a pale gray colour, often mixed with more or less 
of a mucous or white slimy substance, and not unfrequently portions of undigested food. 
They sometimes consist of a copious paste-like brown mass, in a state of fermentation ; occa- 
sionally, they are frothy, with a whitish or pale gray sediment like a mixture of chalk and 
beer; in a few very protracted cases, the discharges are very frequent and copious, quite 
watery, and varying in colour, from a dark-brown to a bright-orange, or from a dirty yellow 
to a pale straw. They are in some cases inodorous, or nearly so; in others they have a 
peculiar sickening odour, and in others again they are more or less fetid. Blood is rarely 
present in the stools, and the patients suffer from fever only in those cases in which there is 
extensive disease of the mesenteric gland — when they occasionally presented a well-marked, 
fever of a hectic character. The abdomen is generally flat, inelastic, and somewhat retracted; 
occasionally, however, tympanitis is a troublesome symptom. The skin is usually dry, shri- 
veled, and desquamating, and of a dirty brown or sallow hue. 

The treatment of chronic dysentery differs but little from that proper in cases of chronic 
diarrlicea. During the continuance of the disease, and for some period after it has been 
removed, the patient is to be strictly confined to a mild, unirritating diet, taken in very 
moderate quantity, and, for drink, to some bland mucilaginous fluid, as toast or rice water — 
and even this only in such portions as are necessary to allay his thirst. He should be 
shielded from the influence of cold and damp, and all sudden atmospherical changes, by 
flannel next his skin and appropriate clothing, and by a careful attention to the temperature 
of the chamber he occupies. 

Leeches or cups to the abdomen will frequently be found of service — but their use will 
require judgment, and a close scrutiny of each case in order that any latent or chronic inflam- 
mation may be at once detected;' Whenever indurations within the abdomen can be felt, 
and they are attended by morbid sensibility on pressure or the least degree of febrile excite- 
ment, the application of leeches or cups should not be neglected. When the indurations are 
without sensibility, or after this has been removed, blisters are generally very important 
remedies. The daily use of the warm bath and warm fomentations to the abdomen assidu- 
ously employed, are means from which, in cases of chronic dysentery, the most decided 
advantage will invariably result. Small doses of ipecacuanha combined with extract of 
byosciamus and the blue mass, and repeated every three hours, with a dose of Dover's pow- 
der at night, will generally be found to aid very effectually in restoring the capillary circu- 
lation to its healthy state, in quieting the morbid irritability of the mucous membrane of the 
intestines, in moderating the profuse morbid discharges, and in rendering the stools less fre- 

3t2 



822 



DIARRHOEA ADIPOSA. 



quent and of a more natural character. The balsam of copaiba and turpentine will often 
be found of equal advantage in many cases of the present affection, as in chronic diarrhoea. 
In regard to the period proper for the employment of astringents, and the articles of this 
kind that are best adapted to the disease, the same remarks may be repeated as were made 
in our note on chronic diarrhcea. — C] 

The fluxes of which I have hitherto spoken have all consisted in an immoderate 
discharge of some of the usual contents or secretions of the alimentary" tube, in an 
altered and unnatural state. But matters are sometimes voided from the bowels, 
totally unlike any of the healthy discharges. Meps is not an intestinal excretion, 
yet it is sometimes passed in great abundance by stool. Many unquestionable 
instances of this are on record, both in ancient and in modern literatuse. I have not 
seen more than one, and therefore have but little to say upon the subject ; yet I must 
not pass it over altogether. A certain quantity, sometimes it has been a large quan- 
tity, of oil, or liquid fat, has been poured forth, in a sort of diarrhcea. Sauvages 
was aware of the disorder, and calls it, in his Nosology, diarrhea acHposa. In a 
paper in the Medico-CIdrurgical Transactions upon this affection. Dr. Elliotson 
refers to an example of it described by Tulpius, in which a Avoman discharged every 
day, for fourteen months, a considerable quantity of yellow fat, that lay upon the feces 
like melted 'butter. When voided into a vessel of water, it floated, like oil, upon 
the surface ; and when cold it assumed the consistence and appearance of fat. Like 
fat, it was very inflammable, and burned with a bright flame. With all this there 
was no kind of distress, nor any wasting of the body ; and the patient was in excel- 
lent health sixteen years afterwards. Dr. Elhotson had a case of this kind under 
his own care. The man had also diabetes and phthisis. The symptoms were pre- 
cisely the same as those described by Tulpius. Dr. Prout and Dr. Faraday ana- 
lyzed portions of the adipose matter, and they pronounced it to be genuine fat. Mr. 
Lloyd, of St. Bartholomew's Hospital, has given us the details of a case in which the 
evacuation of grease was associated with jaundice. The excretion looked hke melted 
fat, but when cool had the consistence of butter. Tt swam on the surface of water, 
melted at a moderate heat, and burned readily. In this instance the head of the pan- 
creas, and the duodenum, were involved in a mass of scirrhous disease. And this is 
a very curious fact : for Dr. Bright also states that in three different persons, each of 
whom he had known to pass fat from the bowels during hfe, and whose bodies he 
had the opportunity of examining after death, he found scirrhous disease of the pan- 
creas, and fungus disorganization of the duodenum. 

The remarkable coincidences, occurring so often, of these fatty discharges with 
cancerous disease of the pancreas and duodenum, is well worthy of being borne in 
mind ; although it may not, as yet, afford any explanation of the phenomenon. 

The single case of which I have had any cognizance is that of a tradesman now 
living in my neighbourhood, who from October 1843 to August 1844, suffered fre- 
quent attacks of this kind. First, he had severe pain in the epigastrium and right 
hypochondrium, with httle or no fever, nor acceleration of pulse. Occasionally, 
when the pain was extreme, it was accompanied by nausea and vomiting. After 
the pain came jaundice and white stools ; and, lastly, a discharge from the bowels of 
a quantity of white fragments, looking exactly like coarse chewings of walnuts. 
Sometimes much larger lumps of the same sort were voided. These lumps and 
fragments were found to be composed of adeps. They floated, many of them at 
least, for a while upon the surface of the w^ater. They felt greasy ; and burned, like 
fat, with a flame. 

After this series of symptoms, the patient would recover perfectly, save that the 
attacks reduced his strength somewhat. They occurred about once a fortnight, so 
that he had about a score of them in ten months. 

The symptoms resembled those which declare the passage of gall-stones: and 
upon one occasion two concretions were detected among the fragments of fat. One 
of these was yellowish ; the other black, hke a cinder. Once also, a considerable 
portion of what seemed membrane came away. My neighbour, Mr. Francis E. 
Hicks, (to whose kindness I am indebted for the opportunity of seeing this patient,) 
is of opinion that a cyst, which secreted the fat, existed in the Hver, and dis- 



INTESTINAL CONCRETIONS. 



823 



charged its contents periodically ; and that the membranous fragment was a part of 
this cyst. 

Projecting a httle into the epigastric notch, I could feel what appeared to be the 
edge of the left lobe of the hver. This spot was slightly tender and dull under per- 
cussion. 

I had previously been consulted by the same patient for a chronic and obstinate 
cough, which, after harassing him for three or four years, ceased suddenly, upon the 
occurrence of the first of these strange seizures. On that occasion, he voided at least 
a quart of the fat. Since August, 1844, he has experienced only two or three shght 
threatenings of an attack ; but lo, his old cough has returned. 

Mr. Hicks tells me that a female relative of his own laboured for four or five 
years under a perpetual dry cough, which was most distressing to herself, and very 
irksome to the hearers of it. A pint of fatty matter was then passed by stool, and 
the cough ceased at once, entirely and permanently. This happened more than ten 
years ago. 

All that we know of the disease seems to amount to this : that it is not a common 
complaint ; and that it is not necessarily di. fatal complaint. Persons who have passed 
great quantities of fat in that way have lived in good health for many years after- 
wards. Yet though not necessarily fatal, it has frequently been found associated 
with incurable malignant disease in the duodenum and pancreas. Dr. Prout informs 
us also that in cases in which a similar oily fluid has been passed through the 'nrethra, 
the kidneys have been found in a state of organic malignant disease. 

With respect to the treatment of such cases, all the hints I can give you are such 
as are furnished by the two following facts : — 

Mr. Howship, in his book on morbid anatomy, mentions the instance of a lady 
who was affected with this diarrhoea adiposa, and parted with vast quantities of fat ; 
and who was cured upon the principle of similia similibus curanfiir, for she reco- 
vered after swallowing a pint of sweet oil. And Dr. Elliotson, acting on this hint, 
gave his patient, who was labouring at the same time under diabetes, a quarter of a 
pint of olive oil ; and the voiding of fat greatly diminished from that time, and soon 
ceased entirely. 

Whether these were really cures, or whether they were coincidences, is a question 
which we want larger experience to help us to determine. 

When I was speaking of the causes of enteritis, I adverted to the presence 
of foreign substances, as they are called, in the bowels, and to intestinal concre- 
tions. 

There are some points connected with these subjects which I had not then leisure 
to pursue, but which you ought not to be ignorant of. 

Intestinal concretions are very common in some of the lower animals — in horses 
and oxen especially. Most of you have seen, I dare say, immense intestinal calculi 
of this kind, and great numbers of them, in the Museum of the College of Surgeons. 
The old remedies called bezoars were of the same nature. 

They occur, also, these intestinal calcuh, in the human entrails, and in various 
parts of them ; chiefly, however, in the caecum and large intestines, but sometimes in 
the stomach : indeed, very large ones have occasionally been met with in the latter 
organ. Bonetus describes one which weighed nine ounces, and was as big as a hen's 
egg. Generally they are few in number in the same person: one only, perhaps, 
exists ; or two, or three. Yet as many as thirty have been found together in the 
stomach in one case ; and in another case nine. One of the Monros of Edinburgh 
(Monro primus) detected twelve in the colon of a boy, during life, by the touch. 
Monro secundis took a concretion that weighed four pounds from the colon of a 
woman. They have been known to measure as much as eight inches in circum- 
ference. In the twenty-fourth volume of the Edinburgh Medical and Surgical 
Journal is an account of one long one, or, perhaps, of three that had become united 
together, weighing twelve ounces. Mr. Turner, of Keith, has very lately published 
the case of a man who passed fourteen large intestinal concretions. 

Now, what are these substances, and how do they get there? What is the patho 



824 



INTESTINAL CONCRETIONS. 



logy of the malady ? Why, they seem to be formed, in many instances, by the 
deposit of saline particles, intermixed with animal matter, upon and around some 
accidental nucleus which has entered the ahrnentary canal, and there stopped. 
Sometimes a gall-stone forms the nucleus : the centre of the calculus has several 
times been found to consist of pure cholesterine. Those matters over which the 
gastric juice has no power, and which pass the pylorus unchanged — such as the 
stones of fruit, husks of grain, many unbroken seeds, portions of bone, and the like. 
Other of these intestinal concretions are evidently composed of a mass of short fibres, 
matted, or interwoven together, after the manner oifelt. These calcuU have a some- 
what soft and velvety feel, yet are too hard to be much compressed. Sometimes 
they involve a nucleus, and sometimes they do not. Their composition has been 
discovered in rather a curious manner. Mr. Clift, who, as you know, has long had 
the main charge of the Hunterian Museum, after attentively examining some of the 
specimens there collected, fancied that they might be formed somehow of the beard 
of oats ; and the late Dr. Wollaston, at Mr. Clift's suggestion, I beheve, undertook to 
analyze them somewhat more rigidly; and he found that Mr. Clift's conjecture was 
well founded. If you have ever looked tlosely into the structure of an oat which 
has been separated from its husk, you may have noticed that one end of it is formed 
somewhat like a tiny brush ; made up of very minute needles or beards. Dr. Wol- 
laston found that these ends were identical in their shape and composition with the 
fibres of the intestinal concretions. 

The accuracy of the result of this analysis is singularly confirmed by the fact that 
this particular kind of intestinal calculus is almost peculiar to the bowels of Scottish 
people ; among whom, as you know, oats form a ver}' common article of diet, in the 
shape of oat-m.eal. 

Concretions of the same species have also been found in the intestines of Lan- 
cashire persons ; and they also use oatmeal a good deal as food. Mr. Chiklren 
gives an account of some in the Philosophical Transactions for 1822. The fibres 
were cemented together by mucus ; and the concretions contained also albumen, 
phosphate of lime and soda, and common salt. 

I mentioned formerl}^ the danger which attends the incautious or excessive use of 
magnesia, whether for stomach complaints or for urinary disorders. When this 
substance is taken habitually, and when due care is not used to ensure its habitual 
expulsion from the intestines, it is liable to accumulate and concrete there, especially 
in the caecum and colon. Large masses of this kind have been met with, composed 
almost entirely of carbonate of magnesia. 

And the habitual use of any other indigestible substance may have the same ill 
consequence. The seeds of figs ; unbruised mustard seeds, which (as I mentioned 
before) are taken daily by some persons; the woody knots found in certain pears; 
all these have been known to form the material of concretions, or of hard injurious 
masses in the bowels. 

Now concretions of this kind come at length to produce symptoms by the pressure 
and distension they occasion, by the ulceration to which they sometimes give rise, 
and, above all, by the obstacle they oppose to the passage of the contents of the 
intestines. They generally cut the patient off by exciting inflammation. 

But they may exist for a long time without producing 'any definite symptoms. 
And when symptoms do arise, or when we ascertain that such concretions have 
formed, we are often at a loss for a remedy. From the colon we may hope at last to 
dislodge them : by mechanical means when they are near the outlet ; by frequent 
injections of warm water, or soap and w^ater, whereby they may be softened or broken 
down, and washed out, when they are beyond the reach of the finger, or of instru- 
ments passed into the rectum. 

We have an illustration of the patience of the alimentary canal under the presence 
of these masses, in what often happens when foreign bodies of some magnitude are 
SAvallowed and remain in the tube. 

In one of the earher volumes of the Medico- Chirurgical Transactions you may 
read the history of a celebrated knife-eater. A sailor, in a drunken bravado, swal- 
lowed a clasp-knife. This was followed by no immediate bad consequences, and 



WORMS. 825 



he used to brag of the feat he had performed. And afterwards, either to satisfy the 
scruples of those who did not believe his assertions, or for the sake of rewards 
which some people were thoughtless and cruel enough to offer, or to win wagers, he 
stupidly repeated his folly, till he had swallowed (I think) thirteen knives of various 
kinds and sizes. They killed him at last; and their remains were found in various 
parts of the ahmentary tract. But he had no serious symptoms for some time. 

Mr. Wakefield has given us an account of a culprit, confined in the Cold Bath 
Fields Prison, who had swallowed seven half-crowns before his incarceration. One 
day out they all clattered into the pan of his night-chair. 

I saw a prisoner myself, last autumn, in the Penitentiary, who, after some sick- 
ness, and tenderness of the belly, voided a half-crown from the rectum. This was 
in November, 1839. He had swallowed the piece of money two years and a half 
before — viz., in March, 1837 ; and, until within a week of his passing it, he had 
enjoyed excellent health. I 

Before I proceed to any of the other viscera of the abdomen, I may as well take 
such notice as the nature and hmits of these lectures admit and require, of the sub- 
ject of ivorms ; in which subject the intestinal canal is more concerned than any 
other part of the body. It seems a strange as it is a somewhat humiliating fact, that 
the human body should furnish food and a habitation for many of the inferior crea- 
tures ; not only after death, but while it is yet alive. The parasitic animals which 
thus prey upon man have been much studied from time to time, and especially of 
late, in their relations to natural history : and some of the facts that have been ascer- 
tained respecting them you ought to be acquainted with. But I shall pursue the 
subject no further in this place than it concerns us as pathologists and physicians. 
Its natural history will, no doubt, be fully taught you by the professor of comparative 
anatomy. 

First, then, it is a notorious fact that numerous parasites do crawl over our surface, 
burrow beneath our skin, nestle in our entrails, and riot, and propagate their kind, in 
every corner of our frame : producing oftentimes such molestation and disturbance 
as require the interference of medicine. Nearly a score of animals belonging to the 
interior of the human body have been already discovered and described : and scarcely 
a tissue or an organ but is occasionally profaned by their inroads. Each, also, has 
its special or its favourite domicile. One species of sirongle chooses the heart for its 
dwelling-place, another inhabits the arteries, a third the kidney. Myriads of minute 
worms lie coiled up in the voluntary muscles, or in the areolar tissue that connects 
the fleshy fibres. The guinea-worm and the chigoe bore through the skin, and 
reside in the subjacent reticular membrane. Hydatids infest various parts of the 
body, but epecially the liver and the brain. A little fluke, in general appearance 
much like a miniature flounder, lives, steeped in gall, in the biliary vessels. If you 
squeeze from the skin of your nose what is vulgarly called a maggot — the contents, 
namely, of one of the hair-follicles, — it is ten to one that you find, in that small 
sebaceous cylinder, several animalcules, extremely minute, yet exhibiting under the 
microscope a curious and comphcated structure. Even the eye has its Kving in- 
mates. But it is, I repeat, in the ahmentary tube that we are most apt to be plagued 
with these vermin. 

Independently of minute scientific divisions into genera and species, there are 
some broad fines of distinction between these creatures. Thus some kinds of worms 
occupy, as I have said, the interior of our bodies ; these are called, accordingly, 
entozoa : some dwell externally, and are named ectozoa ; or, more properly, per- 
haps, epizoa. 

There are five sorts of intestinal worms, sufficiently common to make it likely 
that you will meet with some or most of them in your future practice. I shall, on 
that account, direct your attention first of all to them. 

1. A frequent tenant of the human intestines is the round worm, so like in shape, 
size, and general appearance to the common earth-worm. It is from this species, no 
doubt, that the whole class are called worms. This round worm is often denomi- 



826 



ROUND WORMS. 



nated a lumbricus ; but that is erroneous : it is a species of ascaris, and it has been 
named by naturalists the ascaris lumhricoides — ^the ascaris that is like a lumbricus. 

2. The ascaris vermicularis ; or the oxyuris vermicularis. These animals 
resemble slender maggots rather than worms. They are often called simply asca- 
rides : or, in the vernacular, thread-worms : and they are very much hke bits of 
vi^hite thread. 

3. The tricocephalus dispar ; also a small worm, but longer than the last ; its 
vulgar denomination is accordingly the long thread-worm. 

4 and 5. Two species of tsciiia ; long, flat, articulated animals, resembHng pieces 
of tape. The taenia solium, or common tape-worm of this country ; and the taenia 
lata, or broad tape-worm. 

Of all these I proceed to mention a few more particulars. 

The ascarides lumhricoides, or round worm, is, T say, very like the common earth- 
worm, and used to be thought identical with it. It runs from five or six inches to 
about a foot in length, and it is of a reddish-brown colour, with a tinge of yellow. 
The female worm (for they are of both sexes) is much more common than the 
male, which is smaller also, and may be distinguished by a curved state of its tail, 
and by the genital organs. Sometimes young ones are met with, about an inch and 
a half long. 

I shall not go into any minute description of the anatomy of these worms. You 
cannot mistake them, except for earth-worms ; and the points of distinction between 
the two, when known, are easily perceived. The earth-worm, then, is redder than 
the intestinal worm, and less pointed at its two ends. The mouths of the two differ 
much. That of the earth-worm is a short longitudinal fissure, or slit, placed on the 
under surface of its small rounded head. In the ascaris lumhricoides, the mouth is 
situated at the extremity of the worm, is of a triangular shape, and is surrounded by 
three tubercles. 

It is curious that similar differences, only reversed, exist in respect to the other 
aperture of the alimentary canal, the anus. In the earth-worm this is terminal, at 
the very end of the cylinder : in the ascaris it is a transverse sht near the extremity, 
and on the other surface of the animal. 

Again, the earth-worm has rows of httle projections, like bristles, upon its under 
surface ; feet they may be called, for they appear to serve the purposes of locomo- 
tion. In the parasite there is nothing resembhng this. 

By attending to these plain marks, you may avoid being deceived by impostors, 
who pretend that they are afflicted with worms, and to prove their case bring you an 
earth-worm or two in a bottle. 

The habitat of these worms is in the small intestines. They may, and do, pass 
upwards into the stomach, or downwards into the large bowel : in either case they 
are generally soon voided. Sometimes they are vomited up: but they have been 
known to creep into the gssophagus, and thence into the nostrils. Andral states that 
he saw a case in which a child was strangled by one of these worms, which had 
turned back and become entangled in the larynx. They have been found also in the 
excretory ducts of the hver. This Andral has witnessed ; as has also Dr. Baron in 
this country. 

It was formerly thought that these animals were capable of perforating the coats 
of the intestine : but that opinion is now generally exploded. They do not appear 
to have the means, if they possess the inclination, to bore through. What gave rise 
to this notion was the circumstance of their sometimes passing out of the bowel, 
through ulcerated or other openings, into the peritoneal sac ; or into the vagina or 
bladder; or outwards through hernial apertures. 

The number of these worms existing at the same time in the same person is very 
variable. The late Dr. Flooper mentions a girl, eight years old, who voided upwards 
of 200 in the course of one week. An instance is recorded of a soldier who passed 
367 in six days. Another patient got rid of 460 in a fortnight. 

Fifty or sixty have been found in the same dead body. They often he in packets. 
The corresponding portion of mucous membrane has in some cases been red, in 



THREAD-WORMS — TAPE WORMS. 



827 



others quite natural. Sometimes two are met with ; sometimes one only. So that 
we cannot infer with certainty that because one such worm has been voided, more 
|i remain behind ; although that is always probable. 

I This worm is more common in the early periods of life than afterwards. 
I The other species of ascaris, the ascaris vermicularis or thread-worm, resembles 
j the former in some respects, but it differs from it remarkably in size. Here also the 
I female is longer and larger than the male ; the one being perhaps half an inch in 
j length, the other not two hnes, and very slender. 

The thread-worms hve principally in the rectum, and sometimes exist there in 
vast numbers ; thousands : and they pass out, or are ejected, matted together with 
mucus in the shape of balls, or entangled in portions of excrement. Sometimes they 
emerge of their own accord, and crawl about the neighbourhood, getting into the 
vagina in females, and even into the urethra, and causing intolerable irritation, itch- 
ing, and distress. 

They are seen, when recently expelled, to be very lively ; moving their anterior 
extremity about continually. To this restlessness and activity the animal owes its 
name, which is derived from the Greek word Mxapi^sLv, to leap. The Germans call 
it springiourm. 

This worm also belongs chiefly to infancy and childhood. It does sometimes infest 
adults ; but generally as the patient grows older the animals cease to trouble him, 
whether curative means are employed or not. Bremsen, however, knew a person 
eighty years old, who was nearly killed by them. 

[We have met with these worms nearly as often in the adult as in the child. — According 
to our experience, the female adult is much more liable to them than the male. — C] 

The third kind of these round worms is the long thread-worm ; the tricocephalus 
dispar. It is from an inch and a half to two inches in length. One extremity, that 
to which the head belongs, is extremely fine and small ; and then suddenly bulges 
out into a thicker body. The thinner portion is about twice as long as the thicker. 
Its name is derived from this variation of size. ^pt|, a hair, and xB^aXiq, the head ; 
the portion to which the head is appended being as fine as a hair. At one time the 
head was mistaken for the tail, and then the animal was called tricuris, from ^pt|, 
and oupa, the tail. The thicker or body part is rolled up in a spiral form, especially 
in the male, the female being straighter. This worm is of a white colour, unless 
tinged by its food. It also affects the large intestine as its place of abode ; but the 
opposite end of that gut, the caecum, is its favourite spot. It is sometimes met with 
in great numbers, attached to the mucous membrane by its head ; the body hanging 
loose. 

Although generally overlooked, it is said to be extremely common, and to occur in 
most bodies. I have seldom seen it ; but then I have never hunted for it. It infests 
the dog, the fox, the monkey, and other mammalia. 

This species of entozoon attracted a good deal of attention about seventy or eighty 
years ago ; it being then first observed in Germany during the prevalence of an epi- 
demic fever, which was characterized by a profuse mucous diarrhoea. Roederer and 
Waaler have given an excellent account of this disorder, under the title of morbus 
mucosus. It was thought to have been excited by these worms, which were found 
in abundance in the cascum after death. This opinion must have been erroneous, for 
the animals were known in other places, long before ; and they produce, in general, 
no inconvenience. 

The two tseniee are more formidable beasts. With a general resemblance between 
them, there are strong particular distinctions. 

The tsenia solium, or common tape-worm, has a minute hemispherical head, and a 
long flat body of a whitish colour, composed of many pieces curiously ardculated 
together. The articulated pieces are quadrilateral, very short and small in the crea- 
ture's neck ; they become gradually square as the distance from its head increases ; 
and at length are longitudinally oblong. These portions, or joints as they are called, 
have foramina on their margins, leading to ovaries within. The foramina, which are 



828 



TAPE-WORMS. 



very conspicuous, are placed alternately on the one side of the animal and on the 
other : on the right edge of one joint, on the left of that next to it. This arrange- 
ment is, however, subject to occasional irregularities. Each joint is let in, as it were, 
to that immediately in front of it, and the connection between them is not very firm. 
It is less firm in proportion as the animal is older, and as we approach its posterior 
extremity : so that the segments are apt to come away, by stool, separately. They 
have somewhat the appearance of the seeds of cucumbers or gourds ; and the para- 
sites, for that reason, are sometimes called cucurbitine worms. Blumenbach and 
others have supposed that each articulated piece was a distinct worm : but that is not 
the case. The head of the animal, and its peculiar terminal segment, forbid this belief. 

The common tape-worm is very narrow and thin towards its anterior extremity ; 
one-third or one-quarter of a hne perhaps in breadth. At its broadest part it may be \ 
from three to six lines wide. _ | 

The young tseni© seem to be merely wrinkled ; but they are really articulated. 
The question has been started, whether the lost joints are ever reproduced. It is 
beheved that no new joints are formed, but that the original ones are gradually more 
and more developed. The animal is hermaphrodite. 

Specimens of this worm are preserved, upwards of twenty feet in length. Much 
exaggeration seems to have existed formerly about its size. It has been said to mea- , 
sure 150, and even 300 feet. In all probability separate portions of several have 
been estimated as forming parts of one and the same worm. There is one case well, 
authenticated (it is cited by Bremser from Robin) in which a tape-worm was found 
to extend from the pylorus to within seven inches of the anus ; adhering firmly to 
the mucous membrane all the way. The animal has the power of motion. Its 
movements are feit by the patients, within them. When recently expelled, and 
placed in tepid water, it may be seen to shorten itself; nay, portions protruding | 
many feet from the anus have been known to draw themselves back again. 

This kind of worm is more frequent in adults than in children : yet it is some- 
times met with even in the foetus. It is exceedingly common in dogs. It has been 
badly named ver solitaire, for it is not always single. It is not only found in com- 
pany with different worms, but also with others of its own species. Its natural 
place of abode is the small intestines : but it extends sometimes into the large, and | 
sometimes into the stomach. Vandoverer declares that after an emetic one of his • 
patients vomited forty Dutch ells of the worm, and might have got rid of more j 
" if he had not been afraid of puking out all his guts, and for that reason bit the \ 
worm off." [ 

The taenia lata, or broad tape-worm, has often been confounded with the taenia j 
solium; j^et there are striking differences between them; respecting which, for all 
practical purposes, it is enough to say that the heads (as viewed through a micro- j 
scope) are very dissimilar; that the joints of the taenia lata are shorter and broader, ) 
and adhere together in a different manner ; and that the pores leading to the oviducts j 
are situated not on the edge of each joint, but in the centre of its flat surface. This ! 
variety is not so easily broken across as the former ; and therefore its segments are ' 
less hable to be voided in a separate form. It is probably shorter also than the taenia i 
solium. Fifteen feet have been supposed its average length. Marvellous stories, 
however, are told on this head. Boerhaave declares that he effected the expulsion j 
of one, which was 300 ells long, from the bowels of a Russian. ■ 

The geographical distribution of these two species of taenia forms a curious part j 
of their history, and throws some light upon the doubtful question of their origin. | 
In England, Holland, and Germany, the taenia solium is common, and the taenia lata i 
very rare. In Russia, Poland, and Switzerland, it is just the reverse ; the taenia lata ^ 
prevails ; the taenia solium is seldom seen ; while in France the one species is nearlj' i 
ajs frequent as the other. ' 



HYDATIDS. 



829 



LECTUEE LXXIV. 

Entozoa continued. Hydatids. Trichina Spiralis. The Guinea-Worm. Stron- 
s;ulus Gigas. Origin of Entozoa. Question of Spontaneous Generation. 
General symptoms of the presence of Intestinal Worms. Particular symp- 
toms, and remedies, of the common Hound Worm, of Thread-wornts, of Tape- 
Worms. 

At our last meeting I gave a summary description, sufficient, however, for our 
purposes as medical practitioners, of the five kinds of vermes which are most com- 
mon in the human intestinal canal. There are yet a few more of these entozoa 
which are curious and interesting enough to deserve a brief notice. 

Hydatids — animals like bags or bladders of water — are of very frequent occur- 
rence in various parts of the body. They are also called acephalo cysts, headless 
bags. These are not to be confounded with enlarged Graafian or other vesicles, nor 
with morbid serous cysts in general. They look like, or rather they are, spherical 
sacs having one aperture only, and containing a thin colourless liquid. They are 
usually found congregated, sometimes in vast numbers, within a large cavity or cyst, 
to which they are not attached. This is a consequence of the pecuhar manner in 
which the animals are propagated. The wall of the cyst is laminated, and the young 
hydatids bud forth from between its layers. In the species which most commonly 
infests the human frame, they are born into the cavity of the parent : in some other 
species they are detached externally. We find therefore a parent bag, full of other 
smaller bags ; which, again, are pregnant, as it were, with their own offspring, the 
grandchildren of the primary cyst : and so on, somewhat after the manner of a nest 
of pill-boxes. Minute in their origin, these parasites may thus increase and multiply 
till the original cyst attains an immense size, and at length destroys life by its bulk 
and pressure. Of course the immediate consequences of such pressure will depend 
greatly upon the parts occupied by the hydatids. You may readily imagine what 
kind of symptoms are likely to ensue, when they are lodged within the abdomen, 
within the less yielding thorax, within the unyielding skull. They are more com- 
mon in the liver than in any other single organ. I lately mentioned the case of a 
woman, Harriet Baldwin, who died in the Middlesex Hospital, and whose liver con- 
tained thousands of these globular bodies. The enlarged gland had completely sealed 
up, by its pressure, ^ portion of the inferior cava. 

We can seldom tell that hydatids exist in the body until we see them; nor, if v/e 
knew of their presence, could we propose any rational method of cure. It has been 
fancied that a galvanic current, or an electric shock, passed through the organ con- 
taining these creatures, might kill them, and so at least prevent their increase ; or 
that they might be poisoned by drugs that are not seriously prejudicial to man, such 
as mercury or iodine. But these are mere dreams of our baffled art. They some- 
times open a way for themselves to the surface, and escape through an ulcerated 
outlet : and sometimes they are let out, to the surprise perhaps of the operator, who 
only knew that he was dealing with an abscess which required puncturing. Mr. 
Arnott put a lancet into a fluctuating tumour in the epigastrium of one of my patients; 
very offensive pus issued, with the shriveled skins of sundry defunct hydatids. The 
cyst was situated, I believe, in the fiver. Although the orifice was slow to heal, the 
patient ultimately got well. 

There are single cyst-like bodies, with short retractile necks, bearing the generic 
name of cysticercus. One species of this kind, the cysticercus cellulosus, inhabits 
the interfascicular areolar tissue of the muscles. It is rare in the human subject, but 
frequent in the pig ; giving rise to that condition of the muscles which is famifiarly 
known as measly pork. This is one of the internal parasites with which the organ 
of vision is liable to be infested. A most remarkable instance occurred a few years 

3u 



830 



TRICHINA SPIRALIS. 



ago, in Glasgow. In the eye of a child, who had suffered repeated attacks of ophthal- 
mia, Mr. Logan discovered one day, to his extreme astonishment, a semi-transparent 
body, about two lines in diameter, floating unattached in the anterior chamber. It 
seemed almost perfectly spherical, except that from its lower edge there proceeded a 
slender process, of a white colour, with a shghtly bulbous extremity, which appeared 
to be heavier than the globular part, for it was always turned downwards. This 
head or neck was seen to project or elongate itself from time to time ; and occasion- 
ally it was drawn up and completely hidden in the cystic portion. When the patient 
sat still, in a moderate hght, the animal covered the two lower thirds of the pupil. 
" Watching it carefully (says the gentleman who has recorded the case), its cystic 
portion was seen to become more or less spherical, and then to assume a flattened 
form ; while its head I saw at one moment thrust suddenly down to the bottom of 
the anterior chamber, and at the next drawn up so completely as to be scarcely 
visible." The child's head was now turned gently back, and instantly the hydatid 
revolved through the aqueous humour, so that its head fell to the upper edge of the 
cornea, now the more depending part. Upon the child again leaning forwards, it 
settled, like a little balloon, in its former position ; preventing the patient from seeing 
objects directly before her. 

The animal was carefully watched for three weeks ; and no other change was 
noticed than a slight increase in the bulk of its cystic portion. In six weeks it had 
evidently grown bigger, the eye became injected, and the iris less free in its move- 
ments ; and pain ensued. Extraction of the hydatid was attempted ; but the patient 
was unruly ; the lens was forced out, and the animal ruptured and expelled in 
shreds : the iris became entangled in the wound of the cornea, and vision in that eye 
was spoiled. 

There is a very singular microscopic parasite, the trichina spiralis, dwelling in 
myriads, sometimes, in the muscles of the living human body. It was first de- 
scribed, I beheve, by Mr. Hilton, of Guy's Hospital, and afterwards more fully 
by Professor Owen, in 1835. Mr. Wormald, the Demonstrator of Anatomy at St. 
Bartholomew's Hospital, sent to that gentleman a portion of human muscle, which 
presented a singular speckled appearance, as if it were mouldy. Mr. Owen found 
that each speck was a shuttle-shaped cyst, containing a very minute cylindrical 
worm, coiled up in two, or two and a half, spiral turns. The worm measures, 
when unrolled, no more than J^th of an inch in length, and Ty-oo^h of an inch in 
diameter ; and of course requires, for a satisfactory examination, to be seen through 
a microscope. The longer axis of the containing cyst hes between, and parallel to, 
the fibres of the muscle. Fourteen similar instances have since come to Mr. Owen's 
knowledge. 

This is a very strange kind of parasite. One would imagine that the presence of 
innumerable Hving beings, in or between the muscular fibres, would be likely to give 
rise to symptoms. We might expect pain, or muscular debility, or embarrassed 
movements ; yet no indication of the presence of these worms seems to have been 
aflbrded in those instances in which the condition of the subject in whom they were 
found was known, during life. The principal points that have hitherto been made 
out appear to be the following : — 

1. The muscles thus beset with parasites are the voluntary muscles : and those 
which he superficially are fuller of the worm than the deeper seated. The pecto- 
ralis major, latissimus dorsi, and other large flat muscles, usually present them in 
great abundance. They have been detected in the muscles of the eye : and even 
in those belonging to the little bones of the ear, and of whose action we are wholly 
unconscious. They occur also in the diaphragm, in the muscles of the tongue and 
of the larynx, in those of the soft palate, in the constrictors of the pharynx, in the 
levator ani, in the external sphincter ani, and in the muscles of the urethra. They 
have not yet been seen in the muscular tunic of the stomach and intestines, in the 
detrusor urinse, or in the heart. Mr. Owen makes this interesting remark — that all 
the muscles infested by the trichina are characterized by the striated appearance of 
their ultimate fascicuh : whereas the muscles of organic life, which the animal does 



I 



THE GUINEA-WORM. 831 

not inhabit, have, with the exception of the heart, smooth fibres, not grouped into 
fasciculi, but united reticularly. 

2. It appears, also, from what has been hitherto observed of these entozoa, that 
their presence in the body is unconnected with age, sex, or any particular form of 
disease. They have been concomitant with cancer of the penis ; tubercles of the 
lungs ; exhaustion of the vital powers by extensive ulceration of the leg; fever, com- 
bined with pulmonary phthisis ; aneurism of the aorta ; sudden depression or col- 
lapse after a comminuted fracture of the humerus ; diarrhoea. They have also been 
met with in the muscles of a man who, while in the apparent enjoyment of robust 
health, was killed by a fracture of the skull. 

The Filaria Medinensis — Dracunculus — or Guinea-worm — has its residence in 
the subcutaneous areolar tissue. It is a long, slender, round, uniform animal, like a 
fiddle-string, or a piece of bobbin ; as you may see in the specimens before you. 
Its length varies from five or six inches to twice as many feet. Men's lower hmbs, 
their feet and legs, are the parts most commonly possessed by this worm ; but it 
occurs also in the scrotum, in the parietes of the belly, in the arms, beneath the con- 
junctiva of the eye, and in almost every superficial situation. It is sometimes soli- 
tary ; but several may co-exist or succeed each other in the same individual ; nine 
or ten perhaps. A Dr. Marrudri, a friend of the celebrated Clot Bey, had suffered 
frOm twenty-eight of them in succession. 

This entozoon is epidemic in the hot intertropical regions ; in Asia and Africa ; 
upon the coast of Guinea, whence its trivial name. It sometimes abounds after the 
manner of an epidemic. Sir James M'Grigor tells us that the 86th and 88th regi- 
ments, stationed at Bombay, were much plagued by this pest. The 86th was free 
from it upon entering the fort, in September, 1799 ; and so continued till the setting 
in of the monsoon in 1800. In the course of the monsoon nearly WO of the men 
were attacked. The 8Sth regiment relieved the 86th. No case of Guinea-worm 
appeared among them for nearly a month after their coming into the barracks at 
Bombay, in October, 1800. In the latter end of November, they embarked for the 
Egyptian expedition ; and in the course of the voyage in one ship alone 199 men 
out of 360 were crippled and laid up with this loathsome disease. It was thought 
to be infectious. The artillery-men, who were kept separate, escaped. Of 181 
instances, of which Sir James M'Grigor gives a tabular account, the feet were the 
parts affected in 124. 

These animals sometimes remain for a long while in the areolar tissue without pro- 
ducing inconvenience, and therefore without betraying their presence. Hence they 
are sometimes brought over to this country. The great navigator, D ampler, had no 
symptom of a Guinea-worm which he carried about with him, until about half a 
year after he left the place in which he contracted it. Sometimes the parasite is 
quiet and harmless for a still longer period ; in one recorded instance it was latent 
and dormant for three years. 

The symptoms which do at length arise are the following: — itching of the part 
affected ; a sensation as if there were something creeping under the skin ; sometimes 
a cord-like ridge can be felt in the track of the worm ; at length a vesicle, or a pus- 
tule, or a little boil forms, from which, when it breaks, the head of the animal pro- 
trudes. This process is often attended with fever ; and in certain parts of the body 
the local suffering is considerable : the areolar tissue sloughs ; and sometimes danger- 
ous hemorrhage occurs. 

The only treatment which these cases appear to admit of, is the gradual and care- 
ful extraction of the worm. Lest that part of it which already protrudes should 
recede, or be broken, it is gently wound, day by day, round a small stick, or a little 
roll of adhesive plaster ; pains being taken not to pull upon it so much as to risk its 
being torn asunder. The roll is protected by a bandage. Whenever, by accident, 
the animal is broken, very serious consequences are said to ensue ; violent inflam- 
mation of the part, abscesses and sinuses and high irritative fever. This mischief 
is ascribed by some to the presence of dead animal matter, by others, of young fila- 
liae, in the subcutaneous tissue : for I should have mentioned that the Guinea-worm 



832 



STRONGULUS GIGAS. 



is viviparous ; and although neither digestive organs nor generative organs have yet i 

been discovered in its structure, it is sometimes found stuffed internally with a count- 1 

less offspring. The extraction is tedious work. Where, indeed, the areolar tissue ' 

is very loose, as in the scrotum, the worm is occasionally drawn out at the first | 
attempt : but the process sometimes occupies weeks ; and its average period appears 

to be not less than ten days. When the course of the animal is quite superficial and ' 

obvious, the natives are accustomed to make an incision in the skin, at about the i 

middle point, and to pull the worm through from both ends. When once it is out, i 
the parts presently heal. All other medication (and much has been tried) has been 

found useless ; except, perhaps, the administration of assafetida ; and that not as a .i 

means of cure, but of prevention. It is said that the Brahmins in India, who are in \ 

the constant habit of using this drug, are exempt from attacks of the dracunculus, ' 

Cleanliness was also found, in the army, to be a considerable protection. | 

There is a species of filaria peculiar to the eye, and another to the bronchial | 

glands ; but these are extremely rare. I 

The urinary organs have their parasites also ; of which I shall specify but one, and I 

that chiefly on account of its strange lurking-place, and remarkable size. I alluded | 
to a species of strongle which sometimes occupies the human kidney, and which i^V, 
no uncommon tenant of the same organ in various animals ; the horse, the bull, th«| 
dog, the wolf, the -polecat, and the otter. In the human subject, its length varidW 

between five inches and a yard, and it is sometimes half an inch in diameter. There' , 

is a specimen nearly of that size in the Hunterian museum. It may well be called ' 
the giajit strongle, strongulus gigas. Fancy a creature as big as a snake coiled up 

in one's kidney. It gives rise to no distinctive symptoms, akhough, as you may | 

suppose, it causes much renal distress ; hematuria, retention of urine, and great suf- , 

fering in its passage out of the body, either through the natural urinary channels, or i 

by abscess and ulceration through the back. j 

I 

With respect to some, at least, of the parasitic animals that I have been describing, j 

those I mean which are found shut up in close chambers, our first feeling is that of I 

wonder how they came there. Into all parts from which a road is open to the exter- | 

nal surface, we can conceive that living creatures may enter, or their eggs be carried. I 

But how can either animals or ova find their way unperceived into the substance of j 

the liver and of the voluntary muscles, into the eye, into the brain ? The whole , 

matter is obscure, yet interesting. | 

With respect to the common hydatids, it has been conjectured- — and the conjecture j 
does not seem improbable — that they are not parasites, nor distinct animals in any 

sense ; but merely certain of those primitive nucleated cells — from w^hich the micro- j 

scope asserts that all the varied tissues of the body are originally formed — rendered i 

gigantic and monstrous by some erring or morbid action of the vital forces. Except I 

in size, the cell and the hydatid are declared to be alike : alike in shape, alike in ' 

the mode of their'growth and multiplication. But this view of the matter, granting \ 

it to be the true one, does not reheve our difficulty ; for, within these very hydatids, , 
distinct Hving animals have been found : parasites of the second order, entozoa of an 
entozoon, if the hydatid be itself a separate animal — tenants of a formation-cell, if 

the hydatid be only an extravagant development of the primary corporeal structure. ■ 

Within several of the transparent hydatids which were taken from the fiver of the | 

woman Baldwin, a number of smafi, opaque, white grains, were visible. These were j 
examined by Mr. Tomes and myself, under the lens of his powerful microscope. 
They were plainly minute animals : bagfike, with an orifice or mouth which, in 

some instances, protruded a httle from the bag — in others, was evidently contracted ; 

and drawn inwards. Around this orifice was arranged a circlet of small, flat, spear- i 
shaped rays, somewhat like a vandyke collar. Many of these rays, or spines as 

they have been called, were detached, and lying loose in the surrounding liquid. J 

Being very ill-informed in this department of natural history, I paid less attention to ; 

these creatures than they deserved ; fancying, indeed, that they might be common ; 
and well-known, or rather that they were juvenile hydatids. I have become aware 



ORIGIN OF ENTOZOA. 



83B 



of my mistake through perasing a paper, by Mr. Curling, in the twenty-third volume 
of the Medico-Chirurgiral Transactions, where he m.ore minutely describes pre- 
cisely similar phenomena. Mr. Curling shows that these included animalcules are 
parasitic vermin which infest a pecuhar species of hydatid, called the Echinocuccus 
Hominis. Later opinions assert that what we call the hydatids, is nothing more 
than a nest, or habitation, formed by or for the small indwellers. 

Now, whatever hypothesis we may adopt respecting the nature of hydatids them- 
selves, the puzzling question still remains, whence originated the living beings 
inclosed within them ? How got they thither? 

It was the opinion of Linnaeus, and of other natural philosophers of his time, that 
the intestinal worms were really terrestrial or aquatic animals which had been acci- 
dentally swallowed, either while young and small, or in the antecedent state of ova. 
It was even pretended that these animals had been recognised and detected out of 
the body, in stagnant waters. But later inquirers, especially Bremser and Rudolphi, 
have completely disproved this notion. After dedicating twelve years of his hfe to 
the observation and study of entozoa, Bremser was satisfied that no creatures iden- 
tical in structure with the intestinal worms are ever met with out of the body, 
except such as have come from the intestines of man, or of some other animal ; and, 
conversely, that no terrestrial or aquatic worms are ever found hving within the bodies 
of men or of animals, unless they have been directly or plainly received from without. 

But, then, is it not possible that, as Boerhaave supposed, aquatic or terrestrial rep- 
tiles, casually entering the body from without, being placed under entirely new and 
unnatural conditions, may have attained a monstrous growth, and undergone meta- 
'tnorphoses such as we know that some of the lower animals, by change of circum- 
stance, do undergo ; as the tadpole becomes a frog, the maggot a butterfly ? 

To this theory there are strong grounds of objection. First, there is nCJ ascertained 
relation (as in the other cases) between the structure of intestinal worms, and of ani- 
mals having an independent existence out of the body ; and they are never caught 
(as they would surely sometimes be) in the transition state — the intermediate condi- 
tion. Secondly, opposed to this "accidental" hypothesis are also the facts that cer- 
tain species of worms infest certain species of animals only : that in the same animal, 
different species of worms occupy (as we have seen) special parts of the alimentary 
canal ; have each their pecuhar habitat : that worms and animals of external origin 
mostly die as soon as they are received into the digestive organs, while the true 
intestinal worms perish whenever they are delivered therefrom. Thirdly, the cir- 
cumstances that these worms not only live, but breed within the human bowels, and 
that they are met with even in the intestines of the unborn foetus, are very adverse 
to this theory of an accidental error loci. 

But, to give up the notion of a metamorphosis, may not intestinal worms spring 
from specific germs or ova introduced from without, not casually, but in accordance 
with a natural law : germs or ova which find in the interior of living bodies the 
only conditions that admit of their development, the only soil in which they are 
capable of germinating, the only nest in which they c^n be hatched ? t confess that 
such is my own belief. We have something like this, at least, in that common affec- 
'tion of horses called the "hots." A species of cestrus, or gadfly, deposits its eggs 
upon the animal's hide, where they cause, I presume, some irritation, which induces 
the horse to hck that part with his tongue. The eggs are thus conveyed into the 
mouth, whence they reach the stomach. There they are converted into larvae, and 
affix themselves to the parietes of the stomach. At length, when they are ready to 
'Undergo their final metatnorphosis, they are detached from the interior of the sto- 
mach, pass along with the food and feces through the intestines, and are ejected from 
the rectum with the dung. 

, Why, it is asked, may not similar phenomena take place in the human body ? 
There can be no doubt that we every day swallow, inadvertently, numerous ova, of 
Yarious kinds. It is supposable enough that sometimes the digestive organs may, 
and sometimes they may not, have the power of decomposing or expelling these ova. 

It is quite certain that what are generally called spurious worms may have that 
mode of origin in the body. Thus, Dr. Elhotson states that he had once a patient, 
53 3u2 



834 



SPONTANEOUS GENERATION. 



an infant, who discharged from the bowels a dozen Hve larvse, or maggots, of the 
common fly. The child had eaten part of a high pheasant some months before. 
There was, in that case, this instructive circumstance. The infant had been sufTering 
under a chronic cough, but as soon as those larvse were got rid of, the cough ceased. 
Dr. EUiotson says that he saw them in the napkin moving about in the fecal matter, 
just as they might have done if they had never been in the child's body. The same 
physician tells us that he has twice known, in two different patients of his, a living 
caterpillar to be discharged from the intestines. One of the patients was a woman 
who had been in the habit of eating cabbage stalks while she was washing them for 
the pot. The moth lays its eggs on cabbages, and she no doubt had swallowed some 
of them, and one had hatched within her. In the ninth volume of Dr. Duncan's 
Medical Commentaries is a precisely similar case. A boy, after a dose or two of 
calomel and jalap, discharged from the rectum very many caterpillars, all alive, and 
full of activity. He had been in the habit, when in the garden, of eating young 
cabbage leaves. Till this habit began he had enjoyed good health. While the 
animals were within his bowels he suffered severely ; had locked-jaw ; and fell into 
a state resembling coma. Upon their expulsion he recovered perfectly. Centipedes 
have in like manner been vomited, and voided from the bowels. But the most won- 
derful instance of this kind that ever was heard of, is related by Dr. Pickells in the 
Transactions of the King and Queen's College of Physicians in Ireland. A young 
woman of melancholic disposition and chlorolic appearance, had been in the daily 
habit, from some superstitious motive, of drinking water mixed with clay taken from 
the graves of two priests who hved and died in the odour of sanctity. In this way 
she probably imbibed the ova of the insects which subsequently issued from her 
body. In the course of about three years and a quarter, she discharged, partly by 
vomiting, but chiefly per anum, upwards of 2000 beetles, and their larvae, most of 
them alive. Dr. Pickells counted more than 1300. Larvas, and pupas, and perfect 
insects, all came forth simultaneously. Some of them ran off, as soon as they were 
vomited, into holes in the floor ; and two large winged insects were so lively and 
vigorous as immediately to fly away. These strange births were preceded and at- 
tended by a complicated and distressing train of symptoms ; a gnawing, and sense 
of something creeping at the pit of the stomach, vomiting of blood, amenorrhoea, 
hysterical convulsions, headache, retention of urine, and sometimes a degree of men- 
tal derangement. She was at length freed from this disgusting malady by large 
doses of the oil of turpentine. 

These spurious worms differ from the true intestinal parasites in this — that the 
human alimentary canal is not their only, but their accidental and unusual nidus. 
Nevertheless, their occasional presence, ahve, in that place, adds to the probability 
that some of the entozoa may be originally ectozoa. 

The main difficulty, however, respects those animals which occupy shut cavities 
within us, or are embedded in our solid organs : and this difficulty forms one avowed 
ground of the theory of equivocal generation : which means the spontaneous pro- 
duction of living creatures, independently of any germ, or egg, or parent. The vul- 
gar suppose that dirt engenders fleas, that maggots result from the putrefaction of 
flesh, that eels arise, of themselves, in and out of mud. In other words, they infer 
the spontaneous origin of those creatures, of which they cannot or do not trace the 
procreation by pre-existing parents : and philosophers and men of science have done 
the same. They will not believe that which they cannot see. Now this doctrine 
of equivocal generation shocks, I confess, my mind, and offends my reason. If well 
founded, it strikes at the root of that great argument of Natural Theology, which 
deduces the existence of a First Intelligent Cause, from the marks of adaptation, de- 
sign, and contrivance, so manifest throughout the visible universe. Observe the 
demand which this doctrine makes upon our faith. In defiance of all experieijce 
and analogy in respect to creatures which our finite senses are competent to examine, 
it calls upon us to beheve that living beings, of complex and intricate, yet definite 
and harmonious structure ; provided with a digestive apparatus, with instruments of 
locomotion, with generative organs ; of various species ; in many instances of sepa- 
rate yet answering sexes ; that not one or two of these beings, nor a pair or two, but 



SPONTANEOUS GENERATION. 



835 



beings and pairs innumerable, are daily formed by the casual concourse of " organic 
molecules." The obscurity that hangs over the origin of the entozoa is not indeed 
the only, nor, I think, the chief ground upon which the notion of spontaneous gene- 
radon rests. You are probably aware that minute animalcules, so minute that most 
of them cannot be seen without a microscope, soon become abundant in water wherein 
vegetable or animal matters have been dissolved by infusion. Such animalcules are 
therefore called Infusoria. How do they come there? There are two suppositions 
open to us. One is, that they are formed by the fortuitous union of organic atoms 
contained in the infusion. The other is, that they proceed from ova or germs <?9cist- 
ing in the liquid, or floating always in the atmosphere, and ready to quicken when- 
ever they hght upon their proper element. That the ova of animals which are 
themselves visible only by the aid of a microscope, should be absolutely invisible by 
us, is not surprising. We may conclude that the latter supposition is the most true, 
if we can show that when these ova or germs are excluded, all the other conditions 
of the production of infusoria being present, no animalcules appear. Now Spallan- 
zani long ago found, by careful trials, that no animalcules were discoverable when 
the access of air to the infusion was completely prevented. But it has been objected 
to his experiments, that the presence of atmospheric air may be one of the essential 
conditions upon which the requisite combination of the organic molecules depends. 
Air, solar hght and heat, and organic matters in solution being given — does animal 
(or even vegetable) life ever result? That is the question. The experimentum 
crucis has been made, and has answered " No," as I lately learned from one of Pro- 
fessor Owen's admirable introductory lectures ; by whom, I am glad to find, this 
uncomfortable doctrine of equivocal generation is strongly discountenanced. The 
experiment to which I refer was conducted by M. Schulze, of Berlin. I will read 
you his own account of it, as I find it recorded in the Edinburgh New Philosophical 
Journal. 

"The difficulty to overcome consisted in the necessity of being assured, first, that 
at the beginning of the experiment there was no animal or germ capable of develop- 
ment in the infusion ; and secondly, that the admitted air contained nothing of the 
kind. For this purpose I filled a glass flask half full of distilled water, in which I 
mixed various animal and vegetable substances ; I then closed it with a good cork, 
through which I passed two glass tubes bent at right angles, the whole being air 
tight. It was next placed in a sand-bath, and heated until the water boiled violently, 
and thus all parts had reached a temperature of 212°. While the watery vapour was 
escaping by the glass tubes, I fastened at each end an apparatus which chemists 
employ for collecting carbonic acid ; that to the left was filled with concentrated sul- 
phuric acid, and the other with a solution of potash. By means of the boiling heat, 
everything living, and all germs in the flasks or in the tubes, were destroyed; and 
all access was cut off by the sulphuric acid on the one side, and by the potash on 
the other. I placed this easily moved apparatus before my window, where it was 
exposed to the action of light, and also (as I performed my experiment during the 
summer) to that of heat. At the same time I placed near it an open vessel, with the 
same substances that had been introduced into the flask, and also after having sub- 
jected them to a boihng temperature. In order now to renew constantly the air 
within the flask, T sucked with my mouth, several times a day, the open end of the 
apparatus filled with solution of potash ; by which process the air entered my mouth 
from the flask through the caustic liquid, and the atmospheric air from without entered 
the flask through the sulphuric acid. The aii: was of course not at all altered in its 
composition by passing through the sulphuric acid in the flask, but if sufficient time 
was allowed for the passage, all the portions of Hving matter, or of matter capable of 
becoming animated, were taken up by the sulphuric acid and destroyed. From the 
28th of May till the beginning of August, I continued uninterruptedly the renewal 
of the air in the flask, without being able, by the aid of the microscope, to perceive 
any hving animal or vegetable substance, although during the whole of the time I 
made my observations almost daily on the edge of the liquid : and when at last I 
separated the different parts of the apparatus, I could not find in the whole hquid the 
slightest trace of infusoria, of confervse, or of mould. But all three presented them- 



836 



selves in great abundance a few days after I had left the flask standing open. The 
Vessel which I placed near the apparatus contained on the following day, vibriones 
and monads, to which were soon added larger polygastric infusoria, and afterwards 
rotatoriee." 

This experiment confirms the belief which various other facts had suggested — that 
the different kinds of entozoa are not parentless animals, and that they somehow find 
their way into the body they inhabit, from without. The lowest of the infusoria are 
of fixed and determinate species ; and Ehrenberg states that even the minutest 
tndfi^ds possess a comphcated organization. It may be asked, concerning both them 
and the entozoa, why, if they ever arise spontaneously, should they be furnished 
with a generative apparatus.? Again, some of the entozoa abound in certain places, 
and strangers coming to those places appear to contract them there. The dracun- 
culus was thought by the soldiers in India to be communicable from person to per- 
son, as the itch insect, and the chigoe, to both of which it has some analogy, cer- 
tainly are. The infant filaria probably creeps in through the skin wUhout causing 
any noticeable pain. Even that monster among the entozoa, the tape-worm, invades 
the bodies of those persons who visit the countries to which it belongs. I told you 
before, that when tape-worm occurs in Germany, it is always the taenia solium ; 
when in Switzerland, almost always the taenia lata. Now the celebrated ScEmmer- 
ing was afflicted by one of these beasts ; and he was by birth a German : yet the 
worm that he voided was of the foreign species, the taenia lata. He had resided, 
however, for some time in Switzerland ; and there, we can scarcely doubt, he caught 
the ovum, or the young one, of the parasitic animal. Mr. Abernethy once told me 
the following curious story : — A shepherd had to drive a flock of healthy sheep to a 
distant part of the country. The journey occupied two or three days. On the road 
one of the animals broke its leg, and was carried the rest of the way on horseback. 
All the flock, except this hurt individual, was turned for one night into a marshy pas- 
ture. The broken limb was set, and the patient got well ; and was the only one of 
the whole flock that did not subsequently become affected with the rot; the only one 
that escaped having flukes in its hver. Is it not presumable that the ova of these 
parasites were swallowed with the herbage cropped by the sheep in the damp mea- 
dow ? The germs of the entozoa which dwell in closed chambers, and within the 
sohd viscera of the body, are probably carried thither by the blood. 

Upon the whole, we may reject the hypothesis of equivocal generation, and fall 
back upon the Harveian axiom, taken in its most extended sense, of omne viviim ex 
ovo. If I have digressed somewhat in order to set before you the grounds of my 
own behef in this matter, the interest and importance of the subject must be my 
excuse. 

What I have further to say will relate exclusively to the intestinal worms of the 
human body : their predisposing causes ; the symptoms they occasion ; and the 
modes of getting rid of them. 

However much we may be in the dark as to the exact mode in which these para- 
sites reach their habitations, we do know something of the circumstances that appear 
to favour their production and multiplication. They certainly prevail 7nost in per- 
sons who, from whatever cause, are weak and unhealthy ; and particularly in scro- 
fulous children. There are, however, many exceptions to this : they are not uncom- 
mon in individuals who are robust and vigorous. Intestinal worms, of all kinds, are 
more abundant in some situations than in others ; especially in places that are low 
and moist. They are accordingly very frequent in Holland, and in some parts of 
Switzerland. Wherever there is much debihty of the digestive organs — in leuco- 
phlegmatic habits — in persons who secrete habitually a large quantity of mucus — 
worms are apt to congregate. The children of the Negroes in the West Indies are 
wonderfully infested by them. 

It more concerns us to inquire into the general symptoms, through which the 
existence of wwms in the alimentary canal may be ascertained, or suspected. 

Those symptoms are very multifarious ; and, for the most part, very equivocal. 
I know of none that can be reckoned certain or pathognomonic, except the actual 
appearance of one or more of the animals, or of portions of them, in the excrements 



INTESTINAL WORMS. 



837 



of the body. Yet that they do give rise to a variety of morbid phenomena — which 
morbid phenomena are, however, Hable to be produced by other causes also — there 
can be no question. 

The most common of these are well known to all nurses and old women ; such 
as colicky pains, and swelling of the belly ; picking of the nose, in consequence of 
itching andTrritation there ; itching of the fundament ; a foul breath ; grinding of 
the teeth during sleep ; a variable and capricious appetite, sometimes voracious and 
insatiable, sometimes none at all; and irregular bowels. 

Worms sometimes occasion strange, and even severe, nervous symptoms, explain- 
able upon the principle of the reflex office of the spinal cord. We conclude that 
the symptoms are owing to worms in such cases, because they cease when the crea- 
tures are got rid of. Some examples of this I have already noticed. Thus, Dr. 
Eiliotson's infant patient lost a chronic cough upon the expulsion of the hve iarvse 
of the common fly. Bremser gives a very similar case. A child of eleven, afflicted 
with tsenia, had a troublesome dry cough. It was observed that the cough was sus- 
pended for two months, just after a very large portion of the worm had been brought 
away by anthelmintic medicines. This kind of coincidence happened, not once 
only, but three or four times ; and at length, when the whole of the worm had come 
away, the cough was permanently cured. I mentioned, some time ago, the frequent 
association of intestinal worms with epilepsy, which is then of the eccentric form : 
and I stated that a certain nobleman voided some kind of worm (a tape-worm, I think) 
from his bowels, and was thenceforward free from epileptic fits, under which he had 
long laboured. A curious circumstance, illustrating the fact that irritation of the 
mucous membrane of the alimentary tube may aflect distant parts, is quoted by Dr. 
Joy from Albinus. A soldier received a wound, which led to the formation of an 
unnatural anus, in front of the abdomen, and in the track of the colon. Through 
this opening the mucous membrane of the bowel sometimes protruded ; and when- 
ever it w^as out, and exposed to the contact of cool air, the patient began to cough ; 
and continued to do so till the mucous surface was warm again. Partial palsy, 
amaurosis, aphonia, and other nervous symptoms, occasionally depend upon the pre- 
sence of worms in the intestines. 

[Dr. Schleifer, in the Austrian Weekly Journal of Medicine, relates the case of a child, 
nine years of age, who became dunrib, after suffering in early life from cutaneous eruptions, 
engorgement of the glands, &lg. The loss of hearing was attributed chiefly to a fall, and 
treated accordingly. The child became emaciated, pale, with a dark leaden appearance of 
the contour of the eyes. The tongue was white and loaded, the breath offensive, and the 
abdomen tumid and hard. The muscles of the face were in constant motion, and the patient 
moaned incessantly. Dr. S. suspected the presence of worms, and treated the patient accord- 
ingly. In three weeks, eighty-seven lurabrici were discharged, and, during five weeks, im- 
mense quantities of ascarides. At the end of the sixth week, the child had recovered his 
hearing and speech. 

In the Journal of Medicine and Surgery of Paris, for April, 1844, a case is quoted, from 
the Gazette Medicales of Dijon, of a young man, nineteen years of age, who was attacked 
with all the symptoms of acute pleurisy: chill, followjed by fever; severe pain in the left 
side ; difficult, jerking respiration ; paroxysms of dry cough, which occasioned the patient to 
scream out, &.c. ; all of which symptoms promptly, disappeared after the discharge of seven- 
ty-five lumbrici. — C] 

But let us examine into the symptoms which are more or less proper to par- 
ticular species of intestinal entozoa ; and into the treatment which they severally 
require. 

A variety of symptoms are ascribed to the ascaris lumbricoides. Dr. Baillie 
says that the most characteristic are a tumid belly, emaciated extremities, offensive 
breath, and a deranged appetite. To these may be added cohcky pains of the 
abdomen. When these animals get out of the small intestines, and ascend into the 
stomach or oesophagus, they may occasion pain, nausea, vomiting, even convulsions. 
They have caused death, as I mentioned before, by crawling into the biliary ducts, 
and into the chink of the glottis. Sometimes, on the other hand, they emerge unex- 
pectedly, from person? who had received no previous notice of their presence 
within. 



838 



THREAD-WORMS — TAPE-WORMS. 



This, the commonest parasitic tenant of the human bowels, is also a troublesome 
one to eject. A great variety of anthelmintics have been cried up as successful 
against it ; hut brisk purgatives, and bitter medicines in the intervals, have the best 
evidence in their favour. These animals seem not to hke steel ; and my own plan 
of assailing them is that of purging the patient from time to time by calomal and jalap, 
and administering, three times a day, some preparation of iron ; the sulphate, or the 
muriated tincture. I believe that most of the patent worm-medicines consist of mer- 
cury, jalap, and scammony, given in strong doses. The fetid drugs, assafetida, gal- 
banum, valerian, are often used. Cowhage, also, the dolichos pruriens, which is 
supposed to tease the skin of the parasite no less than that of the human worm ; and 
tin-filings, which are thought to bruise or lacerate the offenders, are favourite reme- 
dies with some persons. I have never tried them. The oil of turpentine I have not 
found so successful in expelling this species of ascaris as I shall presently show you 
that it is against the tape-worm. Croton oil has been much commended, either given 
by the mouth or rubbed upon the abdomen. Common salt, coloured by cochineal, 
and exhibited every morning in half-drachm doses, was found by Dr. Rush to be 
very successful. 

The symptoms produced by the ascaris vermicttlaris are itching and irritation 
about the anus, especially in the evening, and aggravated by the warmth of the bed, 
and by whatever overheats the body. I would refer you to a paper by Dr. Heber- 
den on this subject, in the first volume of the Medical Transactions. The case he 
describes is the more valuable, as it was related to him by a physician who Avas all 
his life plagued by these thread-worms. Generally, however, they infest children; 
and become fewer, and at length disappear, as childhood passes into youth. When 
they do accompany hfe through its several stages, although they are a source of 
serious annoyance and suffering, they do not appear to shorten the duration of the 
patient's existence. 

To introduce at one end of a tube, several yards long, substances which are in- 
tended to act upon animals that five quite at its other end, would be a very round- 
about course. Whether a purgative effect, or a specified destructive effect, be the 
object, enemata are preferable to medicines given by the mouth. Bitters offend i 
and destroy these little worms. I have refieved many patients from their tormentors | 
by prescribing simply the infusion of quassia as an injection. Tobacco clysters are ^ 
praised ; but the remedy is a hazardous one. Dr. Darwall says of an enema com- 
posed of half an ounce of the muriated tincture of iron mixed with half a pint of j 
water, " there are few cases so obstinate that this will not suffice to overcome." Lime- | 
water, injected into the rectum, forms another effectual remedy for ascarides, and (as i 
pharmacologists love to speak) a rather elegant one. I 

Thread-worms may be scooped out of the rectum with the finger. Old women i 
fish for them with a piece of fat meat, or a candle, wherewith the entangled worms ' 
are drawn out of the bowel. Perhaps, in troublesome cases, the plan laid down by 
Martinet is as good as any. He recommends three successive injections : the first i 
merely purgative ; the second specific (common salt in solution, cold vinegar and | 
water, lime-water, some bitter infusion) ; the third, oleaginous and soothing. Oil i 
often allays the itching. This teazing symptom may sometimes be quieted by ap- ' 
plying a tovv'-el, wetted with cold water, to the fundament, while in bed. ; 
• With some means of this kind for expelling the worms, appropriate measures | 
should be combined for improving the general health. 

I 

I know of no" signs by which the presence of the tricocephalus dispar is revealed ; ' 
and I am equally ignorant of any remedies for it. 

That a tape-worm is within, we know when the joints of it are voided. Number- i 
less symptoms have been ascribed to this huge internal parasite. The following are 

probably the most distinctive. Uneasy feehngs in the epigastrium, which often abate | 

or are removed by eating ; the appetite generally craving, but sometimes bad ; itching I 



TAPE-WORMS. 



839 



\ of the nose and of the anus ; nausea ; cohc ; giddiness ; a sour hreath. Less fre- 
quently loud borborig-mi occur ; and sometimes convulsions. 

Louis has watched and recorded, with his accustomed minuteness, the symptoms 
of ten cases in the wards of La Charite. Seven of the patients were males, and three 
females. The youngest was a boy of twelve, the son of another of the patients ; the 
oldest was seventy-four. Most of them were in comfortable circumstances, and had 
been habitually well fed. The greater number of them had for some time been 
passing fragments of tape-worm, with their stools, in their clothes, and in their beds. 
In one of the cases the articulations had been twice only detected in the stools, and 
each time upon the operation of a purgative. 

In all the patients but two, the other symptoms commenced when the evacuation 
of the fragments commenced. This renders it probable that the worms begin to give 
annoyance when they get into the large intestine. The temporary relief that results 
from the expulsion of portions of the animal strengthens that supposition. The case 
*is mentioned in the Medico- Chirurgical Journal of a man who was in the habit of 
freeing himself from large fragments of tape-worm by introducing a stick into his 
rectum, and twisting the worm round till it broke. 

The chief symptoms observed in Louis's cases were colicky pains of the abdo- 
men ; itching of the anus, and of the end of the nose ; uneasiness in the epigastrium ; 
and deranged digestion and appetite. 

Pain in the abdomen occurred in all the instances : but it differed in different 
cases, both in degree and in kind. It was intermittent ; and mostly felt towards the 
flanks. 

There was itching at the margin of the anus in seven of the ten cases ; itching of 
the nose in four. With one exception, only, itching was present in one or the other, 
or in both of these situations. 

The appetite was craving in one patient ; unaffected in four ; variable or bad in all 
the rest. In all, slight emaciation was observed. In all, the pupil of the eye was 
of its natural dimensions. This is noticed, because dilatation of the pupil has been 
set down as one of the symptoms of taenia. 

Louis thinks that the following combination of symptoms indicates with tolerable 
certainty the presence of some kind of worm in the intestines. Pain in the belly ; 
colic of various degrees of intensity, unaccompanied by diarrhosa ; itching about the 
anus, and at the end of the nose. If pains in the limbs, lassitude, and nervous symp- 
toms exist also, the diagnosis is strengthened. 

We have a very effectual remedy for ta3nia — at any rate for the tape-worm of this 
country — in oil of turpentine, given in large doses. The anthelmintic virtues of 
this substance were not generally known till a paper on the subject, by Dr. Fenwick, 
of Durham, was published, in 1811, in the Medico- Chirurgical Transactions. A 
sailor, plagued by this parasite, had noticed that large fragments of the worm were 
passed whenever he had swallowed an unusual quantity of raw gin. Thinking that 
a stronger spirit might have a stronger effect upon his internal enemy, he tried a 
glass of turpentine, which completely cured him. This practice was then taken up 
by some unprofessional persons, who gave turpentine, with similar success, in several 
cases. At last Dr. Fenwick, in conjunction I believe with my friend Dr. Southey, 
investigated the subject ; and when they had satisfied themselves of the value of the 
remedy, the result of their inquiries was communicated by Dr. Fenwick to the late 
Dr. Baillie, in a letter which was read before the Medical and Chirurgical Society. 
But there is nothing new under the sun. Fifty years ago, Mr. Maiden, in the 
Memoirs of the London Medical Society, recommended the same remedy, in the 
same doses, for the same purpose. But his recommendation had been neglected, or 
forgotten. 

The dose of turpentine is from half an ounce to two ounces. It may be given in 
combination with castor oil ; or castor oil may be administered afterwards to assist 
its purgative effect. It should be taken in the morning, fasting : and no drink should 
be admitted into the stomach until the medicine begins to operate, lest sickness and 
vomiting should be provoked. The worm generally is voided, dead, within an hour 
01 two. 



840 



TAPE-WORMS. 



The inconveniences of turpentine as a remedy are its nasty taste, the sort of intOM- ; 
cation it is apt to produce, the distressing sickness it excites in some persons, and the j 
strangury it sometimes occasions. This effect of it, however, is less common from 
large than from small doses of the oil. The bowels should be kept open with castor i 
oil, so long as the urine retains the violet smell, which indicates the presence of the 
turpentine in the circulation. | 

Upon the continent a celebrated empyreumatic oil, called Chabert's, is in great ' 
repute. It contains turpentine ; but is still more nauseous than it. One part of the | 
empyreumatic oil of hartshorn is mixed with three parts of oil of turpentine. Afti r 
the mixture has stood for three days, three-fourths of it are to be distilled over, i« j 
glass vessels, by means of a sand bath. Chabertwas a veterinary surgeon, and had | 
used this remedy with remarkable success upon domestic animals, cows, dogs, and 
sheep. Bremser, after testing its safety by taking it himself, administered it, he tells \ 
us, to no less than 500 individuals troubled with taenia. Among these were two^ I 
children, a year and a half old. He found it both a powerful and a permanent cure. 
Of the whole number treated there were but four who required a second course of j 
the remedy. It seems to kill both the worms and their ova. The dose is two tea- i 
spoonfuls, night and morning, until four or six ounces have been taken ; a purgative I 
being from time to time interposed. K that dose produces any confusion of head, it | 
must be diminished. 

Bremser admits that this curative process is tedious, but affirms that, on the other j 
hand, it is safe, and but little inconvenient. When the patient has continued free 
from any symptoms of tape-worm for three months, he concludes that the cure i» 
absolute. Other practitioners agree with him in attesting the efficacy of this oil ; but 
are not so confident about its perfect safety and convenience. ^ 

Another great remedy is the bark of the pomegranate-root. This is at least as old> 
as the time of Celsus. It has long been employed in India. Its value has only ; 
been recently appreciated in France ; and in this country it is not much used, V \ 
believe, even yet. You may read a very instructive account of its effects in a paper* I 
communicated to the Medical and Chirurgical Society by Mr. Breton. He boiled: 
two ounces of the fresh bark of the root in a pint and a half of water, till the decoc- 
tion was reduced to three quarters of a pint. Two ounces of this, cold, he gave to- | 
a patient who had tape-worm, and repeated the dose every half hour until four doseS' ; 
had been swallowed. About an hour after the last dose, an entire taenia was voided i 
alive. 1 

The bark dried in the sun he found still more active. A stout man forty years i 
old, took a decoction prepared in the same way as the former, only with the dried 1 
instead of the fresh bark. Three hours after the first dose, a five tape-worm came- | 
away, nineteen feet two inches long. The medicine thus prepared seemed to be too- j 
strong ; the patient was sick, giddy, and trembling for several hours. He, also, had ] 
taken four doses. i 

To two boys, of seven and ten years of age, he began early in the morning to- 
iidminister one ounce of a decoction made of half the previous strength, every half , 
hour, for six times ; and then stopped. In the middle of the day he resumed the- i 
medicine in half-ounce doses. Giddiness and faintness soon came on ; and, about | 
five o'clock, each of the patients passed a taenia of the solium kind. ; 

A scruple of the powder was given, mixed wath water, every hour for five succes- 
sive hours, to a boy of nine. Forty minutes after the last dose a living taenia was- j 
expelled. | 

The same quantity was given to a girl, ten years of age ; beginning at eight, and j 
repeating the dose hourly till twelve o'clock. At twenty-four minutes past one she- , 
voided a living taenia lata; and the next morning, at nine o'clock, a dead tcenia ! 
sohum. This curious case shows that the two species may exist in the same person • ; 
at the same time. ; 

Mr. Breton relates other examples, but those which I have cited are quite suffi- | 
cient to demonstrate the power of this substance. The bark appears to act upon the 
worm as a poison. In tepid water taeniae will five for several hours. When they- i 
are plunged into the aforesaid decoction, they writhe and manifest great uneasiness, j 



INFLAMMATION OF THE LIVER. 



841 



Between the first dose of the medicine and the expulsion of the worm, the shortest 
period appears to have been three hours, the longest twenty-five. 

Louis's ten cases, before referred to, were all treated by a nostrum called the potion 
of M. Darbon. It proved successful in all. Eight or ten ounces of it were taken 
in the morning, before breakfast ; and the cure was accomplished by that single dose. , 
It is said to be quite safe, to have no very decided taste, and to cause no further in- 
convenience than a shght colicky feeling, and uneasiness in the epigastrium, less 
than is produced by many a purgative : and even these sensations were probably 
owing to the movements of the worm ; for when, after the lapse of four months, 
the dose was repeated, it was followed by no inconvenience at all. The medicine 
is not strongly cathartic, and sometimes requires the aid of a lavement. In each 
of these cases the expelled tasnias were apparently dead. Their heads were detected 
in the evacuations : in one instance seven heads were seen. Louis says that within 
a few days at furthest after the discharge of the worms, all the previous symptoms 
of their presence ceased ; and the patients improved in respect to appetite, digestion, 
complexion, flesh, and strength. They all remained well four months afterwards,, 
and then the potion was again administered ; but it brought away no more worms. 
Some of the patients, who had previously tried other modes of cure, had never 
enjoyed so long an interval of freedom. 

Various other remedies have been employed, and employed with more or less 
success. One of them, the root of the male fern, formed the basis of a nostrum, 
called Madame Nouffer's, which was so highly thought of, that in 1776 the King 
of France gave that lady some hundred pounds sterling for the secret of its com- 
position. I think, however, you will find the oil of turpentine equal to the cure of 
tape-worm in most instances. Should it fail, or should circumstances forbid its use, 
I would advise you to resort to the bark of the pomegranate root. It seems pro- 
bable that M. Darbon's remedy, if its nature were divulged, would supersede all 
others. 



LECTUEE LXXV. 

Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and 
Treatment of Acute Hepatitis. Chronic Hepatitis. Jaundice. Its Symptoms^ 
Causes^ and Species. 

From the alimentary canal I go to the other organs directly or indirectly con- 
cerned in the digestion and assimilation of our food. And, first, let us look at that 
large gland, the fiver, of which the main office, so far as we can perceive, is the se- 
cretion of bile. 

The liver is hable to various forms of disease : but it is not so frequently in 
fault as many would have us befieve. It is often blamed most gratuitously and 
unjustly. 

The researches of Mr. Kiernan, recently published in the Philosophical Trans- 
actions, have paved the way for a better understanding in future of its pathology. If 
I did not feel myself too much circumscribed by the remaining limits of this course 
of lectures, I should be glad to attempt to assist you in construing Mr. Kiernan's 
somewhat difficult and very valuable paper. But doubtless you are made familiar 
with the anatomy of the organ, as described by him, in other lectures : and I must 
content myself with' noticing, as we go along, one or two points, in respect to its mor- 
bid appearances, concerning which, before Mr. Kiernan took the subject up, great 
mistakes prevailed, even among the most celebrated pathologists. 

I shall follow the usual order, and consider first, inflammation of the liver, which 
may be .either acute or chronic. 

These are, both of them, diseases that are much more common in warm climates 
than heje. 

Of well-marked acute hepatitis the symptoms are fever, with pain and a sense of 

3v 



842 



INFLAMMATION OF THE LIVER. 



tension in the right hypochondrium, inabihty to he on the left side, difficulty of breath- 
ing, a dry cough, vomiting, hiccup. 

You will not find all these symptoms present in every case : yet they are all worth 
attending to. 

The pain is sometimes sharp and pricking, hke a pleuritic stitch: sometimes dull 
and tensive. In the former case the peritoneal covering of the gland is supposed to 
be affected ; in the latter its parenchyma. The pain sometimes extends to the right 
clavicle and to the top of the right shoulder. This circumstance was noticed by 
Hippocrates ; and I have referred to it before as a good example of what are called 
sympathetic sensations. The existence of this pain makes it probable that the 
inflammation affects the convex surface of the hver. Occasionally the left shoulder 
is painful : the left lobe of the hver being involved in the disease. The pain in the 
right side is aggravated, often, by the movements of the diaphragm in respiration ; 
and this explains the embarrassment of the breathing, and the short dry cough. Why 
the patient cannot well lie on the left side is obvious enough : all the connections of 
the inflamed organ are then put upon the stretch by its weight. There are, how- 
ever, some exceptions to this rule. On the under or concave part of the Hver lies the 
pyloric extremity of the stomach ; and that viscus often sympathizes with the hepatic 
inflammation : nausea and vomiting occur ; and hiccup. The thoracic symptoms 
on the one hand, or the stomach symptoms on the other, may be expected to predo- 
minate, according as the convex or the concave surface of the organ is chiefly the 
seat of the inflammation. 

The situation of the pain, the cough, the short and shallow breathing, used to 
puzzle the older observers : and they confess their occasional inability to determine 
whether the inflammation w^as situated in the lower lobe of the right lung, or in the 
liver. But now-a-days we need have no difficulty in making the diagnosis. The 
ear will teli us, if we employ auscultation and percussion, whether the contents of 
the chest or of the belly are suffering : and my own experience has taught me that 
sharp pain, with feverishness, occurring in the debateable ground of the right side, 
denotes pleuritic inflammation far more often than it denotes hepatic. 

Jaundice is an occasional, but by no means a necessary effect or accompaniment 
of hepatitis, whether acute or chronic : and, therefore, what I have to say of that 
symptom I shall give under a separate head. 

Acute hepatitis may terminate in resolution ; or it may terminate in diffused sup- 
puration ; or, what is more usual, in the formation of a circumscribed abscess, or of 
abscesses, in the liver. In this climate we do not often meet with hepatic abscesses ; 
but they are very common in hot countries : and some of the most interesting events 
of the disease have relation to the progress of these collections of matter. When 
they approach the surface of the liver, adhesions generally take place (in virtue of 
that conservative principle of which we so constantly discern the working) between 
the diseased organ and the neighbouring parts. If no such adhesion occurred, the 
matter would at length burst. into the cavity of the peritoneum ; and this does some- 
times happen. The peritonitis, which is thus suddenly set up, is almost fatal. I 
referred, however, in a former lecture, to one instance in w^hich it was recovered from. 
Sometimes the adhesion is effected between the liver and the parietes of the abde- 
men, and the abscess points externally, and may be opened by the surgeon. Such 
a case occurred in my neighbourhood last year. Sometimes the liver glues itself to 
the stomach, or to the intestines ; and then the abscess breaks into the alimentary 
tube, the matter is evacuated by vomiting, or by stool : and all goes on tolerably 
well again. In other instances the agglutination is to the diaphragm, which is per- 
forated, and the pus makes its way into the sac of the pleura, or through the lung 
to the bronchi, and so out by the mouth. I have seen three examples of this my- 
self. In one the abscesses originated in the formation and degeneration of h)'^datids 
in the liver ; and the patient (a woman, she was under Dr. Macmichael's care in 
the Middlesex Hospital) spat up quantities of yellow fluid, consisting partly 1 sup- 
pose of pus, but chiefly of pure bile. The examination of the dead body ultimately 
demonstrated the nature of that case. The second of the three patients got well : 
yet I cannot doubt that, bating the hydatids, the disease was essentially of the same 



INFLAMMATION OF THE LIVER. 



843 



kind. It also occurred in a woman, whom I admitted into the hospital. She was a 
kitchen-maid at the Thatched House Tavern in St. James's Street ; and she had 
received a violent blow at the back part of the right hypochondrium. This was fol- 
lowed by pain there and by fever; and at length she began to have cough, dyspnosa, 
and expectoration. She brought up an abundance of frothy mucus of a bright yel- 
low colour: not at all resembling the rusty sputa of pneumonia, but exactly of the 
tint which bile wouid give to it. At the same time large crepitation could be traced 
from the bottom to the top of the right lung. I fully expected that this woman would 
die : but by degrees the yellow expectoration ceased, all the auscultatory signs gra- 
dually disappeared, and she recovered perfectly. 

It is plain that in such instances as this, there must be adhesion of the lung to the 
diaphragm also : but cases have occurred in which the matter burst into the cavity 
of the pleura, and presently destroyed the patient by suffocation. 

The event of the third case is still sub judice. A gardener, of forty-five years 
old, was attacked, four weeks before he came under my care in the hospital, with 
severe pain in the right loin. Just at the edge of the short ribs, and not far from the 
vertebral column, on the right side, I found a large elastic swelling, very tender, and 
of a bluish red colour. As the patient's urine was most remarkably loaded with 
amorphous deposits, my first suspicions turned towards the kidney. It soon, how- 
ever, became evident that, although the tumour was below the diaphragm, the parts 
above that muscle were involved in the disease. The right half of the thorax was 
dull to percussion ; no vesicular breathing was audible there, but some scattered cre- 
pitation and bronchophony. Four days subsequently to his admission the patient 
began, during an effort of coughing, to discharge almost in a stream, from his mouth, 
a considerable quantity of gray, pultaceous fluid, of the consistence of gruel, and hor- 
ribly foBtid. Altogether the amount of matter thus expectorated was estimated at 
two quarts. The pain then ceased ; and the swelling was observed to be less. After 
three days more, it was deemed proper to puncture the tumour, and matter was let 
out having precisely the qualities of that which he had ejected through the mouth. 
The patient remained eleven weeks in the hospital, the expectoration becoming less 
unnatural, and the discharge from the abscess gradually diminishing. He then 
chose to depart. Some months afterwards he applied for re-admission, and again 
stayed with us a week or two. His health had much improved during the interval : 
but the wound in his back was still open, and he still continued to expectorate some- 
what : and yellow bile was frequently to be seen, both on the dressings which 
covered the puncture, and in the vessel into which he spat. I think it probable that 
this man may eventually recover, at the expense, however, of a permanently da- 
maged lung. 

Rigors occurring during the progress of hepatitis should make us suspect that 
suppuration is taking place : if the pain is thenceforward mitigated, or exchanged 
for a sense of weight, and hectic fever sets in, we may be tolerably certain that pus 
has formed. 

Of the several courses taken by an hepatic abscess, that towards the surface of the 
body is the most common ; and it is the only one with which we are able to interfere. 
And the chief thing we have to look to, is not to interfere too soon. The adhesion 
of the inflamed organ to the wall of the abdomen is the indispensable condition, not 
of success only, but of safety, where the question arises of puncturing the tumour. 
Without such adhesion the pus will be transferred from the cyst to the cavity of the 
peritoneum ; or if the abscess be not reached by the scalpel, that cavity will be laid 
open. Now it is not easy to ascertain whether there be adhesion or not. Certainly 
the operation ought not to be attempted until the parts above the abscess are very 
thin, and are verging to a point ; and even then, unless there were some distinct 
purpose, besides that of saving a hitle time, some urgent distress or danger to reheve, 
I think such abscesses might be more prudently left to themselves. Dr. Gregory, 
of Edinburgh, used to mention a case in which, as fluctuation was palpable, and the 
tumour pointed, it was proposed to open it ; but the patient died, somewhat suddenly, 
before the operation could be performed ; and inspection of the dead body showed 
that no adhesion existed. Mr. Malcolmson has lately published, in the Medico-Chi' 



844 



ACUTE HEPATITIS. 



rurgical Transactions, two or three instances of a like kind. These are circum- 
stances which teach us to be cautious about recommending the operation. 

A case is recorded of the bursting of an hepatic abscess into the pericardium ; 
another into the vena cava. Facts of this kind constitute mere medical curiosities, 
and have no practical bearing. 

It is clear, both from the size of the organ, and from its situation in the body, that 
an abscess in the liver can never be otherwise than gravely hazardous. Yet many 
recover from them. Much evidently depends upon the manner and direction in 
which the pus seeks a vent. The most desirable road for its exit is one which it 
sometimes takes, but which I have not yet mentioned. It occasionally flows out into 
the duodenum through the excretory ducts of the liver, when these happen to have 
been laid open by the suppurating process. Next to this we may hope for its dis- 
charge through the adhering parietes of the abdomen ; next by a breaking of the 
abscess into the ahmentary canal. The escape of the matter through the air-pas- 
sages is fearfully perilous ; and its entrance into the shut serous sacs, or into the 
great blood-vessels, almost necessarily fatal. 

I have spoken of an abscess in the liver, as an event of acute inflammation of that 
organ. Such inflammation is apt to arise, in tropical countries, after exposure to cold. 
In any chmate it may be excited by a blow, or other mechanical injury. But abscess 
in the liver seems to be far more frequently the result of other remote causes. You 
will call to mind those collections of matter which form in the liver, as well as else- 
where, in consequence of suppurative phlebitis. There is, moreover, acknowledged 
connection between hepatic suppuration and dysentery. In hot chmates the two are 
often found coincident. It has commonly been thought that, in these cases, the affec- 
tion of the liver happens first, in the order of time ; that the hepatic disease, inter- 
fering with the freedom of the portal circulation, occasions congestion of the submu- 
cous capillary blood-vessels, and so disposes the membrane to take on inflammation 
under the influence of any shght exciting cause. In some recent lectures, however, 
dehvered before the College of Physicians, Dr. Budd has proved, by a careful colla- 
tion of a large number of authentic instances, that the relation of these two morbid 
conditions to each other, is exactly the reverse : that the dysentery is the primary 
disorder, and the hepatic abscess the secondary ; the link of connection between I 
them being the same as between suppurative inflammation of a vein, and the forma- ' 
tion of pus in parts more or less remote. The blood, in its return through the i 
veins which are tributaries of the vena porta, carries with it, if not pus, yet some i 
vitiating ingredient from the inflamed membrane : and this vitiating ingredient pro- I 
vokes inflammation in the capillary vessels of the hver. i 

This, to the best of my knowledge, is a new, and certainly it is an important view | 
of the pathology of hepatic abscess. I trust that, ere long, Dr. Budd will lay before | 
the public the evidence upon which it is founded. 

Acute hepatitis, when it occurs, requires vigorous treatment in the outset. Our 
object is, if possible, to prevent suppuration. jBlood should therefore be freely taken ; 
from the system by venesection, and from the neighbourhood of the inflamed part 
by leeches. I w^ill not weary you by going over the old ground that we have so, | 
often trodden already, nor repeat observations which have been many times made j 
respecting the methods, and the requisite amount, of this great antiphlogistic remedy. ■ 
Depletion of the portal vessels may also be indirectly obtained by purgatives ; espe- ' 
cially by such purgatives as produce copious and watery stools. The neutral salts i 
are therefore proper in this disorder. It may be, as some suppose, that they operate i 
beneficially, as counter-irritants, upon the duodenum ; but their efl^ect in draining 1 
the veins that feed the vena porta, and thereby reheving the hepatic congestion, is , 
more obvious and more intelhgible. These sahne medicines should be much diluted; ' 
and their action may be quickened, if that be necessary, by adding the infusion of ' 
senna. 

After blood-letting has been duly performed, and the force of the inflammatory j 
action has been broken, blisters may be apphed to the right hypochondrium : and I 
believe that repeated blistering is more serviceable than a single bhster kept open by 
savine ointment. 



CHROxNIC HEPATITIS. 



845 



Some difference of opinion prevails among medical men in regard to the employ- 
ment of mercury in the outset of acute hepatitis. I cannot pretend to offer you the 
results of my own observation on this point, but I find that the best authorities, 
among those who have had to treat the disease in hot climates, are against its use at 
the very first, as being stimulating to the liver. I suspect that this is a piece of 
theory : but at all events, after the first violence of the inflammation has abated, that 
remedy is not to be omitted, either in the acute, or in the chronic form of the disorder, 
to be mentioned presently : only in the one case it should be so administered as to 
affect the system as speedily as possible ; in the other it is to be introduced with a 
slowness which bears a proportion to the pace of the disease. 

When suppuration has taken place, or is unavoidable, when the patient ceases to 
complain of pain, but has in its stead a feehng of weight in the hypochondrium, 
and becomes distinctly hectic, a corresponding change must be made in the treatment. 
Active depletion is no longer admissible ; you must sustain the strength by a more 
nourishing diet, and prescribe some tonic remedies ; the sulphate of quina, with 
sulphuric acid ; or the nitro-muriatic acid, which enjoys a considerable repute, greater 
perhaps than it merits, for the relief of liver complaints. 

Acute inflammation of the liver is apt to degenerate into chronic. Chronic in- 
flammation may also arise under the circumstances that give birth to the acute form. 
Chronic hepatitis, again, is not unfrequently produced by the presence of specific 
disease in the hver ; of carcinoma ; of scrofulous tubercles. Melanosis and hydatids 
are both of them of common occurrence in the same part ; and they may give rise 
to symptoms, or they may not : and when these morbid conditions do declare them- 
selves by external signs, those external signs are very much the same as belong to 
chronic hepatitis. The precise diagnosis is exceedingly obscure ; the symptoms 
point distinctly to the liver as the seat of the disorder ; but as to its exact nature, we 
must often be content with probabilities alone. 

The symptoms of chronic hepatitis — or of the chronic forms of disease to which I 
have alluded, when they show themselves by symptoms — are (I give you them in 
Cullen's words) "some fullness and some sense of weight in the right hypochon- 
drium ; some shooting pains felt at times in that region ; some uneasiness or pain 
felt on pressure in that part ; some discomfort from lying upon the left side ; perhaps 
some degree of jaundice ; and sometimes a certain amount of fever combining itself 
with more or fewer of these symptoms." In short, they are just the symptoms of 
acute hepatitis occurring in a minor degree. 

Chronic affections of the liver are sometimes attended with an increase, and some- 
times with a din$,inution, of its size. When it is augmented in bulk, its place and. 
enlargement may be ascertained by palpation and percussion ; nay, the magnified 
gland may sometimes be seen, extending beyond its proper situation in the hypo- 
chondrium, and passing far down into the abdomen. I have known the hver reach 
to the right groin : and when its left lobe is affected, it will sometimes stretch across 
towards the lower part of the left side of the belly. On the other hand, the liver 
may shrink into a much smaller space than it naturally occupies. These small livers 
are usually hard. Interfering more with the portal circulation than many enlarged 
hvers do, they are more frequently attended with dropsj^ of the peritoneum. 

The " hobnail" liver, the cirrhose of modern French writers, is nodulated as well 
as hard. The irregularity of its surface may be so great as to be perceptible to the 
touch. I fully described this condition of the liver when I was upon the subject of 
passive ascites, of which it is the most common cause. 

I mentioned, also, some time ago, the "fatty" hver, so frequently found associated 
with pulmonary consumption. The liver in this state is soft, enlarged, smooth on its 
surface, and of a buff or tawny colour throughout. Mr. Bowman has lately shown 
that these changes are owing simply to the unwonted abundance of certain small 
granules of fat, of which, in the healthy organ, each lobule contains a few only. If 
in a phthisical patient we find the liver palpably enlarged, we may guess that it is 
encumbered with this interstitial fat : but there are no symptoms peculiar to the fatty 
hver. As to its cure, we are quite helpless : and the same may be said of the hobnaii 

3v3 



846 



CHRONIC HEPATITIS. 



liver, as well as of all those forms of disease in which the organ is loaded with specific 
deposits. 

Dark masses of extravasated blood are sometimes found interspersed through this " 
gland, and then, by an absurd perversion of language, the patient is said to have had 
*' apoplexy" of the hver. 

The same causes which produce acute hepatitis, acting in a Jess intense degree, i 
will excite chronic inflammation of the same textures. Intemperance, also, and par- ! 
ticularly the habitual and excessive use of alcoholic liquors, certainly tends to generate | 
hepatic inflammation, especially in its more chronic form. We see this even here, 
and it is still more strikingly perceptible in warm chmates, as you may learn by ; 
reading the works of those persons who have had experience of the diseases of India. ' 
Dr. William Ferguson, for example, who was for some time chief of the medical 
staff of the windward and leeward islands in the West Indies, observed that there was i 
a regular increase and aggravation of these chronic affections of the hver among the \\ 
troops after they received their monthly pay, when they drank great quantities of I 
ardent spirits ; arrack in the East Indies, and rum in the West. ! 

There has long been supposed to be what is called a gin- drinker^ s liver, in which \ 
a section of that gland presents an appearance very closely resembling the section | 
of a nutmeg ; and a good deal of useless speculation has been employed as to the | 
nature of the change which has taken place in such cases. Mr. Kiernan has clearly 
shown that the nutmeg aspect of the liver is produced by mere congestion of blood. 
Congestion of the liver is, indeed, very likely to arise under the daily stimulus of 
distilled spirits, but it arises under various other circumstances besides ; and there- \ 
fore it is no safe test of the intemperate habits of the party. And of this we had 
sufficient evidence before Mr. Kiernan's observations were published.. Again and : 
again have I met with the nutmeggy liver, strongly marked, when there was reason ' 
to beheve that the possessor of it had never transgressed the strictest rules of tem- : 
perance in drinking: in young persons, for example, of both sexes, who certainly | 
never had been dram-drinkers. Disease of the heart is a very obvious, and a very | 
common cause of hepatic congestion. 

You are aware that the congestion occure under two forms, according as the 
branches of the hepatic vein, or of the vena portse, are gorged. If both these sets j 
of vessels are full, the hver is universally red. If the hepatic vein alone be the seat 
of the congestion, then in the centre of each lobule we see a red speck, surrounded |l 
by yellowish matter ; the specks are isolated, the yellow colour is arranged in a sort . 
of net-work. Whereas, if the portal system be greatly engorged, the red streaks ] 
will be continuous, and the yellow portions hemmed in by them, and isolated. I { 
show you these distinctions in some specimens prepared by Mr. Kiiernan himself. | 

I should have stated, when speaking of the signs of chronic hepatitis, what is sin- | 
gularly true of chronic hver affections in general, that they are apt to be attended | 
with much languor and lassitude, and a remarkable depression of spirits ; and with ! 
that sort of dread, and apprehension of impending evil, which I mentioned as being ' 
a striking feature of hypochondriasis: the very derivation of which term marks its " 
frequent connection with hepatic disorder. There is sallowness of the complexion | 
also; and sometimes emaciation. ! 

The same remedies are adapted to the chronic as are proper for the acute infiam- ' 
mation of the liver: the comparative mode of their exhibition, however, differs 
somewhat. 

Blood-letting is not often necessary or advisable, except when more violent aggra- | 
vations than usual of the inflammatory symptoms supervene. Topical bleeding, and ' 
blistering, are more expedient. 

But the two main remedies to be tried in this complaint are mercury, and the , 
saline purgatives, given in small doses, and repeated for a long time together. Five 'j 
grains of biue-pill every night, or every night and morning; and as much of the 
sulphate of magnesia as will produce one or two watery stools every day, for weeks, | 
perhaps, in succession. Patients are not so well content to bear this discipline when j 
it is administered in boxes and phials, as physic; but they have more faith in the ! 
natural mineral waters: so that a residence at Cheltenham, or some such place, is 



I 

\ 



JAUNDICE. 



847 



exceedingly proper to be recommended in these cases ; where the daily use of the 
waters may keep up a continual drain on the system of the vena portse ; and where 
relaxation from business, the amusements that are constantly going on, with change 
of scene and of society, may contribute to dissipate the hypochondriacal feelings 
which are so apt to render the subjects of chronic hepatic disease supremely 
wretched. * 

Moderate exercise, in the open air, on horseback and on foot, should be encouraged. 
There is no doubt that hepatic as well as gastric derangements are fostered by 
sedentary habits. Tepid bathing is another expedient from which benefit may be 
hoped. In many instances it will be proper to make trial of Scott's nitro-muriatic 
bath. 

Iodine has been thought of much use in certain kinds of hepatic disease ; in those 
kinds especially which are connected with enlargement of the viscus. The iodide 
of potassium, or a mixture of the iodide and of iodine, or some of the combinations 
of iodine and mercury, may be given in such cases ; or the unguentum iodinii 
coinpositum, or the unguentum hydrargyri iodidi of the Pharmacopoeia, may be 
rubbed night and morning upon the hypochondrium. I have not seen much benefit 
from these forms of medicine myself, in such cases ; but they are said, by persons 
of experience and credit, to have been successful in their hands. 

Taraxacum is also a drug which has been much employed in liver complaints, 
since Dr. Pemberton's book on the diseases of the abdomen was published ; but it 
is very doubtful, in my mind, whether it ever does much good. The Germans are 
very fond of giving the muriate of ammonia in small and frequent doses. They 
have the same behef in the virtues of this salt, in various disorders, as the Enghsh 
practitioners have in those of mercury ; and, what is curious, they attribute to it 
some specific agency upon the functions of the liver. 

In the account which I have now given of the principal diseased conditions of the 
liver, I have not included nor dwelt upon all the changes of structure and appear- 
ance to which that organ is hable. There are various conditions which disclose 
themselves by no intelligible symptoms during life, of which the nature has not yet 
been determined, and of which the cure still remains to be discovered. At this 
advanced period of the course, and with no time to spare, I do not think it necessary 
or right to trouble you with the unprofitable discussion of matters that are not strictly 
practical. 

I have mentioned jaundice as an occasional symptom both of acute and of chronic 
inflammation of the liver. But jaundice is spoken of, in general, as constituting, 
itself, a distinct form of disease. If we consider it in that light, its diagnosis is most 
easy. We have only to look upon our patient to know what is the matter with him. 
But jaundice depends upon various and very different morbid conditions ; and, look- 
ing to those conditions as the true objects of diagnosis, we find that the real nature 
of a given case of jaundice is often involved in very great obscurity. 

Let us first consider the constituent features of jaundice, whether it be regarded 
as a disease, or as a sign of disease. They are, yellowness of the skin and of the 
eyes; whitish feces; urine having the colour of saffron, and communicating a bright 
yelloAv tinge to white Hnen. 

The characteristic yellow hue is owing, no doubt, to the presence of bile, or at any 
rate of the colouring matter of the bile, in the circulating blood. And the deep tint 
of the urine is evidently derived from the same source. On the other hand, the 
paleness of the feces is to be ascribed to the want of bile, which always exists in 
healthy and natural excrement. This last symptom is not, however, a constant one ; 
there may be jaundice while bile appears in the stools. I shall explain how this is 
supposed to happen, presently. 

It has been made a question how the bile, or its colouring matter, comes to be 
visibly present in the blood, or rather in many of the tissues supplied by the blood, 
and in several of the other fluids of the body. The general opinion, and probably 
the true one, is, that the bile, after being secreted in the liver, is reabsorbed, and car- 
ried into the circulation, and so conveyed to the surface, and to the parts in which 



848 JAUNmcE. 

the change of colour is observed. This explanation is consistent with the pheno- 
mena which we notice in the disorder. 

But another theory has been broached on this subject ; first, I believe, in this 
country, by Darwin. It has been more recently revived by M. Chevreul, who is 
followed by Mr. Mayo. These pathologists are of opinion that the bile is formed, 
not by the Hver, but in the blood : that the office of the hver is to strain off or with- 
draw the bile from the circulation, constantly, as fast as it is formed; just as the per- 
petual ehmination of urea from the blood appears to be one great purpose of the 
kidneys. They hold, therefore, that jaundice manifests itself whenever the due 
separation of the bile from the blood is suspended or imperfect. Failing of its natu- 
ral vent, this peculiar substance accumulates in the blood, seeks other outlets, is 
deposited in various places, and, in fact, partly escapes through unaccustomed chan- 
nels. They speak of jaundice as a symptom of suppression of bile, while others 
consider it as a sign of retention ; using these words, suppression and retention, in 
the sense in which they are applied to the secretion of urine. They maintain that 
the proper function of the liver, the abstraction of bile from the blood, may be 
arrested by alterations of the substance and structure of that gland ; or by the oblite- 
ration or obstruction of the gall-bladder or ducts, impeding or forbidding the removal 
of the bile already formed ; or by some obscure influence of the nervous system 
upon these organs. They introduce the last kind of cause with the view of explain- 
ing those cases, which certainly occur, in which jaundice is the result of severe 
bodily pain, or strong mental emotion. Nay, on their supposition, we might even 
suppose that the yellowness is sometimes due to a spontaneous and unwonted abun- 
dance of the elements of bile in the blood ; in which case, we need not wonder that 
jaundice should go along with perfect integrity of the biliary apparatus. 

The advocates of the first-mentioned supposition are aware of the difficulties 
opposed to its reception, by the occasional absence, even in cases of well-marked 
jaundice, of all organic disease or apparent obstruction to the excretion of the bile. | 
They show that in very many cases there is some obvious mechanical obstacle to the i 
efflux of the secreted fluid ; and in those instances in which none can be discovered ; 
after death, they conceive either that the ducts of the liver had been temporarily \ 
plugged up by inspissated bile, or a sort of biliary sand — or that they were closed | 
for a time by spasm — or by some morbid condition of the duodenum. ! 

Now, of these two hypotheses, that which ascribes the yellowness to the reabsorp- j 
tion of secreted bile is, to my mind, the most probable and the simplest ; and I can- i 
not see that it is attended with more difficulty than the other. But you may choose | 
for yourselves between them ; and I pass from this digression to a somewhat closer i 
examination of the principal circumstances noticeable in the complaint. Its technical | 
appellation, I should observe, is icterus, which is the Greek name for a bird with a | 
yellow plumage, the galbula, or golden thrush ; the sight whereof, by a jaundiced i 
person, was death (Phny tells us) to the bird, and recovery to the patient. Various ! 
other terms have been apphed to the disorder, most of them having reference, like ' 
jaundice itself (from the French j«ime), to the unnatural colour. Morbus arquatus, 
from its exhibiting some of the bright hues of the rainbow; aurigo, from its resem- i 
bhng gold ; and we hear the common people say, now-a-days, such a one is as yel- [ 
low as a guinea. The Latins spoke of it, also, under the title of morbus regius. ' 
Why they so called it, we learn from the following curious passage in Celsus, giving 
an account of the pleasant regimen, fit for royalty itself, to be adopted by those who 
labour under the malady: "Per omne vero tempus utendum est exercitatione, fric- | 
tione: si hiems est, balneo; si «stas, frigidis natationibus ; lecto etiam et conclavi i 
cultiore, lusu, joco, ludis lascivia, per quee mens exhilaretur : ob qui3e regius morbus 
dictus videtur." ■ 
The whiteness of the stools I have mentioned as being a very common, but not a ' 
constant appearance. It clearly depends upon the absence of bile. But sometimes 
there is bile in the discharged feces, and, at the same time, the yellow colour of the. 
skin and eyes. This probably depends upon the circumstance that some branches 
of the hepatic ducts are obstructed, while the others are free ; and thus the bile that i 
is secreted is, in part, reabsorbed into the bloody and in part carried off into the intes- | 



JAUNDICE. 



849 



tines. In a former lecture, I stated that one of the uses of the bile appeared to be 
that of stimulating the bowels to action ; it is the natural purgative. Accordingly, 
in most cases of jaundice, the bowels are costive. But neither is this uniform. In 
some of the worst cases, wherein the jaundice depends upon hepatic disease, which 
is connected with disease also of the mucous coat of the intestines, there is constant 
diarrhoBa. 

In some instances the yellowness of the skin is at first attended with itching, which 
is occasionally so intolerable as to require the employment of opiates to allay it. In 
most cases there is no itching at all. The bile never fails to appear in a deep vessel, 
even black ; and which tinges any white substance that is dipped into it of a bright 
yellow. The urine which thus sometimes seems black, may be proved to derive 
that appearance merely from concentration of the yellowness, by pouring a little of 
it into a shallow white dish, or by diluting it with water ; when the brilliant yellow 
tint will become manifest. Bilious sweat sometimes occurs, staining the patient's 
linen yellow. The saliva, in some jaundiced persons, has the same yellow tinge, 
and a distinctly bitter taste. It has been said that the milk of women who are nursing 
is made yellow in this disorder. Dr. Heberden, however, states that he never wit- 
nessed this ; and he had known a woman with a very deep jaundice upon her, 
suckle her infant for six weeks together with no apparent bad effects upon its health. 
One man assured him that his tears were yellow. You are aware of the vulgar 
notion, that to a jaundiced eye all things appear yellow. It is an old notion, for we 
find it expressed by Lucretius : — " Lurida prasterea hunt qusecunque tuentur Ar- 
quati." Heberden was disposed to regard this as a mere poetical fiction. But cer- 
tainly it is sometimes, though very rarely, indeed, a fact. Two women, whom he 
considered, however, to be of Httle credit, told Heberden that objects appeared yellow 
to them. I have been assured of the same thing by a medical man who experienced 
it in his own person. If I do not mistake, Dr.'Mason Good saw all things yellow 
when he was jaundiced. Dr. Elliotson has had some very interesting cases of this 
phenomenon. One of his icteric patients declared that objects seemed yellow when 
looked at with one eye, but not with the other ; and in the eye that perceived the 
yellow tint he observed two large red vessels running towards the cornea. And in 
one or two instances, which he met with afterwards of yellow vision with both eyes 
in jaundiced patients, he found inflammation, or distended blood-vessels in both eyes. 
This very morning I saw in the hospital a patient of Dr. Wilson's, a middle-aged 
woman, affected with jaundice. She affirms that all objects seem yellow to her 
vision. In both eyes there are several varicose and singularly tortuous vessels, pro- 
ceeding across the sclerotica towards the cornea, and some of them reaching its 
margin. It seems probable therefore that the ophthalmic vessels, in their natural 
state, do not permit the colouring matter of the bile to pass through them ; but that 
when they become enlarged by disease, so as to admit the colouring particles of the 
blood, they may also give a passage to the yellow colouring matter, which tinges 
the humours of the eye : and in that case the objects seen through the yellow fluids 
would appear like those viewed through a piece of yellow stained glass. This is a 
point which is worth your attention in future. 

The shades of yellowness are different in different patients. Those who are pale 
and fair present a bright lemon colour. But in those who are florid, or whose cheeks 
and skin are flushed with fever, the tint will more resemble that of the Seville orange. 
Again, if the patient be naturally swarthy, or if his visage is livid or dusky through 
imperfect arteriahzation of his blood, the superaddition of jaundice will give him a 
greenish hue. These differences result from natural or acquired differences of com- 
plexion antecedent to the icterus. But sometimes the bile that is reabsorbed is 
vitiated and dark; and we may have, for that reason, as Dr. Bail lie has pointed out, 
cases of green or black jaundice. You will remark that from whichever cause the 
green or dark colour proceeds, whether from a minghng of the yellowness of the 
bile with the blueness of lividity, or from the circulation of green-coloured bile, such 
cases are especially unpromising cases. 

Icterus depends, as I have said, upon various and different internal causes : and 
frequently we cannot determine at all, until death affords us the means of inspecting 
54 



850 



JAUNDICE. 



the parts concerned in its production, what the precise exciting cause may be ; even 
when it is simply mechanical. Any kind of pressure made upon the excretory ducts 
of the hver will produce it ; and such pressure may be exercised by tumours sealed 
in the hver itself; or by a scirrhous pylorus ; or by specific disease situated in the 
head of the pancreas, of which I have seen several examples ; or by a diseased con- 
dition of the duodenum : and these possible causes of a detention of the bile in its 
receptacle should always be borne in mind when we are investigating an obscure 
case of jaundice. 

The impediment, in the cases just supposed, is external to the ducts ; but they 
may be obstructed within, plugged up by inspissated bile, or by a biliary calculus. 
This forms one of Cullen's species of icterus — the icterus calculosus. The concre- 
tion is most commonly situated, I beheve, in the ductus choledochus ; sometimes, 
however, in the cystic, and sometimes in the hepatic duct. The pain that attends 
the passage of a gall-stone through these ducts is often dreadful. Perhaps there is 
no pain to which the body is subject that is more severe. You will not wonder at 
this, when you consider that through a tube, of which the natural size scarcely ex- 
ceeds that of a goose-quill, there sometimes passes a stone as big as a walnut. The 
common duct has been found so dilated as readily to admit one's finger. Cullen's 
definition of this species is "Icterus, cum dolore in regione epigastrica, acuto, post 
pastum aucto, et cum dejectione concretionum biliosarum." JNow the last of these 
circumstances, the voiding of bihary calculi by stool, may happen over and over 
again, without its being noticed, and it does not help us at all to judge of the nature 
of the complaint at its commencement, while the gall-stone is still in the ducts. With 
the pain, which is not constant, but comes and goes, there are much nausea and 
vomiting ; and sometimes hiccup ; and the matters vomited are usually very sour. 
The patient is flatulent and dyspeptic ; languid and gloomy. At length the concre- 
tion passes into the intestines ; the pain suddenly ceases, and all is soon well again. 
Attacks of this kind, having happened once, are very apt to be repeated. 

Now this pain you might readily mistake for the pain of inflammation, were it not 
marked by these two circumstances — the absence of tenderness and the absence of 
fever. Pressure, instead of augmenting, usually mitigates it. The patient keeps 
his hand firmly appHed to his epigastrium ; or rests, perhaps, the weight of his body 
upon some hard substance placed beneath his stomach. I speak now of the begiti- 
ning of the attack, before there has been much retching ; for a degree of tenderness 
of the abdominal muscles is often produced by repeated straining and vomiting. The 
pulse is unaffected, or I should rather say it is not accelerated, during the pain : 
occasionally it is even slower than natural, and the skin cold. Though there be no 
inflammation, rigors may occur ; just as they sometimes happen when a sohd sub- 
stance — a bougie to wit — is passing through, and distending the urethra. 

Nevertheless, inflammation does sometimes arise, and then the pulse becomes 
frequent, and the skin hot, and thirst and headache are complained of, and the epi- 
gastrium is tender ; and if blood be drawn it exhibits the bufly coat. Sometimes the 
gall-stone makes its way, by ulceration, through the contiguous structures, and so is 
discharged outwardly, or into the bowels. In such cases there must have been 
inflammation. 

As jaundice often occurs without any pain, so a gall-stone may enter and pass 
through the ducts, and produce pain, when there is no jaundice. The cystic duct 
alone may be blocked up, and that portion only of the bile be prevented from escaping 
which is accumulated in the gall-bladder. It is probable that re-absorption of the 
contents of that cistern is not very active. Or a calculus of an angular shape may 
stick in the common duct, and thus impede, without entirely stopping, the egress of 
the bile. Dr. Heberden thought that gastrodynia was not unfrequently owing to 
biliary concretions : founding his opinion upon the fact that many persons suffer, for 
months or years, under occasional attacks of epigastric pain, which is at last asso- 
ciated with jaundice. But after all, this might happen from progressive disease ia 
the stomach itself ; and it is a pity that Dr. Heberden's views were not fortified by 
^dissection. 

When once a large calculus has forced its way through the natural channels of 



JAUNDICE. 



851 



the bile, they remain permanently dilated ; and smaller stones may be afterwards 
voided without pain or other notice of their passage. There are persons who get 
rid of scores of them in this way, during the course of their lives. 

Sometimes a large concretion, after its extrication from the biliary passages, lodges 
in the more capacious intestines, and gives rise to serious obstruction there. I men- 
tioned, recently, one case of this kind which had fallen under my own notice. But 
in general the concretions are presently voided with the stools : and they should 
always be looked for. The patient is much gratified by seeing that his enemy has 
been expelled j and also by the proof he thus obtains of the sagacity and judgment 
of his physician. The feces should be mixed with water, upon the surface of w^hich 
any gall-stones, since they are specifically hghter than that fluid, will float. I never 
but once succeeded in thus catching a concretion in the evacuations of a patient, 
whose symptoms had led me to search for it. 

We often find gall-stones, even in vast numbers, in the gall-bladders of persons 
who, during their hfetime, had never been known to suffer pain about the hver, or 
to have jaundice, or to exhibit any token of the presence of such concretions. We 
infer from this that, while they remain in the reservoir of the bile, they are harm- 
less ; and that the suffering and the hazard they occasion are mechanical conse- 
quences of their transit through the gall-ducts. I have heard of an instance in which 
upwards of 1,300 gall-stones were taken from a human gall-bladder after death. 

These gall-stones are not, as you might suppose, mere lumps of inspissated bile. 
There are, I believe, concretions of that kind, but they are very rarely met with in 
the human subject. The ordinary calculi consist, in a great measure, of a pecuhar 
substance, cholesterine, which exists in a state of solution in healthy bile, but which, 
in some morbid conditions of that fluid, being released from its solvent, assumes its 
proper crystalline form. Very little is known respecting the circumstances under 
which the change takes place. Cholesterine, Dr. Prout tells us, is the product of 
some modification of the oleaginous principle. Biliary concretions seldom form in 
children. They are much more common in women than in men. They occur 
most frequently in persons who are corpulent, lead sedentary lives, use generous 
fare, sleep much, and neglect their bowels: all which things foster or denote a torpid 
and congested state of the hepatic system. Cattle are said to be subject to bihary 
calcuh when shut up in stalls during the winter, and to lose the complaint when 
they are again turned out into the pastures in the spring. Hence the absurd notion, 
countenanced even by Van Swieten, that grass is a good remedy for jaundice. 

Another variety of jaundice, also noticed by Cullen, is supposed to depend upon 
mere spasm of the gall-ducts. ^^Icterus spasmodicus, sine dolore, post morbos 
spasmodicos, et pathemata mentis." 

Now the existence of this cause is Jiypothetical. The gall-ducts, though not dis- 
tinctly muscular, possess a vital power of contraction. I am not aware that the 
disease has ever been clearly traced to a connection with " morbi spasmodici." It is 
an alleged cause which we can neither prove nor disprove. Certainly the " pathe- 
mata mentis" play their assigned part : fits of anger, and of fear, and of alarm, have 
been presently followed by jaundice ; and it has also been produced by great bodily 
suffering, by a severe surgical operation, or, perhaps, by the dread which attended 
it. Mr. North witnessed a case in which an unmarried female, on its being acci- 
dently disclosed that she had borne children, became in a very short time yellow. A 
young medical friend of mine had a severe attack of intense jaundice, which could 
be traced to nothing else than his great and needless anxiety about an approaching 
examination before the Censor's Board at the College of Physicians. There are 
scores of instances on record to the same effect: and this is observable of such cases, 
that they are often fatal, with head symptoms : convulsions, delirium, or coma, super- 
vening upon the jaundice. But with respect to the immediate cause of the icteric 
symptoms, they may, I say, depend upon a spasmodic constriction of the gall-ducts. 
Mr. Mayo has suggested another cause, viz., the sudden formation of bile in unusually 
large quantity in the blood, by some influence propagated through the nerves. 

Jaundice sometimes supervenes upon violent and long-continued vomiting; in 



852 



JAUNDICE. 



which case the extremity of the gall-ducts is supposed to have been compressed by 
the coats of the duodenum. 

Jaundice may also occur, as I stated before, as a symptom of acute or chronic 
inflammation of the liver ; and then its treatment will merge in that of the primitive 
disease which occasioned it. 

Icterus occasionally comes on during pregnancy ; and disappears after childbirth. 
The pressure of the gravid uterus may thrust other organs, a loaded colon for ex- 
ample, against the liver, and so impede the passage of the bile. The Kttle exercise 
that pregnant women are apt to take, and the costiveness that frequently attends 
their condition, may have some influence in causing the icterus gravidarum. 

All systematic writers follow CuUen in making jaundice a common disorder among 
newly-born children. The icterus neonatorum occurs, they say, a few days after 
birth ; is not attended with any suffering, or obvious disturbance of the bodily func- 
tions ; and soon disappears. Now there seems reason to beheve that this is not 
icterus at all ; and has no relation to the biliary organs. The surface of the infant, 
at its birth, is frequently of a deep red, from hyperemia or congestion of blood ; pre- 
senting a condition which falls httle short of a mild but universal bruise. By degrees 
the redness fades, as bruises fade, through shades of yellow into the genuine flesh- 
colour. Such, 1 am assured by those who are more conversant with these matters 
than myself, is the pathology of the icterus infantum. Of course true jaundice may, 
as well as most other complaints, befall the earhest period of hfe ; but I conceive 
that it seldom does. 

The prognosis in jaundice is generally favourable ; except when it depends upon 
structural disease of the Hver, or supervenes suddenly upon some great mental or 
bodily shock. In both these cases the prognosis is bad, or doubtful. It is better, in 
that variety connected with hepatic disease, if the disease proceeds from some known 
cause, by which a low degree of inflammation has been produced ; and the cause is 
such as can be avoided for the future. Just, indeed, as in chronic hepatitis, of which 
the icterus is simply an occasional symptom. The prognosis is worst of all in old 
persons, when the constitution is impaired, and there is no obvious cause for the 
disease ; and particularly when the colour of the skin is greenish, or approaching to 
black. 

[Mr. Twining, in his work on the Diseases of Bengal, has presented some very interesting 
and important views in relation to the pathology of jaundice. 

Mr. T. has found tliat jaundice, not only during its early stage, but for a long period subse- 
quently, while the discoloration of the skin remains, is very generally attended with some 
morbid sensibility when pressure is made over the situation of the gall-bladder and capsule 
of Glisson, though the uneasiness, during the absence of pressure, is most generally referred 
to the epigastrium. 

When the disease occurs in plethoric subjects, and the stools are of a pale clay colour, Mr. 
T. has found it almost always attended with fever, and in some cases he has known robust 
patients to die, with symptoms of oppressed brain, within thirty-six hours after the sudden 
appearance of intense jaundice, for the accession of which no cause could be assigned. 

In conseqijence of the acknowledged obscurity which exists in regard to the true pathology 
of the disease, he was anxious to ascertain the exact condition of the liver and biliary ducts 
in persons labouring under jaundice. The almost invariable existence of pain, increased 
upon pressure, confined to a circumscribed spot on the right side, just below the centre of a 
line drawn from the right nipple to the umbilicus, led him early to suspect circumscribed 
inflammation of some part of the liver as the most frequent cause of the disease. This 
opinion he believed to be confirmed by the good effects which, in the majority of cases, are 
produced by a systematic course of depletion : nevertheless, if circumscribed inflammation 
be the efficient cause of jaundice, he found it difficult to explain why the disease was so 
frequently absent during the progress of the most unequivocal and intense inflammations of 
large portions of that organ. The examination of individuals who had recovered from jaun- 
dice only a short time before death occurred from other diseases, exhibited no appearances 
in the liver indicative of any circumscribed portion of it having been the seat of recent 
inflammation. In the course of his dissections, however, Mr. T. found that albuminous infil- 
tration into the cellular structure of the capsule of Glisson was sometimes present. Within 
this capsule are situated two small bodies, which, from their structure, appearance, and uni- 
formity of situation, he is inclined to believe are absorbent glands : one of them is situated 



JAUNDICE. 



853 



near the termination of the gall-bladder in the cystic duct, the other, at the upper part of the 
ductus communis ; the superior gland is sometimes very small, and occasionally, it is more 
closely attached to the side of the gall-bladder than to the cystic duct; the lower one 
is more uniform in bulk, being usually half the size of a small bean ; it is always placed 
just at the common biliary duct. Irritations affecting the absorbent vessels passing through 
this gland may, Mr. T. conceives, cause in it such a degree of swelling as would produce 
transient compression and closure of the common duct, and thus prevent the passage of the 
bile into the intestines, and give rise to the phenomena of jaundice. So long as the obstruc- 
tion is complete, the stools will be nearly white, or of a very pale gray colour ; when, how- 
ever, the jaundice is attended with severe fever and symptoms of intense gastro-enteritis, the 
stools will very often be coloured by the blood which is poured out by the capillary vessels 
of the intestinal mucous membrane, as well as by other morbid secretions. 

When previous inflammatory disease of the capsule of Glisson has caused an infiltration 
of coagulable lymph into the cellular structure of that part, at a remote period, and its sub- 
sequent absorption has left a degree of induration and constriction, Mr. T. believes that a 
very slight enlargement of the lower gland will effectually compress the common biliary 
duct ; he has seen its canal obliterated, from this cause, exactly at the point of contact witla 
the swollen and indurated gland. He has, also, seen the cystic duct obliterated where it 
was in contact with the upper gland, in consequence of the enlarged and diseased condition 
of the latter ; but he does not believe that this could have any influence in the production 
of jaundice. 

Mr. T. does not deny the agency which biliary calculi — tumours of the pancreas, liver or 
spleen, or scirrhous pylorus may occasionally have in the production of the phenomena of 
jaundice, nor that, in some rare cases, the disease may have been excited simply by mental 
emotion; nor is he willing to place undue importance on the observations upon which his 
views of the most frequent cause of the disease are based. Should these, upon more ample 
investigation, be found to be correct, they will have an important influence upon the treat- 
ment of the disease. 

According to Mr. T., the most successful plan of treatment in those cases of jaundice ac» 
companied with pain, augmented upon pressure, of the right side of the abdomen, is by 
depletion by the lancet and leeches — active purgation — the daily use of the warm bath — and 
sudorifics, aided by low diet and perfect rest, in the commencement of the disease ; followed 
by milder purgatives, and a small blister over the region of the gall-bladder, kept open for 
a long time. Subsequently, a course of Cheltenham salts, or small doses of rhubarb and sal. 
polychrest, with gentle exercise, and frictions with camphorated liniment over the right hypo- 
chondrium are advisable : at the same time, it may be proper to allow a mild unirritating 
diet, in such quantities as shall improve the patient's strength. The disease may sometimes 
occur under circumstances that forbid depletion. This Mr. T. considers an unfortunate cir- 
cumstance, as he has but little confidence in other modes of treatment. 

In those cases in which the stools indicate the entire absence of bile from the intestines, 
Mr. T. considers the use of mercurials to be of doubtful propriety ; but, when bile does pass 
into the duodenum, he admits that calomel may be useful, in conjunction with the remedies 
already detailed. Excepting in cases where there is pretty positive evidence of the exist- 
ence of biliary calculi, which he believes to be less frequently a cause of jaundice than is 
generally imagined, he doubts the propriety of having recourse to opiates. 

Whether the views of Mr. Twining in regard to the pathology of jaundice be or be not 
correct, must be determined by the result of future and more extended observations ; they 
are sufficiently plausible and important, however, to demand the attention of the physician 
and to influence him in his treatment of the disease. In respect to the plan of treatment re- 
commended by Mr. T., we believe it will be found, with one exception only, to be, in a large 
number of cases, the only proper and successful one. The exception to which we allude, is 
the indiscriminate administration of active purgatives : jaundice is, not unfrequently, connected 
with more or less extensive inflammation of the stomach and small intestines, and in these 
cases, the employment of active purgatives to the extent recommended by Mr. T. would un- 
questionably be decidedly injurious. — C] 



3w 



854 



JAUNDICE. 



LECTURE LXXVI. 

Treatment of the various Species of Jaundice. Diseases of the Gall-bladder ; of 
the Spleen ; of the Pancreas. Diseases of the Kidneys. Nephritis and Neph- 
ralgia. Phenomena constituting a ''fit of the Gravel.''^ Different hinds of 
Gravel. Diseased states of the Urine. Description and remedies of the Lithic, 
Phosphatic and Oxalic Diatheses. 

In the last lecture, after describing the symptoms, causes and treatment of acute 
and chronic inflammation of the liver, and after pointing out various other forms of 
chronic disease to vv^hich that organ is obnoxious, I spoke of jaundice. I offered 
you some comments upon its phenomena ; and I indicated several different internal 
conditions upon vsrhich it may, in different cases, depend ; and the lecture was closed 
with some brief hints respecting the prognosis of icterus. I have yet to consider the 
plans of treatment best adapted to the several varieties of the complaint. 

Some kinds of jaundice are obviously and absolutely irremediable. From others 
the patients recover, vi^hatever treatment may be adopted, or without any treatment 
at all. Hence, as is customary in such circumstances, remedies the most worthless 
and absurd are extolled for their efficacy against jaundice. The patient gets well, 
and the drug last tried is held to have cured him. Post hoc, ergo propter hoc, is an 
argument more often apphed I believe to the variations of disease, than to any other 
class of events. 

In that species of icterus which occurs, sometimes, in connection with acute or 
chronic inflammation of the hver, the treatment must be such as I yesterday recom- 
mended for acute and chronic hepatitis. Mercury forms an essential part of that 
treatment; and, unless the disease yielded sooner, I should urge the remedy until 
its effect upon the gums, and, therefore, its presence in the circulating blood, was 
apparent. 

But to the icterus calculosus, mercury is not so well adapted. What we want is, 
not a more plentiful or a more healthful secretion of bile, but to get rid of the me- 
chanical impediment to its excretion : or, at any rate, if that cannot be accomplished, 
to ease the acute sufferings of the patient. Should fever attend the passage of a 
gall-stone, or, should the epigastric pain become epigastric tenderness, leeches may 
be applied, or a vein may be opened. The abstraction of blood may prevent any 
thickening of the distended gall-ducts ; or it may perhaps relax their spasmodic 
closure around the calculus. But, in general, blood-letting is not of service nor 
requisite in this variety of jaundice. Our great resource, for relieving the pain, and 
for loosening the presumed spasms, is opium, given in full doses: and I can add 
but little, with any advantage, to the directions laid down, on this head, by Dr. He- 
berden. " This pain (says he) can only be assuaged by giving and repealing opium 
and its preparations, as often as the continuance of the pain requires them ; and be- ' 
cause this pain is very apt to return, the patient should always be advised to keep 
by him, as long as the distemper lasts, pills of pure opium, each weighing one grain 
— or what is equivalent to them — that no time may be lost in quieting a sensation 
which is so difficult to endure. One of these pills may be taken as soon as the pain 
comes on, and it may be repeated once or twice in the course of two hours, if the 
pain require it ; and I have often found it ^oth safe and necessary to give much 
more." 

This plan, of giving opium in the form of pills, is the more judicious, because, 
from their small bulk, they are more likely to be retained than draughts would be. 
Sometimes the stomach is so irritable as to reject even a pill. I would add, there- 
fore, to Dr. Heberden's recommendations, that of throwing an opiate injection into 
the rectum; half a drachm or a drachm of laudanum, mixed with a small quantity 
of warm gruel. Another very useful expedient is the warm bath. If this cannot 



THE GALL-BLADDER. 



855 



be readily procured, hot* fomentations to the epigastrium, the mustard-poultice, the 
turpentine stupe, are valuable substitutes for it. Dr. Prout states that he has seen 
more alleviation afforded by large draughts of hot water, containing the carbonate 
of soda in solution (one or two drachms to a pint), than by any other means. " The 
alkali counteracts the distressing symptoms produced by the acidity of the stomach ; 
while the hot water acts like a fomentation to the seat of the pain. The first por- 
tions of water are commonly rejected almost immediately; but others may be 
repeatedly taken ; and after some time it will usually be found that the pain becomes 
less, and the water is retained. Another advantage of this plan of treatment is, that 
the water abates the severity of the retching, which is usually most severe and 
dangerous where there is nothing present upon which the stomach can react. This 
plan does not supersede the use of opium, which may be given in any way deemed 
most desirable ; and in some instances a few drops of laudanum may be advan- 
tageously conjoined with the alkaline solution, after it has been once or twice 
rejected." The pain having been quelled, the bowels should be swept out by a 
brisk purgative. 

When the jaundice appears to have been suddenly engendered, by moral causes, 
the rationale of its production is obscure; and the treatment has a corresponding 
uncertainty. The bile, retained or readmitted into the blood, is supposed to operate 
as a poison upon the nervous system. But the mental state which precedes and 
seems to occasion the jaundice, may possibly be itgelf the cause of the nervous symp- 
toms that follow. In other forms of the malady patients remain intensely yellow, 
often for a long time together, without becoming comatose, delirious, or convulsed. 
Not that this is conclusive. We know that a given poison may influence different 
persons very differently. The same dose of opium that will put one man to sleep, 
will stimulate a second to madness, and will have no sensible effect upon a third. In 
the very complaint before us, one patient is tormented with a universal itching, which 
we attribute to bile in his blood ; and ten others remain free from that disagreeable 
feeling. If we were sure that the bile was the material cause of all the cerebral 
symptoms, we might hope to draw some of the poison off by blood-letting : but we 
are not sure of this ; and reasoning upon the matter helps us not much towards the 
cure. The lesson which experience has furnished amounts to no more than this : 
that active purging is sometimes followed by evident amendment, and ultimate 
recovery. I would bleed also, if the pulse warranted venesection, but not otherwise. 
In all the varieties of what, from its intensity and rapid accession, I may call acute 
jaundice, purging is strongly indicated : and we sometimes succeed in rectifying the 
whole morbid condition by thus applying a sudden wrench (so to speak) to the 
biliary organs ; by giving, for instance, half a scruple or a scruple of calomel, and, 
a few hours afterwards, half an ounce of castor oil, with half an ounce of spirit of 
turpentine. 

When green jaundice arises from hepatic disease, we can only palliate. Mild 
laxatives and anodynes comprise all that such a state admits of. For the icterus 
gravidarum-, delivery is the natural cure : it may sometimes be removed by the 
careful employment of aperients. 

The gall-bladder has its own diseases, which I do not stop to investigate, for they 
seldom become the objects of specific treatment. Sometimes it is found shrivelled 
up, and nearly empty: sometimes enormously distended; sometimes ruptured. 
Of these conditions, the distension of the gall-bladder is the only one that we can 
ever expect to recognize in the hving body. The bag then projects beyond the 
edge of the liver, and is palpable externally, forming an elastic tumour in the right 
side. Authors lay down- marks for distinguishing a distended gall-bladder from 
abscesses of the liver, and from an hydatid cyst ; but they are not much to be trusted 
to ; nor is the precise diagnosis of any great moment. The practical rule seems to 
be that, when the sweUing is adherent to the parietes of the abdomen we may punc- 
ture It, whatever is its nature : but under no other circumstances. 

I have already, incidentally, described most of the morbid states of the spleen 



856 THE SPLEEN — NEPHRITIS AND NEPHRALGIA. 

which are susceptible of rehef from medicine: especially* the enlargement of that \ 

body constituting the ague-cake of the fens, and occuring in connection with inter- 1, 

mittent fever ; and that other kind of enlargement which sometimes goes along with ^ 

hsematemesis and melsena. The spleen is liable to tubercles also; to deposits of j 

other specific tumours, and of bone ; and to softening of its substance. , 

The best remedy for the ague-cake is the remedy for intermittent fever, quina. 

Purgatives also have the effect of reducing hypertrophy of that curious organ. One , 

caution enforced by Dr. Abercrombie, is, that in splenic disease, mercury should be | 

sedulously avoided, or rather such an employment of mercury as would risk tender- | 

ness of the gums. Dr. Williams, of St. Thomas's Hospital, states in a recent pubf | 

lication, that he has made many trials of the bromide of potassium as a remedy in [ 
various disorders : but that he has satisfied himself of its utiUty only in cases of dis- 
eased spleen. Of this I know nothing. 

Again, it may seem a slight to the pancreas to pass it over without noticing the 
diseases to which it is subject. But really those diseases appear to be but few ; and 
they do not signify their existence by any plain or intelhgible signs. I have, nine 
or ten times perhaps in my life, met with carcinomatous deposits in the pancreas. 

In every instance the head of the gland, that extremity which hes next to the bowel, | 

has been the exclusive or the principal seat of the disease. I have known this j 

change in the pancreas to cause jaundice, by obstructing the bile-ducts : I have j 

known it in the same way to occasion very great enlargement of the liver itself ; and j 
I have known it to produce enormous and slowly fatal distension of the stomach by 

compressing the duodenum, and so preventing the free passage of the aliment | 

through that gut. As to remedies for pancreatic diseases or disorders, I do not know | 

of any. ; 

Diseases of the kidneys — and disorders of their function — and alterations in the I 

fluid they secrete — require more consideration. And I proceed at once to the sub- i 

ject of their inflammation ; to nephritis : and it will be practically convenient to ' 

take nephralgia, or pain of the kidney, into the account at the same time. Nephral- | 
gia is commonly, but not always, produced by the transit of a urinary calculus from 

the pelvis of the kidney, through the ureter, towards the bladder. This constitutes, ] 

what is called, in common parlance, a fit of the gravel. The symptoms are these :— \ 

pain, sometimes dull, but more frequently very severe, in the loins, usually on one | 

side, and descending often along the track of the ureter of the same side ; numbness i 

of the corresponding thigh ; in the male, retraction, and perhaps pain, of the testicle; j 

a frequent desire to make water, which is generally high coloured ; nausea and I 

vomiting. | 

If to these symptoms there be added pyrexia, we learn the important fact that in-? i 

flamraation is present : we have the symptoms of acute nephritis. The passage of j 

gravel from the kidney sometimes does, and sometimes does not, provoke inflamma- j 
tion of the gland. Nephritis is very seldom idiopathic. It may sometimes arise 

under the influence of cold : more frequently it is excited by calculous matter lodged i 

in the kidney ; by a blow or fall upon the loins; by the internal administration of | 

cantharides, or of turpentine. It is to the presence of fever that we look, to establish | 

the inflammatory character of the renal affection. \ 

Nephralgic pains require to be distinguished on the one hand from rheumatic, and 

on the other from colic pains. In lumbago there is pain in the back, and it may or i 

may not be attended with fever; but the pain usually affects both sides, and is ag- | 

gravated by such movements of the body as call the muscles of the loins into action, ^ 

particularly by stooping. It originates, frequently, in some strain or effort, of which i 

the patient is made painfully conscious at the time. It is seldom accompanied by ! 

any notable trouble of the urinary functions. When rheumatic pain extends from ' 
the back into the thigh, it mostly follows the course of the great sciatic nerve, and is 

felt down the outer part of the limb ; whereas the pain that accompanies nephritis or i 
nephralgia shoots rather along the track of the anterior crural nerve. Lastly, lumbar 

pain, depending upon rheumatism, is not attended with nausea and vomiting. j 

The pain of colic is often associated with sickness and retching ; and it may occupy | 



NEPHRITIS AND NEPHRALGIA. 857 

those parts of the abdomen which correspond to the place of the ureters. The uri- 
nary functions are undisturbed; and this is a capita! point of distinction. The 
numbness of the thigh, and drawing up of the testicle, are sufficiently characteristic 
when they happen ; but they are frequently altogether absent. 

Some years ago I was sent for by an exceedingly intelligent surgeon, who had 
been one of the house-surgeons at the Middlesex Hospital. 1 found him in bed. He 
told me he had pain in the abdomen. It had begun in the morning in the situation 
of the right kidney, and soon extended round to the right side of the abdomen and 
the groin. Two days before, he had experienced a similar attack of pain in the 
renal region, stretching round into the hypogastrium. When I saw him, he de- 
scribed the pain as lying more round the umbilicus than elsewhere ; and he expressed 
a strong persuasion, from the feelings which attended it, that it would be removed by 
free action of the bowels. But he felt nausea, and had vomited some medicine 
which he had taken. He had no fever, no retraction of the testicle or numbness of 
the thigh, and the pain was not increased by pressure. Neither had there been any 
marked irritation of the bladder. He said, indeed, when I questioned him on that 
point, that he thought he had made water rather more frequently than usual the 
day before. I mention this case to show you the occasional obscurity of the symp- 
toms. Here a well-instructed medical man believed that nephralgia, existing in his 
own person, was colic. To my judgment, however, it seemed most probable that a 
small calculus had been passing from his kidneys, towards and perhaps into his 
bladder. I may as well tell you the event of the case, which interested me a good 
deal-; for it exhibits the train of symptoms that are apt to ensue after nephritic 
attacks, although in this instance they were but slightly pronounced. His bowels 
were well acted on by a purgative, and the next day he was free from pain, and 
apparently well. 

Two days after this, he had more frequent calls to pass urine than were usual with 
him, and having done so on one occasion, he presently feU the want again, and then 
passed a little blood. The urine had been of a clear amber colour throughout. At 
the expiration of two or three days more he called upon me to say that, after making 
water, he had perceived in the vessel a small crystallized mass, which he took out, 
supposing it to be (what it very much resembled) a fragment of sugar candy. In 
fact, he had been eating sugar candy, and thought some portions of it had fallen 
down between his waistcoat and shirt, and afterwards into the chamber-pot. He had 
the curiosity, he said (some misgiving he must have had, too, for I had told him my 
own opinion of the nature of his attack), to put a small crystal from this fragment 
into his mouth ; and as it neither tasted sweet nor dissolved, he suspected it might 
be a urinary concretion, and brought it to me. And sure enough it was so ; a piece 
of very pure oxalate of lime, which he had been fortunate enough thus to get rid of. 
It was a quarter of an inch in length, and less than one-eighth of an inch broad, 
consisting of an aggregation of small crystals. It was exactly similar in appearance 
and colour to a piece of brown sugar-candy of the same size. It would pass, long- 
ways, into a large crow-quill. 

That it was oxalate of lime, was proved in this manner. A little separate crystal 
was heated to redness on a piece of platinum foil, by means of a spirit-lamp and 
blowpipe. By these means the oxalic acid was destroyed, and quick-lime left. This 
residue, moistened, and pressed into a powder on a piece of turmeric paper, gave 
the characteristic brown colour. 

You see, then, that a nephritic affection may be mistaken for an attack of colic. 
In reference to practice, it would indeed be a mistake of no great importance, since 
the remedies that are proper in the one case are generally proper, or not improper, 
in the other. If the pain be attended with fever, antiphlogistic measures are ahke 
indicated in each of the two diseases. 

The numbness of the thigh, and the drawing up of the testicle, are analogous 
phenomena to the pain which affects the shoulders in hepatic disorders. Irritation 
of one extremity of a nerve, situated internally, and belonging to an organ which 
is not endowed with a high degree of sensibihty, causes sympathetic sensations in 

3 w 3 



858 



NEPHRITIS AND NEPHRALGIA. 



the sentient extremities of other branches of the same nerve, or of communicating 
nerves. 

And this sympathetic affection of distant parts is sometimes attended (as I formerly 
observed) not merely with pain, but with some degree of inflammation also. The 
testicle occasionally swells, and becomes tender during a nephritic attack. On the 
other hand, as the nerves which communicate with those of the testicle or thigh, may 
or may not be implicated in the renal disorder, so we see how it happens that these 
curious symptoms, so instructive when they do occur, may frequently be wanting, 
as they were in the example I just now detailed to you. 

When the symptoms I specified in the outset are attended with fever, we conclude 
that we have to deal with nephritis ; and when inflammation of the kidney, how- 
ever produced, lasts for a certain period, without abatement, suppuration is to be 
dreaded. Such suppuration is marked, sometimes, by the supervention of rigors, 
by throbbing, perhaps, and it may be by a remission of the pain : but I beheve it 
may take place without throwing out any such signals. Nay, I think it probable 
that inflammation, confined to the parenchymatous substance of the kidney, may 
arise, and run through all its stages, without denoting its presence or progress by 
any noticeable local signs ; and that the sharp and peculiar symptoms ascribed by 
authors to acute nephritis manifest themselves only when the investing membrane 
of the gland, or its pelvis and excretory tubes, are involved in the inflammatory pro; 
cess. However this may be, suppuration leads to ulceration, to the formation of 
renal fistulas, to the establishment of a purulent discharge, and hectic fever ; and 
finally, in most cases, to a fatal event ; whether the inflammation was at first idiopa- 
thic, or dependent on a calculus. 

I may illustrate these remarks, by stating the heads of a case which has occurred 
to me since this course of lectures began. I admitted Caroline Barnard, a married 
woman, forty years old, into the hospital, on the 18th of October. Among other 
things she complain&d of pain in the situation of the right kidney. She had been ill 
six weeks, and at the commencement of her illness her urine had been very turbid,' 
as indeed it still was : and she had experienced much pain and difliculty in passing 
it, and after it had passed. From that time she had frequent nausea and retching, 
and occasional numbness of the right thigh. She had been losing flesh fast ; and 
her pulse was frequent. There was some tenderness discoverable in the right renal 
region ; and after a time a manifest fulness there, and hardness ; and at length cedema 
of the integuments and extreme tenderness. • She suffered also well marked hectic 
fever, and had severe and repeated rigors. On the 4th of November, after a careful 
examination of the right loin, we satisfied ourselves of the presence of matter. I got 
Mr. Arpott, therefore, to see her, and put a lancet into the abscess ; and a large 
quantity of faint-smelhng pus came out. She was greatly relieved by the operation; 
and a purulent discharge, mixed with shreds of cellular membrane, came away in 
abundance for some days : but in time the discharge ceased, the swelling subsided, 
and the opening healed. We began to hope that it had been merely an abscess in 
the neighbourhood of the kidney, irritating it and affecting its functions. But in 
three weeks after the abscess was punctured, the swelling was found to have re- 
curred ; and she again began to suffer much. The tumour was again opened, and 
pus of a more offensive character than before evacuated. In the early part of De- 
cember she sank. 

We found the right kidney small, collapsed and hollow ; in some parts a mere 
flabby bag. On its posterior surface there was an opening, which formed a commu- 
nication between the interior of the kidney, and the abscess in the areolar tissue, 
which had pointed externally. The pelvis of the kidney was much dilated ; and 
the substance of the gland destroyed to a considerable extent, by suppuration and 
ulceration. The ureter, where it left the pelvis of the kidney, was found to be im- 
pervious. 

The other kidney was much enlarged, but of quite healthy and sound structure. 
That kind of compensation had occurred which I formerly mentioned as not unusual 
when, of double organs, one has been rendered incapable of its natural functions, and 
the other takes up its duty and performs a twofold amount of work. The organ of 



NEPHRITIS AND NEPHRALGIA. 



859 



which the function is thus increased, becomes hypertrophied. This woman did not 
die because there was not urine enough secreted ; but she sank under the wasting* 
purulent drain, the irritation and pain she suffered, and the protracted hectic fever. 
In this instance the inflammation and suppuration occurred independently of the for- 
mation of calculous matter. 

Sometimes the pus finds its way out of the body through the natural passages, and 
appears in the urine. This woman's urine was thought, by some of the pupils, to 
contain pus. Tt was quite thick, and of a yellowish colour. But heat rendered it 
transparent. You must not judge by a cursory look at the water. The effect of 
heat proved that the yellow material was not pus : the impervious condition of the 
ureter showed afterwards that it could not have been. 

When calcuh exist in the kidney, they often betray their presence there, by 
causing bloody urine. But bloody urine may proceed from various causes ; and in 
conformity with my usual custom, I shall by and by offer you some general remarks 
on hasmaturia, as one of the hemorrhages. 

I showed you, at our last meeting, that gall-stones might inhabit the gall-bladder 
in considerable numbers, and be quite harmless, unless they attempted to escape from 
their prison, through the very narrow channel of egress from it ; and I intimated that 
the same observation was often applicable to urinary concretions. Renal calculi do, 
indeed, in many cases, produce abiding uneasiness, or frequently recurring pain, in 
the situation of the affected kidney, bloody urine, and gastric disturbance ; especially 
when the concretions are shaken or displaced by sudden jolts, or jarring movements 
of th,e body ; or when the system is deranged by intemperate habits. But in many 
other instances these calculi cause no pain or annoyance, so long as they remain in 
the kidney ; although they inflict horrible suffering, in general, while, for the first 
time, they are forcing their way along the narrow ureter. A concretion cannot be 
formed in a moment ; yet the attack of pain often comes on in a moment, without 
any previous warning. After a while it remits, perhaps, as sudden I}'- ; the calculus 
having passed (it may be presumed) from the ureter into the bladder; and then in- 
dications, more or less palpable, usually begin to declare themselves of its presence 
in that reservoir. Moreover, it is not uncommon to find calcuh in the kidney 
after death, of the existence of which there had been no symptom manifested during 
life. 

The treatment of nephritis — or of the nephralgia calculosa, when accompanied by 
fever, or occurring in young, strong, and plethoric persons — is just such as would be 
proper in cases of severe coHc, or enteritis : and therefore it is that any mistake between 
these disorders at the outset is not of so much practical consequence. The objects of 
treatment are, to arrest the inflammatory process ; to quiet existing irritation ; and to 
obviate any fresh causes of irritation. Venesection, therefore, in proportion to the 
strength of the patient and the violence of the symptoms, will sometimes be proper: 
and it will always be advisable to take away blood freely from the neighbourhood of 
the suffering part by cupping. Warm fomentations ; the warm bath ; the injection 
of warm water into the bowel; these are all expedients of which practical men ac- 
knowledge the value. The warm enemata not only clear out from the large intes- 
tines any irritating matters they might contain, but, from the proximity of the colon to 
the kidney, they perhaps have the effect of an internal fomentation. It is desirable 
also to get the bowels well acted upon by purgative medicines as soon as possible : 
the relief that follows free alvine discharges is often very marked. There is some- 
times a difficulty, from the irritabihty of the stomach, in administering purgatives by 
the mouth. Calomel, however, will often be retained, when other substances are 
rejected. It is generally considered of importance to give those purgatives only 
which are not likely, after being absorbed into the blood, to irritate the urinary pas- 
sages. On this account the saline purgatives are to be avoided. Nothing is so 
ood as castor oil, if the stomach will bear it ; or infusion of senna, with manna, may 
e used ; or, if the stomach be very queasy, pills, composed of cathartic extract, and 
calomel. 

When there is no fever, i. e., when the case is one of nephralgia, and a calculus 
is passing, after the intestinal canal has been cleared by a purgative, it will be 



860 



GRAVEL. 



necessary to give opium in full doses to allay the pain: and it may either be 
administered in the form of pill through the stomach ; or introduced into the rectum. 

When a person suffers what is called a fit of the gravel, the pain, I say, is at length 
very suddenly relieved, in general, in consequence of the calculus having emerged 
from the ureter and entered the bladder. We judge that this has taken place, first, 
by the cessation of the pain ; and secondly, by the supervention, sooner or later, of 
symptoms indicative of stone in the bladder ; viz., a more than usually frequent in- 
clination to make water ; pain, referred to the extremity of the urethra, especially 
just after passing urine : and stoppage^ and renewals of the stream of water while the 
patient is endeavouring to void it. 

The time which a calculus takes in travelling from the kidney to the bladder 
varies a good deal. The painful journey may be over in a few hours ; or it may 
last two or three days. More rarely the symptoms continue, with irfegular intervals 
of comparative quiet, for weeks. And sometimes, notwithstanding the peculiar pain, 
which amounts to torment, all morbid symptoms cease, and yet no calculus has 
passed, apparently, into the bladder : none, i. e., of the symptoms of stone, ensue ; no 
calculus is voided by the urethra ; and none found in the bladder when the patient 
at length dies. 

What is the explanation of these circumstances ? Why, as calculi have been 
discovered in such cases in the kidney, it has been supposed that a concretion may 
get into the very beginning of the ureter, where it is a little larger than elsewhere, 
and give rise to the peculiar symptoms, yet never pass fairly into that narrow 
tube ; but at length fall back again into the pelvis of the kidney : when the symptoms 
cease. 

But the same symptoms undoubtedly occur, occasionally, when there is no cal- 
culus at all. Sir B. Brodie has referred to this form of complaint. In people who 
live intemperate and luxurious lives, pain is apt to seize upon one renal region, and 
to extend round and downwards into the groin : and these symptoms will be followed 
by frequent, difficult, and painful micturition, the urine being unusually acid, high- 
coloured, and sometimes turbid. The whole irritation appears to be produced 
by this unhealthy urine : at least the complaint vanishes after cupping the loins, 
purging, the warm bath, and two or three full doses of colchicum given at short in- 
tervals. 

Sometimes the little stone becomes immovably wedged in the canal of the ureter. 
If it completely shuts the tube, the urine accumulates behind it, and that portion of 
the ureter dilates. The obstruction usually proves fatal, by its influence upon the 
functions of the kidney, and thereby upon the whole economy. But if the urine 
finds a passage by the side of the impacted concretion, this danger is averted, or post- 
poned. 

W^hen we have reason to believe, from the nature and course of the symptoms, 
that a calculus has come down from the kidney, and lodged in the bladder, then it 
becomes an object of deep interest to the practitioner, and of fearful importance to 
the patient, to try all means to bring about its expulsion before it grows too large to 
be voided. For grow it almost surely will, by the continual accretion of earthy 
matter upon its surface, if it remains long in the bladder. We know that it may, at 
first, be voided, provided the urethra be in a healthy and natural state ; that what- 
ever has passed through the ureter, may pass through the urethra also. 

The objects to be kept in view are these : first, to procure a plentiful secretion of 
bland urine, wherewith the bladder may become filled ; secondly, by luUing the sen- 
sibihty of the parts concerned, to prevent or lessen that spasmodic effort of the 
sphincter of the bladder, which the presence of the calculus is apt to provoke ; and, 
thirdly, to ascertain that the channel of the urethra is open and unimpeded. 

To effect the first of these purposes, the patient should be instructed to drink freely 
of diluent Hquors; such as barley-water, or linseed-tea, in which may be mixed a 
small quantity of the sweet spirits of nitre. To fulfil the second, he should take a 
full dose of opium at bed-time. By these means the pain and irritation which may 
have been produced by the calculus, will be soothed ; and the bladder will gradually 
fill. He should then make water, having first placed himself in such a position 



GRAVEL. 



861 



that the outlet of the bladder shall be at the lowest part of that receptacle. He may 
stand up, and lean forwards ; or it may be well to make water while kneeling, in a 
warm bath. If these expedients are not presently successful, the urethra may be 
cautiously expanded, and habituated to the contact of a sohd body, by the daily in- 
troduction of a full-sized bougie. Sometimes the calculus will follow the bougie, 
as it is withdrawn, through the urethra. In this way the patient will have a fair 
chance of getting rid of the stone. In this way a very near friend of my own, a 
physician now practising in this tow:n, did expel a formidable, though not very large, 
piece of rough oxalate of lime several weeks after its entrance into the bladder. 
Out it came, at last, with a smart clink, which was music to his ear, against the 
chamber-pot. A gentleman was not long since sent up to me from Kent, by a former 
pupil of this College, with the following history. About a month before he had been 
suddenly attacked with acute pain in the loins, extending forwards into the left flank 
and pelvis, with nausea and vomiting. For nearly ten days these symptoms con- 
tinued to occur at intervals ; then they ceased : and then he began to be troubled by 
a frequent and very urgent incKnation to make water, and by pain after voiding it, 
just above the arch of the pubes. I gave him directions, in accordance with the 
plan just now mentioned ; and wished him to allow some surgeon to explore the 
contents of his bladder. To this he would not, as yet, he said, consent. I saw him 
on the 2d of August. He returned into Kent the next day. On the 5th, while 
taking a walk, he was seized with a most imperative desire to make water, but found 
that he could part with none. Concluding that a calculus had entered, and stopped 
up the urethra, he was proceeding homewards, but was soon constrained again to 
try to empty his bladder : and then he had the satisfaction of feeling, and seeing, a 
stone fly out with great force : but, as he had turned towards a hedge, he could not 
find it. From that moment he was quite easy. 

When a calculus of a certain size has once traversed the tubes that lead respect- 
ively to and from the bladder, others sometimes follow it with more ease. I show 
you here a large concretion which was passed, or pissed if you will, by a patient of 
mine without his knowing it. He is subject to epilepsy, which is probably eccen- 
tric, and excited by renal disease. He is closely and anxiously watched by his wife. 
One day last year she noticed that the urine he had just voided was shghtly tinged 
with blood : and she then found this oblong stone, which is composed of lithic acid, 
in the vessel. 

If the renal calculus, after it has reached the bladder, cannot be got rid of by the 
expedients I have been recommending, the question arises, whether medicine can do 
any further good, or whether the patient is to be dehvered over to the surgeon. 

Most of these small concretions admit of being mechanically crushed into smaller 
fragments, which are then readily washed out by the stream of urine. Larger stones 
are extracted entire, through incisions of the bladder. Yet there are many cases in 
which, for various reasons, surgery dechnes to attempt the removal of vesical calculi. 
Medicine still offers to these unfortunate patients the means of mitigating, at least, 
their sufferings. But it often can do more than this. It is very important for you 
to know that judicious medical treatment may retard or prevent, and that injudicious 
medical treatment may promote and hasten the enlargement of such calculi. Let us 
briefly consider the principles by which our judgment and our practice, in this serious 
matter, must be guided. 

I have described a fit of the gravel. We say that a patient has the gravel when 
he passes concrete matter with his urine, whether in the form of powder, of grit or 
sand, or of more massive calcuh. We do not apply that term to the cases in which 
the urine is clear when recently voided, and warm ; but throws down an earthy sedi- 
ment as it cools : which sediment redissolves if the urine be again artificially heated. 
Now,- besides the different forms which the gravel assumes, of powder, sand, and 
httle stones, there are (as you may Jaave guessed from certain terms that I have been 
obliged to employ) several kinds of gravel; differing, I mean, in their chemical com- 
position. The main signs — the pain, the sickness, the affection of the testicle, the 
subsequent bladder symptoms — are much the same, whatever be the nature of the 
sohd matter that descends from the kidney, and fingers in the bladder. But other 



862 



LITHIC DIATHESIS. 



circumstances differ widely. The qualities of the water previously to the formatioh, 
and to the discharge, of the sabulous matter ; the state of the system at large. And 
it is quite impossible to treat cases of calculus in the kidney, or of stone in the bladder, 
with propriety, or safety, without constant reference to the condition of the urine. 
The morbid states of that secretion are of the greatest interest. I cannot undertake 
to enter upon the subject in much detail. Yet some outline of it I must attempt, 
especially where it touches upon points of practice. 

You know, probably, that the urine voided by a person in health always exhibits 
acid properties, always turns Htm us paper red. Not that healthy urine contains a 
free acid ; but only (according to Dr. Prout, who is the great authority in these things), 
that certain of the alkaline and earthy bases are not exactly neutrahzed, but exist 
in the state of supersalts. The pure lithic acid is nearly insoluble ; but the hthate 
of ammonia is very readily soluble : and it is this which reddens the vegetable blues. 
Now, whether out of the body, or within it, the hthate of ammonia will, of course, 
be decomposed, if any acid be present in the urine, for which ammonia has a stronger 
affinity that it has for the Uthic acid : and the latter will be thrown down, in the form 
of a red sand : little crystals, in point of fact, they are very much like, in shape, size, 
and colour, to the particles of Cayenne pepper. I show you some collected by one 
of my out-paiients at the hospital. He must have passed' a peck of it while under 
my observation : and I am sorry (having lately lost sight of him) that I did not 
procure a large quantity for the museum. 

Now this lithic acid, or red sand, or gravel, is hable to form in the kidney, if not 
in the bladder, and to concrete into calcuh ; and the calcuh once formed, or, indeed, 
any solid substance, will constitute a nucleus, upon and around which a further and 
repeated incrustration of a similar nature is almost sure to take place. You will at 
once perceive the importance of doing nothing to aggravate this disposition to deposit 
lithic acid ; but of trying to prevent, or stop it. If there be symptoms of stone in 
the kidney, or in the bladder,- and we have reason to believe that it consists of hthic 
acid, there are medicines which would tend to render matters worse, and there are 
others of which the effect would be to correct the lithic acid diathesis, as it is called. 
But how are we to know whether the presumed calculus be of that kind or not? 
or, rather, how are we to know that the hthic diathesis exists 1 Why, we learn that 
it exists by noticing the habitual qualities of the urine, and the habitual state of the 
patient's general health. 

In the urine of persons who have the lithic diathesis, you wall find that there are 
frequent deposits, after it has become cool, of reddish sediments, looking like brick- 
dust, and, therefore, called lateritious. These sediments consist chiefly of the 
lithate of ammonia, tinged with certain colouring matters in the urine. Sometimes 
pure lithic acid appears, in the shape of fine sand, or in larger crystals.- The urine 
itself is bright, of a dark coppery colour, hke brown sherry. It is more acid than 
the urine of health, and gives to htmus paper a deeper shade of red. It is apt, too, 
to fall below the average quantity. 

The presence of this diathesis is likewise accompanied, and so far denoted, by a 
tendency to feverish and inflammatory complaints. The patients are troubled with 
acidity of stomach and heartburn ; many of them are subject to gout or rheumatism. 
They are mostly also indolent and luxurious, or intemperate in their mode of hfe. 
Adults are peculiarly obnoxious to this condition of the system after the age of 
forty. But children, up to the period of puberty, are very liable to have lithic acid 
gravel. 

Whenever a paroxysm of nephritic pain befalls a person whose time of life, whose 
habits, the characters of whose heahh, and the habitual qualities of whose urine, are 
such as I have been describing, you may conclude that the concretion which has 
occasioned the symptoms is of the lithic acid kind : and you may expect that such 
attacks will recur; for it is observed of these lithic acid renal calculi, that they are 
generally numerous in the same individual. I speak of the habitual — or of the 
frequently recurring — qualities of the urine : for a deposit of lithic acid gravel, or 
of superabundant hthates, may occur to the healthiest individual, under accidental 
and transient disturbing causes. iVIany persons will tell you that their w^ater becomes 



LITHIC DIATHESIS. 



863 



turbid with red sand whenever they have a cold. Febrile and inflammatory ailments 
will produce the sediment : even too full a meal: or exercise taken immediately 
after a full meal. In all such cases it seems probable that the customary evolution 
of lactic acid through the skin is somehow prevented : in consequence either of a 
check given to the perspiration, or of imperfect assimilation of the food. The lactic 
acid, thus diverted from its natural emunclory — or some other acid generated within 
the system — is determined to the urine, and precipitates the Kthic. 

Now the formation of lithic acid, and of the lithates, may be controlled by the 
exhibition of alkaline remedies. You will find that free livers use alkalies to neutralize 
the excess of acid which results from their intemperate habits ; the carbonates of soda, 
or of potass. They do this, without any reference to the appearance of their urine, 
to prevent or appease the uneasy feelings produced by a debauch. But it is of im- 
portance to be aware that one of these alkalies is preferable, for the purpose of 
obviating the hthic acid diathesis, to the other. Soda will sometimes combine with 
the hthic acid, and form an insoluble salt, as hard, and as pernicious, when deposited 
around a nucleus, as the hthic acid itself. With potass there is no such danger. If 
it should combine with the lithic acid, the resulting sak is perfectly soluble, and will 
pass away dissolved, in the urine. Magnesia is also a good medicine in such cases ; 
but it has this disadvantage, as I showed you indeed before, that it is apt, when taken 
habitually, to cause intestinal concretions : and these may be as dangerous as the 
urinary ones. One of the best modes of giving the bicarbonate of potass is in the 
common saline draught. The stomach has the power apparently of destroying the 
vegetable acids ; and the remedial properties of the bicarbonate become thus equally 
certain with those of the pure alkali, while it is much less likely to derange or dis- 
agree with the stomach. Of course the mode of living ought to be changed when 
the hthic diathesis prevails ; the patients should dine moderately and plainly, eating 
of one dish, and avoiding acids, and all articles of diet hkely to generate acid in the 
stomach ; saccharine substances, therefore, and fermented hquors. But, as I men- 
tioned in a former lecture, they will not, if they can help it, give up their accus- 
tomed indulgences : and they attempt, and we attempt, but the attempt is often 
made in vain, to remedy disorders, which might with ease and certainty have been 
prevented. 

You must take care not to give these alkahne remedies too long ; nor in too great 
quantity. You must not push them to such an extent as entirely to destroy the 
acidity of the urine : for if you do, your patient is exposed to the same danger as 
before, but from an opposite cause. A white sand or gravel will be apt to form in 
the alkahne or neutral urine : and this will collect itself, by the force of aggregation, 
around any existing calculus, or foreign substance. The white deposits consist 
mainly of the triple phosphate of ammonia and magnesia ; and if you examine 
collections of urinary calcmi, you will find that they are sometimes made up of 
concentric layers ; and one layer may be composed of lithic acid, and the next of 
the triple phosphates ; and so on, as the condition of the urine has alternated. You 
must test the urine, therefore, and see that it still reddens htmus, though perhaps 
famtly. Indeed it may do so, without containing any free acid : so that urine which 
only shghtly reddens litmus paper may nevertheless be capable of depositing the 
triple phosphate. The saHne draught has always a tendency to make the urine 
alkahne ; and thus it is, probably, that it proves of use in febrile disorders : but it is 
an absolute poison to those whose urine is already alkaline. Colchicum has a similar 
tendency to diminish the acid reaction of the urine. So has mercury. And I may 
tell you — speaking generally of morbid states of the urine — that it is much more 
easy to correct too great acidity than to rectify the opposite condition. We can almost 
always make acid urine neutral or alkaline : but to render alkaline urine acid is often 
beyond our power. 

It is scarcely less important to attend to the functions of the skin, in persons having 
the lithic acid diathesis, than to the functions of the stomach. The warm bath is 
often an excellent adjuvant, in their treatment. In cold weather, warm clothing must 
be enjoined ; and the avoidance, in all weathers, of such exposure to cold as might 
suppress or materially lessen the amount of healthy perspiration. 



864 



PHOSPHATIC DIATHESIS. 



You will have gathered, from what I have already said, that there is a morbid 
condition of the system, the opposite of that in which the lithic diathesis prevails. 
The phosphatic diathesis, namely ; in which there is a readiness to deposit white 
gravel; composed of minute shining crystals of a triple salt, the phosphate of ammo- 
nia and magnesia. The way in which this is formed, according to Dr. Prout, is as 
follows. Healthy urine contains the phosphate of magnesia, which is very soluble ; 
and, therefore, is dissolved in that fluid. But, under certain circumstances, the urea 
of the urine becomes decomposed in the kidneys, and ammonia is extricated, which 
combines with the phosphate of magnesia, and forms an insoluble triple salt. Some- 
times with the triple phosphate just mentioned, there is also an admixture of phos- 
phate of lime. 

It is a fact of great practical importance, that' the tendency to the formation of the 
phosphates goes along with a debilitated condition of the system. Persons who have 
been rendered weak and feeble by overmuch toil, by mental anxiety, by insufficient 
nourishment, are very apt to pass water that is alkalescent or but faintly acid, and 
to exhibit the tokens, in their urine, of the phosphatic diathesis. They are, for the 
most part, cachectic, sallow, languid, spiritless, exhausted. The urine itself is pale, 
copious, slightly turbid or opaline, of a low specific gravity, and it does not smell 
like healthy urine : sometimes it has somewhat the faint odour of weak broth. It 
is occasionally alkalescent when voided ; never more than slightly acid. As the 
urine cools, the white sand is thrown down ; and in many cases a sort of film is 
formed upon the surface of the water, exhibiting, as you see it in different lights, all 
the colours of the rainbow : an iridescent pellicle. This has been found to consist 
of the triple phosphate. If you skim the pellicle off, by placing a bit of paper under 
it, and then suffer the paper to dry, you may distinctly see the little crystals. Urine 
of this kind speedily grows putrid and highly offensive. Sometimes it has a strong 
ammoniacal smell. You may estimate the intensity of the phosphatic disposition by 
the rapidity with which the urine becomes alkalescent. Occasionally the salt is so 
abundant that it is thrown down while the urine is still in the bladder ; and the last 
portions of the issuing stream look milky. 

Anything which tends further to depress the powers of the system will aggravate 
the phosphatic diathesis. When you find that your patient passes urine such as I 
have been last describing, which does not redden htmus paper, but on the contrary 
turns litmus paper that has been reddened by a weak acid, blue again, or even in 
some cases is alkaline enough to make turmeric paper brown — in such cases you 
must cautiously abstain from all remedies that are calculated to lower the vital 
powers ; from saline draughts, and alkalies of every kind ; from mercury and col- 
chicum ; from bleeding ; and even from active purgation : or you will add to the 
patient's dangerous weakness ; and promote the more a]|undant deposit of the alka- 
line phosphates. But you may do more than abstain from what is hurtful : you 
may counteract the phosphatic tendency by a generous diet and by the exhibition 
of tonic medicines ; bark, wine, and acids ; the muriatic acid, or the nitric, or both 
together, may be given in such cases with vast advantage sometimes. Opium is 
also a remedy to be employed in this form of disease. No single drug probably 
has so much power in rendering alkaline urine acid, as opium. And it is indicated 
for other reasons ; it composes the nervous anxiety to which these patients are mostly 
a prey. Mental relaxation — freedom from care — the relinquishment of all exhaust- 
ing habits and pursuits — these, too, are points of vast importance, whenever they are 
attainable. 

I should state that the tendency to deposit the mixed phosphates, though sometimes 
idiopathic, is much more often consequent upon local disease in some part of the uri^ 
nary organs, especially in the bladder and prostate gland. It is also a frequent result 
of certain injuries of the back. 

There is yet another diathesis sufficiently common and important to claim your 
best attention. I mean the oxalic ; in which there is a tendency to the formation, 
in the kidney, of the oxalate of lime, or mulberry calculus ; an epithet derived from 
the occasional resemblance of the concretion to that fruit, in respect to colour and 



OXALIC DIATHESIS. 



865 



inequality of surface. This diathesis is not so obvious as the other two, but it is no 
less real. 

The urine differs much in its sensible quaUties from that of both the preceding 
varieties. Unhke the urine of the phosphatic diathesis, it is bright and clear; un- 
hke that of hthic, it is remarkably free from sediment. The mulberry calculus is 
sohtary also ; or recurs at long intervals ; and the diathesis prevails chiefly during 
the prime of hfe. In both these particulars the contrast with the lithic diathesis is 
striking. 

The persons who manifest this disposition are usually dyspeptic ; sometimes 
very much so ; sometimes very slightly. They are uneasy during the assimilation, 
of their meals ; suffer flatulence when the stomach is empty ; prefer vegetable diet 
to animal ; are fond of sweets, especially of sugar. They are liable to boils and 
carbuncles, and to scaly cutaneous eruptions. According to their original tempera- 
ment, they are nervous and irritable, or dejected and desponding in mind. A neph- 
ritic attack reheves them from all this discomfort for years perhaps. When the 
oxalic diathesis is strongly marked, the skin. Dr. Prout says, "is apt to assume an 
unnatural appearance, difficult to describe, but the colour of which may be said to 
vary from dull greenish yellow in the sanguine, to dark oHve or livid in the melan- 
cholic temperament." 

The formation of the oxalate of lime within the body depends, according to Dr. 
Prout, either upon the non-assimilation of oxahc acid taken with the food, or upon 
the mal-assimilation of saccharine aliments. Hence, as a general rule, both curative 
and prophylactic, sugar and other saccharine substances should be rigidly excluded 
from the diet of these patients. They should avoid, also, all kinds of fermented 
liquor. The young stalks of the r/iw6ar6-plant, which of late years have come into 
such general use in this country for tarts in the spring ; and sorrel, of which our 
neighbours, the French, consume a good deal in salads, and in other ways ; both con- 
tain oxalic acid ; and hard water contains lime. Dyspeptic persons who drink such 
water, and eat such articles of food, and are thus daily introducing, without suspect- 
ino- it, the constituent ingredients of the mulberry calculus, are very likely indeed to 
incur the pain and the exceeding peril of a renal concretion of that kind. You must 
see, therefore, the great importance of detecting the oxalic diathesis ; and of forbid- 
ding, to those who have it, all such viands as contain the oxalic acid, and of recom- 
mending them to use pure water, even distilled water, for drinking. Animal food, 
and the stronger farinaceous matters, are best for them. 

Dr. Golding Bird refers the oxalate of lime to a different source : maintaining that 
it results from a re-arrangement of the Elements of urea, whereby oxalate of ammo- 
nia is formed in the first instance ; and afterwards oxalate of hme, by the decompo- 
sition of the calcareous salts natural to the urine. 

Agreeing with Dr. Prout that the mulberry calculus is not of very frequent occur- 
rence — Dr. Bird nevertheless finds that small crystals of the oxalate of hme are 
extremely common : although from their transparency, and from their having nearly 
the same specific gravity with the urine in which they exist, they do not disclose 
themselves to the naked eye, nor sink down in manifest deposit. They are made 
plainly visible by the microscope. 

The same writer states that the persons whose urine is thus charged with crystals 
•of oxalate of Hme are, for the most part, highly sensitive and irritable, hypochon- 
drically apprehensive of impending evil, full of gloomy fears concerning their bodily 
and mental powers, dyspeptic, weak, and usually emaciated. 

With respect to direct remedies for this diathesis, Dr. Prout tells us that he has 
seen more benefit derived from the mineral acids, alone or combined with tonics, than 
from any other. But the effects of these acids must be watched : and when they 
begin to produce a deposit of the hthate of ammonia, or of lithic acid, their use must 
be suspended. He recommends to patients who happen to be at a distance, the 
muriatic, or nitro-muriatic acid, tfll the hthate of ammonia, or lithic acid, begins to 
appear in the urine ; or for a month. " By adopting," he says, " such a course of 
acids three or four times in the year, and by carefully regulated diet, I have seua 
55 3x 



866 



SUPPRESSION OF URINE. 



the diathesis gradually subdued, and at length removed altogether." Dr. Bird also 
testifies to the efficacy of similar measures. 

These observations will serve, I hope, in some degree, as landmarks, to guide . 
your treatment of patients labouring under renal or vesical calculi, or presenting 
symptoms such as warrant the apprehension that disorders so fearful may occur. It 
is impossible for me to do full justice to this interesting subject in these lectures; and 
I must refer you, for more minute information respecting it, to Dr. Prout's invaluable 
volume ; to Sir Benjamin Brodie's most instructive book on the Diseases of the Uri' 
nary Organs ; and to an excellent work recently pubhshed by Dr. Golding Bird, on 
Urinary Deposits, 



LECTURE LXXVII. 

Suppression' of Urine. Diabetes : Qualities of the Urine ; Symptoms ; AnatO' 
mical Appearances ; General Pathology of the Disease ; Treatment. Diuresis. 

Systematic writers have adopted the term Ischuria to express that condition in 
which no urine is voided. It includes, therefore, those cases in which no urine is 
secreted ; and those in which, although secreted, it is not discharged from the body. 
Now these two conditions are exceedingly different from each other in most respects ; 
and I shall prefer making use of the two plain English names, suppression of urine, 
and retention of urine. Even these terms are sometimes confounded with each 
other. In suppression, the secretion is suspended : in retention it may be as active 
as ever. Retention of urine is a surgical case ; involving points of great practical 
interest. Suppression belongs to the physician: and the technical term for it is 
Ischuria renalis. It is sometimes spoken of as paralysis of the kidney ; a phrase 
to which I object, because I think palsy is a word which ought to be restricted to a 
loss of power over the muscular fibre. 

This affection usually occurs in persons who are advanced in life, and inclined to 
corpulency. Why it should be so I cannot tell you, but such is the fact as stated 
by most observers. Sir Henry Halford has related one of five instances of this dis- 
ease that he had met with in the course of seven-and-twenty years. He says it was 
an exact copy of all the others that had fallen under his notice : and as his account 
of the general course of the symptoms coincides with the statements of other writers, 
I may give you his narrative, in heu of a foemal description. 

"A very corpulent robust farmer, of about 55 years of age, was seized with a 
rigor, which induced him to send for his apothecary. He had not made water, it 
appeared, for 24 hours. But there was no pain, no sense of weight in the loins, no 
distension in any part of the abdomen : — and therefore no alarm was taken till the 
following morning, when it was thought proper to ascertain whether there was any 
water in the bladder, by the introduction of the catheter : and none was found. I 
was then called (says Sir Henry), and another inquiry was made, some few hours 
afterwards, by one of the most experienced surgeons in London, whether the bladder 
contained any urine or not : when it appeared clearly that there was none. The 
patient sat up in bed, and conversed as usual, complaining of some nausea ; but of 
^nothing material in his own view : and I remember that his friends expressed their 
surprise that so much importance should be attached to so little apparent illness. 
The patient's pulse was somewhat slower than usual ; and sometimes he was heavy 
and oppressed. 

" I ventured to state (continues the author) that if we should not succeed in making 
the kidneys act, the patient would soon become comatose, and would probably die the 
following night : for this was the course of the malady in every other instance that 
I had seen. It happened so ; he died in thirty hours after this, in a state of stupe- 
faction." 

This is the curious and important point in the history of such cases. If no urine 
he separated from the blood, coma soon supervenes, and death. It is believed that 



SUPPRESSION OF URINE. 



867 



these consequences result from the detention of urea in the S5^stem. Urea is a mere 
excrement, which, in health, is removed from the blood by the kidneys, as fast as it 
enters that fluid. When it is not so carried off, it accumulates in the blood, circu- 
lates with it to every part of the body, and acts as a poison, especially upon the 
brain. This is one of several cases, showing that the carrying fluid of the body may 
become the vehicle of disease and death, if it be not duly purged of deleterious mat- 
ters which pertain to the unceasing processes of organic hfe. If carbonic acid be 
not extricated by the lungs, the animal functions are as certainly and almost as 
speedily extinguished by that gas, as the flame of a taper might be. And we have 
recently seen that when the outlet from the liver is shut up, when the blood is not 
purified from the excrementitious bile^ the powers of animal life are weakened, and 
sometimes utterly and rapidly destroyed. 

Suppression of urine, for a considerable time, is not, however, necessarily and 
universally fatal. Patients labouring under the epidemic cholera would secrete not 
*a drop of water for some days ; and yet recover. It was remarkable how entirely 
free such patients were from any approach towards coma. Was the urea here 
drained off from the blood in the enormous and unnatural flux from the stomach and 
bowels ? I think it probably was : but I do not know that any chemical search was 
ever made for that substance in the fluids so effused. There are, however, some 
very singular instances on record of persons who have passed days and even weeks 
without secreting urine ; and without showing any other indication of impaired 
health. What degree of credit such narratives deserve I do not know ; but assuming 
that there was neither fraud nor mistake, it may be suspected that either the natural 
secretion was compensated by some vicarious or supplemental discharge ; or that a 
small quantity of urine was actually separated by the kidneys. " If any water, 
however small the quantity (remarks Sir Henry Halford), had been made in these 
cases, I should have thought it possible that the patient might have recovered: for it 
has often surprised me to observe how small has been the measure of that excre- 
mentitious fluid which the frame has sometimes thrown off, and yet preserved itself 
harmless. But the cessation of the excretion altogether is universally a fatal symp- 
tom in my experience^ being followed by oppression on the brain." The same emi- 
nent physician states that in three of his five cases there was observed a remarkably 
strong urinous smell, in the perspiration, for twenty-four hours before death. This 
I believe is of common occurrence in such cases. Other patients have vomited, or 
passed by the bowels, watery matters possessing some of the sensible quahties of 
urine : and a urinous fluid is said to have been found in the ventricles of the brain 
in some of the fatal examples. 

I have spoken of suppression of urine as a malady, though it probably is never 
anything more than a symptom. Yet it is one of those symptoms which, from our 
uncertainty respecting their origin and determining cause, we are obhged to treat, 
and to study, as if they were substantive diseases. In the only well-marked instance 
that I have seen of suppression of urine coming on in an apparently healthy person, 
some blood had appeared in the urine' for a day or two before the secretion was 
totally suspended ; and the kidneys were found gorged with blood. Extreme con- 
gestion, or inflammation, of the substance of the gland, is probably at the bottom of 
many of these cases. The same train of symptoms supervene not unfrequently upon 
organic renal disease. They happen, too, when the ureters bdfcome impervious 
from disease, or from impacted gravel. In this condition urine continues to be 
secreted, for a time at least, and distends the ureter behind the seat of the obstruc- 
tion. The apoplectic state which ensues may arise from a re-absorption of the 
secreted fluid ; or, in consequence of the obstacle, the secretion itself, after going on 
to a certain point, may stop, and then the case becomes a case of suppression. 

Respecting the treatment of this formidable condition I can say but little. Cup- 
ping upon the loins, venesection, if warranted by the state of the pulse, the hot bath, 
sudorific medicines, purgatives, and large warm enemata, seem to me the kind of 
remedies indicated. To endeavour to force the secretion of urine by strong stimu- 
lating diuretics, would strike one, a priori^ as being hazardous. Yet this practice 
has its advocates ; and should experience declare in its favour, theoretic objections 



868 



DIABETES. 



ought to he disregarded. If benefit is so to be obtained, probably the best drug for 
our purpose would be cantharides. Dr. EUiotson refers to some examples of its 
success in the hands of Sir Astley Cooper ; and afterwards of another practitioner 
who took the hint from Sir Astley. He suggests that as the tincture of cantharides 
is a very uncertain preparation, the remedy should be given in the sohd form, a grain 
at a time, and that a large blister should be laid upon the loins. Beyond these hints 
I am unable to give you any assistance towards the management of this obscure but 
serious complaint. 

The opposite condition of the kidney, in respect to its peculiar function — that, I 
mean, in which its secretion is largely and morbidly augmented — is scarcely less 
fatal than the total suppression we have just been considering; but it is not so rapidly 
fatal. When the amount of urine secreted and passed is permanently too great, 
when it is constantly running off, as it were, from the system, the patient is com- 
monly said to have diabetes: from 6ta)3atfco, to pass through. * 

But it is not every case of an excessive fiov/ of urine that deserves to be called 
diabetes. Great quantities of aqueous urine are passed by hysterical and nervous 
patients. We all make more water in cold weather than in warm ; the functions of 
the skin and of the kidney compensating each the occasional defect of the other. 
Certain drugs and articles of diet are also well known to cause a temporary excess 
in the amount of urine secreted. 

In fact, although the quantity of urine voided is the most obvious and striking 
symptom of diabetes, its definite and characteristic symptom is a most remarkable 
change in the quality of that hquid : in its becoming loaded with sugar. You will 
find, indeed, two species of diabetes mentioned by many authors — the diabetes in- 
sipidus, and the diabetes mellitus. The former term ought in my opinion to be 
abolished. If it refers merely to an unnatural abundance of urine, not otherwise 
differing in its composition from healthy urine than in containing a large proportion 
of water — by calling such a state diabetes, we link together in the same genus two 
essentially different conditions. In true diabetes the urine is never without sugar. 
The quantity may indeed be small ; and it may not be sensible to that coarse test, 
the taste: but modern observers almost all agree in rejecting any species of diabetes, 
in which the urine is not at all saccharine. 

The sensible qualities of diabetic urine differ strikingly, in many particulars, from 
those of the urine of health. Its chemical quality differs strikingly too, as I have 
already told you ; but it is in one particular only. Fortunately, no extraordinary skill 
is required to recognize the morbid secretion. 

Diabetic urine is hght-coloured, and transparent ; of a pale straw, or greenish tint. 
Its odour is peculiar. According to Dr. Prout the scent somewhat resembles that 
of sweet hay, or that of milk ; but to my nose it is more hke the faint smell of certain 
apples, or rather of an apple chamber. Its taste is, more or less decidedly, sweet. 
Notwithstanding its limpid and aqueous appearance, diabetic urine is remarkably 
heavy. 

It was long believed that the quantity of urea in diabetic urine was reduced much 
below the natural standard ; and that the sugar was somehow formed at the expense 
of the urea. Dr. Prout, in his earlier researches, always detected a little, and but a 
little, of this pecllhar principle. Later observations have shown, however, that the 
urea is not so scanty ; nay, that it is generally as abundant as in the urine of health, 
and sometimes even more so. The presence of the sugar conceals the urea ; inter- 
feres with the action of the ordinary tests of that substance. By certain modes of 
procedure, which I need not stop to descrine, the urea may readily be discovered : 
and it is often found, I say, to be rather excessive than deficient. The usual saline 
matters belonging to healthy urine are present also in that of diabetic persons ; and 
in the same relative proportions ; but, as might be expected, their absolute amount, 
in a given quantity of the liquid, is very much diminished. In short, the only essen- 
tial deviation from the standard chemical constitution of the urine is, that it holds in 
solution a quantity of sugar. This explains its peculiar odour, its sweetness, and 
perhaps its excessive quantity. It accounts also for another very characteristic pro- 



DIABETES. 



869 



perty of diabetic urine ; I mean its high specific gravity. In general, you know, the 
specific gravity of the urine is inversely proportional to the quantity secreted in a 
given time ; the more copious and dilute it is, the lighter it is. But in diabetes, so 
strong is the saccharine impregnation that the specific gravity more than keeps pace 
with the increased quantity of the liquid secreted. The specific gravity of diabetic 
urine is always much higher than that of healthy urine. 

The quantity of urine secreted and voided is sometimes enormous : far more than 
could be supphed by the quantity of fluid taken as a drink, although that, as I shall 
presently explain, ig excessive too. A healthy person passes from one to three or 
four pints of urine in the twenty-four hours. The quantity, as you well know, is 
liable to considerable variation : perhaps the average may safely be laid at about forty 
ounces. But patients in diabetes will void 40 pints in the same time. I have 
myself seen 26; 13 or 14 are not uncommon; and cases are recorded by writers of 
credit and veracity, in which 70 pints were passed daily. Nay, one Italian author 
declares tRat 200 pints have been discharged in that time. 

The saccharine matter thus held in solution may be obtained in its solid form, by 
evaporating the urine. I have seen large flat cakes of beautifully crystalhzed diabetic 
sugar. It differs somewhat from common sugar, the produce of the sugar cane ; and 
approaches more nearly to the sugar of grapes. By rapid evaporation of the water a 
thick syrup is procured resembling treacle ; but Dr. Maclntyre, who has presented 
to our hospital-museum some very perfect specimens of this sugar, prepared by Mr. 
Blandford, informs me that to get it well crystallized, the evaporation in a steam bath 
should be stopped while the urine is still of thin consistence. It may be quickly re- 
duced to one-half, perhaps, of its original quantity. Then it should be set aside, in 
shallow plates ; and in the course of ten days or a fortnight the sugar will be depo- 
sited in a regularly crystalline form. 

The sugar is sometimes so abundant, that it undergoes a rude crystallization as the 
urine dries, wherever it happens to fall. A girl who was in St. Bartholomew's 
Hospital, while I was a student there, observed that if her water was accidentally 
sprinkled upon her black stuff shoes, every drop left a white powdery spot behind it. 
So also an aged patient under Dr. Maclntyre's care expressed to him her alarm at 
finding that her black worsted stockings were covered with a white dust, from the 
same cause. A man recently under my charge in the Hospital, complained that 
two pair of his black cloth trowsers had been spoiled in a similar manner. I re- 
member hearing from a diabetic patient in the Edinburgh Infirmary, that his atten- 
tion was first drawn to his urine by the number of flies and wasps which its sweet- 
ness attracted to the chamber-pot. 

This daily produce of sugar from the laboratory of the human body, is surely a 
very singular and surprising phenomenon. Sugar is not a constituent of healthy 
urine. Dr. Prout (who is more consulted on this subject than any one else, and 
whose experience in respect to it is commensurably great) says that he has never 
known saccharine matter to occur in the urine of any other animal than man. I 
once had a coach-horse which I supposed might have diabetes. He was a greedy 
feeder, and drank eagerly, yet he grew thinner and thinner ; and wherever I had 
occasion to stop, there he invariably began to stale : so that I became thoroughly 
ashamed of his leaking. Dr. Prout was good enough to examine his urine for me. 
It contained no sugar, but its healthy properties were much changed : it had less than 
the natural quantity of hippuric acid, and more of earthy matters. The disease, he 
tells me, is known at the Veterinary College ; whence specimens of such urine have 
been sent to him for inspection : but it is not true diabetes. 

The unnaturally high specific gravity of diabetic urine is a constant quality; and 
you. must attend to this, for it is almost always a faithful index, not only of the pre- 
sence, but of the severity of the disorder. Dr. Prout places the specific gravity of 
healthy urine between 1015 and 1025, that of distilled water being represented by 
1000. Different authors vary somewhat in their estimate of the natural standard; 
but we may be content to follow Dr. Prout. He says that the specific gravity of 
diabetic urine has been stated to vary from 1020 to 1050: that he has many times 

3x2 



870 



DIABETES. 



seen it higher than this, but very seldom so low. In fact it ranges generally between 
1030 and 1060 ; and the average may be taken at 1040. 

So much with reference to the quantity and qualities of the urine discharged in 
this complaint. It is attended, however, as you may suppose, with other and im- 
portant symptoms. 

As so much fluid is evacuated from the body through this channel, it might be ex- 
pected that the other channels for the excretion of liquid matters would be compara- 
tively dry: and so they are. The skin is arid, harsh and unperspirable. The 
patients tell you that they never sweat : that they cannot get into a perspiration. 
This is a very general symptom ; yet in some few patients, especially as the fatal 
period of the complaint draws near, the surface readily becomes humid. Again, the 
bowels are mostly costive, and the feces remarkably sohd and free from moisture. 
The tongue is dry, parched and sticky ; sometimes unnaturally red and clean : and 
the waste of watery particles from the system seems to be felt and expressed by the 
inordinate thirst which the patients suffer. Their drought is often insatiable. I re- 
member one girl telling me that when she was debarred from an excess of water to 
drink, she would get up if she heard it raining in the night, and catch some of the 
descending drops to satisfy the tormenting sensation of thirst. And another patient, 
a very sensible fellow, informed me that, beheving it could not be good for him to 
drink so much, and feeling no confidence in his own resolution to refrain, he was in 
the habit of betaking himself in the summer time to fields and dry pastures, where 
no water was at hand to quench his strong desire for it. The appetite for food is 
often, but not always, equally keen ; and the patients, especially those in the lower 
ranks of society, are apt to think, while they wonder at their weakness, that there 
cannot be much the matter with them, since they continue to eat and drink so fa- 
mously. 

Again, the enormous daily drain upon the system may be expected to cause 
various symptoms and sensations which may all be referred to debility and defective 
nutrition. Dr. Henry published a table, showing the quantity of solid extract in 
every wine pint of urine of different specific gravities from 1020 to 1050. Taking 
1040 as the average specific gravity, and ten pints as the average quantity of the 
urine discharged daily, the patient would in this manner lose, every twenty-four 
hours, 15 ounces 7 drachms — or more than a pound and a quarter — of sohd ma- 
terials. 

We need not be surprised, therefore, at the hunger, the wasting, the hectic fever, 
the feehng of emptiness and sinking at the stomach, the debility, the chilly state of 
the bod)'-, and especially of the extremities, the aching and sense of weariness in the 
loins and legs, the aversion to exercise, the loss of virility; all of which symptoms 
are generally present. I may add, to complete the picture, some others, enumemted 
by Dr. Watt, and confirmed by Dr. Prout, and consistent with my own experience 
of the disease. They are, uneasiness in the stomach after meals, flatulence and acid 
eructatibns, dimness of vision, redness of the whole interior of the mouth, spongi- 
ness of the gums, looseness of the teeth, and some degree of irritation and inflam- 
matory redness about the external orifice of the urethra : these last are symptoms 
noticed in persons dying of inanition. Again, listlessness and depression of 
spirits, weakness and peevishness of temper : " the once vigorous mind becomes 
feeble, oblivious, and vacillating — the once amiable temper, fretful, suspicious, and 
intolerant." With all this there is a peculiar faint and unpleasant odour of the breaih 
and person ; an odour which Dr. Prout says is hay-like, which some call melleous, 
but which reminds me, as I said before respecting the urine, of the smell of a room 
in which apples have been kept. I have recognized the complaint, upon first enter- 
ing the sick-chamber, by this peculiar scent. 

Diabetes is generally a chronic disorder, creeping on at first insidiously, and 
spreading itself, under judicious management, over many years. Yet it is some- 
times fairly entitled to be called an acute disease ; for it occasionally breaks out sud- 
denly, is attended with much febrile disturbance, and runs a short course, uncon- 
trolled by any treatment. One such instance I have seen. Much more frequently 
it proves fatal through the supervention of some organic mischief, such as debility is 



DIABETES. 



871 



calculated to foster and develop. It often becomes associated in its progress with 
pulmonary disease, especially with tubercular phthisis. So common is this, that 
some persons have thought it universal. But it is not so. I have myself witnessed 
more than one or two dissections of persons dead of diabetes, whose lungs did not 
contain a single tubercle. Sometimes the disease terminates in incurable dropsy : 
and sometimes the patient is cut off suddenly, either by apoplexy, or by some pecu- 
liar affection of the stomach. 

There is some kind of connection between diabetes and certain affections of the 
skin, and of the subjacent reticular membrane. Dr. Prout remarks that it usually 
follows cutaneous complaints, but accompanies or precedes those which involve the 
areolar tissue. Persons have been known to lose chronic eruptions upon the super- 
vention of diabetes. On the other hand, carbuncles and malignant boils are frequently 
the companions of that disorder. The examination of the dead body throws little or 
no hght upon the pathology of diabetes. We naturally look with interest to the 
kidneys. But we find nothing there to explain the symptoms noticed during hfe. 
What I have usually remarked has been a deep purplish red colour of the kidneys, 
which were veined and vascular, but not otherwise altered in texture. Andral and 
others tell us that the kidneys are found hypertrophied in diabetes. But hypertrophy, 
and unnatural vascularity, are circumstances which we are not surprised at when we 
reflect upon the vastly increased quantity of work which the glands have been per- 
forming. We must regard both these unnatural conditions rather as being the con- 
sequence, than as being the cause, of the morbid flow of urine. In one instance, 
after sudden symptoms of gastritis, which followed the incautious potation of strong 
ale, I found the mucous membrane of the stomach distinctly inflamed, in its cardiac 
portion. I have found also the mesenteric glands diseased, converted almost entirely 
into bone. But neither of these changes is constant. They were purely accidental 
in those particular cases. 

What, then, is the origin and source of this strange complaint ? whereabouts in 
the body is the sugar formed ? is it made, by the kidneys, from the blood? or is it 
made, from the food, by the stomach ; and carried into the blood to be simply cast 
out through the urinary channels ? or is it elaborated in some intermediate stage of 
what Dr. Prout has called the secondary assimilation ; which includes the formative 
and the destructive processes that take place in the body subsequently to the act of 
sanguification ? These questions, which are full of interest, have been much de- 
bated ; and until very lately pathology was unequal to their solution. It was natu- 
rally thought that, if the sugar pre-existed in the blood, and was only withdrawn 
from it by the kidneys, it would be discoverable in the blood. Yet able chemists 
sought for it there in vain. Hence it was inferred, that by some new combination 
of its elements, saccharine matter was actually formed in the kidneys. The chemistry 
and the reasoning were both faulty. Sugar has, now, been detected in diabetic 
blood. It is detected with some difficulty, partly perhaps because its presence is 
masked by the albumen of the serum, but partly because its quantity is small ; and 
its quantity is small because it is continually decanted out of the blood, as fast as it 
enters, and with it a profusion of water also, through the kidneys. In this respect 
the sugar and the urea are alike. They are both excretions which the blood is in 
haste to cast forth. It vt'ould seem also as if the sugar necessarily carried with it a 
large quantity of aqueous fluid from the blood, and was simply diuretic. When the 
amount of sugar eliminated is diminished, as by certain remedies it may be, the 
quantity of urine diminishes too. 

Traces of sugar had, I believe, been found in the blood by some previous in- 
quirers : but it is to Mr. M'Gregor, of Glasgow, that we are indebted for the full 
exposition of this interesting fact. His researches, published last year (1837) in 
the Medical Gazette, have thrown a new and strong hght upon the pathology of 
diabetes. 

By a peculiar process, he did, I say, that which many preceding chemists had 
failed to accomplish ; he detected sugar in the serum of the blood of diabetic patients. 
The serum had a milky appearance, he says; and I have seen that myself: its 
specific gravity was above the healthy standard. Having coagulated the serum by 



872 



DIABETES. 



heat, he carefully dried it ; then cut the dried mass into very small pieces, and boiled 
them in distilled water; and lastly, he evaporated the decoction to a certain point. 
To the liquid thus concentrated he added a portion of yeast, and the presence of 
sugar was manifested by the fermentation w^hich ensued, and which lasted for several 
hours. Yeast, I should tell you, is a most dehcate test of sugar, and will readily 
detect half a grain in two ounces of liquid. 

Mr. M'Gregor went a step further back. He obtained, b}^ means of an emetic, 
the digested food from the stomachs of two men who had dined two or three hours 
before. One man w^as in health ; the other had diabetes. In each case the food had 
been of the ordinary kind. Applying, after due preparation, the test of yeast, he 
found that the vomited matters fermented strongly ; especially those from the diabetic 
patient. 

Then he varied the experiment. Thinking that the sugar, in these cases, might 
have been introduced in the vegetable portion of the food, he adopted precautions to 
exclude that possible source of fallacy. He administered to a healthy man, and to 
a diabetic man, a vomit and a purge, to clear out the ahmenlary canal. Next he fed 
them upon roast beef and water, and nothing else for three days. Then, three or 
four hours after a meal, the contents of their stomachs w^ere procured by the operation 
of the sulphate of zinc, as an emetic ; and treated as in the former case. What 
the healthy man vomited did not ferment at all. What came from the diabetic pa- 
tient fermented " pretty briskly." 

The fault, then, we may safely conclude, lies in the digestive organs. Instead of 
healthy and nutritive chyle, saccharine matter is prepared by the stomach, and enters 
the circulation. That which should be converted into muscle, and fat, and bone, 
and nerve, and membrane, is hurried out of the system, as sugar, with the urine. 
Thus far we see our way with tolerable clearness. But why the stomach should 
cease to perform its accustomed chemistry upon the food, and even upon sugar itself 
as an article of food, we have not yet learned. That sincrle important step is still 
wanting to the complete solution of the pathological problem. 

I may mention that Mr. M'Gregor carried his inquiries further still, and met with 
some curious results. He examined the saliva ; the feces ; and the sweat. He 
found sugar in the saliva. He could find none in the sweat. The feces of one pa- 
tient, allowed to dry spontaneously, became covered, after the lapse of some time, by 
distinct crystals of sugar. And yeast having been administered to two patients, in 
ounce doses, after each meal, had soon to be discontinued, because the patients, to use 
their own expressions, feh as if they " were on the eve of being blown up." 

We know but httle about the causes of diabetes. It is not a very common dis- 
order; and in those who become afflicted with it, there probably has existed a pre- 
disposition to it. Dr. Prout remarks that the complaint runs sometimes in families, 
and is inherited. I had under my owm observation, for some time, three children, 
two brothers and their sister, all affected with diabetes. The mother, a maternal 
uncle, and a sister of a friend of mine, all died of this malady. The same author 
mentions among the predisposing causes, long-continued intemperance, and especially 
the immoderate use of spirits, severe evacuations, excessive labour joined with a poor 
acescent diet. Distress and anxiety of mind are held also, and justly I think, to be 
among the predisposing causes. It occasionally seems to be produced, at once, by 
the operation of some exciting cause, such as exposure of the body to cold; or the 
drinking of large draughts of cold fluid while the person was hot and perspiring. 
Dr. Bardsley states that, in twelve instances of the disease which had fallen under 
his own notice, the patients attributed their ailment to one or the other of these two 
causes. Now these are common causes of disease ; and that a predisposition does 
exist is probable from the fact, that where the exciting cause has acted on several 
individuals at the same time, one alone has become affected with diabetes. There is 
a narrative illustrating this, by Sir Henry Marsh, in the third volume of the Dublin 
Hospital Reports. A patient of his traced the apparent origin of his diabetes to ex- 
posure to wet, cold, and privation, at sea, while in imminent danger of shipwreck. 
Another of the crew fell ill of ague. Others escaped entirely, or had only common 
colds. , . 



DIABETES. 



873 



If the account which I have been obliged to give you concerning the intimate 
nature, and the causes, of this curious malady, should appear unsatisfactory, so also, 
I fear, will what I have still to say respecting its cure. I dare not affirm that diabetes, 
although it seems a merely functional disorder, has ever been cured. Dr. Prout has 
known some few patients, two perhaps, or one, recover. Apparent recoveries — nay, 
apparent cures — are not very uncommon. And this it is of great importance to 
know. Remedies are not useless because they fall short of their full scope. It is 
better to keep a man on the edge of a precipice, if you cannot pluck him away from 
it, than to let him fall over. And many diabetic patients are kept in this predica- 
ment of dangerous safety. There are certain remedies that exercise a strong con- 
trolling influence over some of the most prominent and troublesome of the symptoms; 
and that sometimes even restore the patient to a state which he mistakes for heakh; 
and which a medical man, unwarned of its fallacious character, might also mistake. 
The urine may recede within the natural limits. There may remain one morbid 
circumstance only, and that of a nature easily overlooked : indeed it is sure to escape 
observation if it be not especially searched after. I allude to the unnaturally high 
specific gravity of the urine. So long as the density of the urine continues perma- 
nently and decidedly above the heakhy standard, there is no real security. The 
smallest disturbing cause — exposure to cold, an intemperate meal, unusual exertion 
and fatigue, sudden or strong mental emotion — may bring back all the symptoms ia 
their former severity. If these and similar hurtful agencies can be averted, life may 
sometimes be prolonged, in much comfort, for many years. 

"There are three objects to be kept in view, in the treatment of every case of 
diabetes. 

First, to restore the defective power of the digestive apparatus : 

Secondly, to cut off, or restrict as much as possible, the supply of saccharine mat- 
ter from without : 

Thirdly, to mitigate or remove the most distressing symptoms. 

If we could achieve the first of these objects, the other two would fall out of sight ; 
for the disease, which is really a variety of dyspepsia, would be cured. But hitherto 
all the resources of our art have, in this respect^ been baffled. Our main hope of 
ukimate success must lie in the regulation of the ingesta; whereby, also, the second 
indication is to be fulfilled. Some of the food is, in every case, carried to the proper 
account, or the patient would speedily die. If we can succeed in directing a sufficient 
amount of healthy nutriment to the organic tissues of the body, the draining away 
of any superfluous sugar will be borne well enough. 

About the beginning of the present century, Dr. Rollo discovered and taught that 
a diet composed exclusively of animal matters had a signal effect in reducing the 
quantity and in diminishing the sweetness of diabetic urine. Mr. M'Gregor's experi- 
ments tell us why this is. Animal food furnishes but scantily the materials for the 
formation of sugar. " The saccharine alimentary principles are chiefl}^ derived 
(says Dr. Prout) from the vegetable kingdom, and indeed constitute what may be 
called, by way of distinction, vegetable aliments.''^ If, then, we can exclude ahments 
of this kind, and confine the patient to animal food alone, we thus cut off' the supply 
of the materies morbi ; and without indeed curing the disorder, suspend its worst 
effects. But unluckily very few persons can long endure this mode of living. So' 
far as they can endure it, they are comparatively safe. We are obliged to relax, in 
some degree, the rigour of our rule ; and it is curious to observe how suddenly and 
decidedly the saccharine properties and the quantity of the urine are augmented, 
when, by stealth, or by permission, the patient adds to his meal the smallest portion 
of vegetable food — even a biscuit or two. 

We must therefore contrive to vary the animal diet as well as we can ; encourag- 
ing the patient by a free license to choose among the different kinds of meat, game, 
poultry, and eggs, in their diversified modes of preparation, and admitting into his 
bill of fare as small an admixture as possible of vegetable substances. Green gar- 
den-sluff', the oleracca, spinach, cabbage, celery, and the like, maybe taken with less 
risk of increasing the saccharine matters in the system, than potatoes, and those other 
articles of vegetable diet which contain a notable proportion of sugar, gum, or starch. 



874 



DIABETES. 



All kinds of fruit must be forbidden. You will seldom be able to debar your patients 
elilirely from bread : none should be allowed but such as is well fermented, and 
somewhat stale, or thoroughly toasted ; and even that as sparingly as may be. 

It is also of much importance to admonish the patient, whose appetite is generally 
ravenous, against eating too large a quantity, even of animal food, at any one time. 
Not only is the digestion still further weakened and oppressed by an intemperate 
meal, but the patient's life may be put in peril by every such act of unwise indul- 
gence. Of this I have witnessed one example, and have heard of several more. 

The quantity of drink should likewise be limited. It may properly enough con- 
sist of animal broths : and these should be taken tepid, for they are then more likely 
to be taken in moderation. The patients must, however, and will, have something 
else, to slake their urgent thirst. I have found (acting upon a suggestion of the 
eider Dr. Latham) that distilled water, acidulated with phosphoric acid, appeases, 
more than most things, that painful sensation. The water of the Bristol Hot Well, 
which contains carbonate of hme in solution, is praised by Dr. Prout for the same 
purpose. 

Dr. Christison gives an important caution in respect to drinks ; viz., that, when 
the thirst has already been much indulged, the quantity of liquid taken must not be 
greatly reduced all at once. Sudden failure of the vital powers has not unfrequently 
ensued upon abrupt changes of that kind. 

Very numerous are the remedies which have been tried, and which have been 
recommended, for this disorder. I shall notice those only of which I have had per- 
sonal, and in some degree favourable experience. 

The first of these is blood-letting, which has been strongly advocated by Dr. Watt, 
of Glasgow, and by Dr. Satterley, formerly one of the physicians to the Middlesex 
Hospital. It is not a remedy which would naturally occur to one's mind as being 
likely to prove of service in such cases ; but both the authors I have mentioned 
speak of it in terms of high commendation. They affirm that, under small and 
frequent bleedings, the strength increases ; the clamminess of the mouth, and dry- 
ness of the skin, diminish ; and the blood by degrees assumes the huffy coat. I have 
once seen the method of frequent blood-letting fairly put to the test. At first, the 
patient did seem to be benefited by it; but she ultimately died: and I am satisfied 
that her death was accelerated by one bleeding too many, or by too large an abstrac- 
tion of blood at one time. 

This measure has the best chance of being useful, when the malady is recent, and 
attended with febrile disturbance. In chronic cases, in old persons, and whenever 
the debility is already great, venesection can seldom be requisite or proper ; although 
even then, as Dr. Prout remarks, it may be borne better than one might expect. 
Local bleeding is, however, of much service in relieving local uneasiness. Leeches 
may be applied to the epigastrium, if the patient has tenderness there, or complams 
of a sense of fullness or of burning in the stomach. Cupping to the loins, if they 
greatly ache. 

Opium is a treasure to us in this disorder. It quiets the nervous irritabihty of the 
patient, allays many of his most distressing sensations, and restrains in a remarkable 
manner the morbid profluvium from the kidneys. But you must not suppose, from 
observing these favourable changes, that you are curing the disease by it. It appears 
to control the diuretic influence of the sugar in the blood ; but it does not banish the 
sugar itself. And, as far as my experience goes. Dr. Prout is in the right when he 
states that moderate doses of opium generally suffice to check the excessive dis- 
charge. Five grains of Dover's powder, for example, three times a day, will do as 
much good, and on the other hand be productive of far less inconvenience than larger 
quantities of that narcotic substance. The sudorific properties of this compound 
are thought to render it eligible ; although it has seldom any apparent effect, in that 
way, in diabetes. If the ipecacuanha which it contains should disagree with the 
stomach, an equivalent quantity of any other preparation of opium may be substituted 
for it. 

There is another remedial measure which has also, in some cases at least, a most 
beneficial influence on the condition of the patient ; I mean forced perspiration — 



DIABETES. 



875 



perspiration induced by the hot-air bath. Of this I have seen some striking exam- 
ples. A very well-marked case of diabetes came under my care in the Middlesex 
Hospital several years ago. A vapour, or hot-air bath, had just then been constructed 
in the hospital, and I thought it a good opportunity for trying whether the sus- 
pended functions of the skin might not be restored, and the extravagant action of the 
kidneys perhaps corrected, by that powerful mode of exciting perspiration. I should 
tell you that other plans of treatment had already been put in force, with but partial 
advantage. It would occupy more time than 1 can now spare to enter upon the 
details of this case ; but I will read to you the man's own statement, which he wrote 
down before he left the hospital, in evidence of the benefit he derived from the 
sudatorium. 

" The urine" (these are his words) " is reduced more than one-half, and does not 
contain much sweetness, but sometimes tastes salt, with a mixture of bitter. My 
stools, which were dry, and like bails packed together, are now quite natural. The 
pains in my hmbs are entirely removed. My spirits, which were very much de- 
pressed, are now revived, and cheerful. The unpleasant aching of my kidneys, of 
which I spoke httle lest 1 should be cupped in the loins, is now removed ; only I feel 
weak there. I am cured of the pain in my stomach, and the circuitous working of 
the wind in my bowels, which formed lumps in my belly as it passed, resembling 
those formed by the cramp. 1 have likewise ^ot rid of the palpitation at my breast, 
which was accompanied with a sort of dread. My breathing is much improved ; 
perspiration, in a great measure, restored ; and my skin, which was dry, is now be- 
come moist. I sleep well at night, whereas I could not sleep more than two or three 
hours out of the twenty-four. My thirst, which was excessive, has ceased to be 
troublesome." 

This man, who, in the statement I have just read, has so graphically described 
his own morbid sensations, and the rehef from them which he had obtained, left the 
hospital thinking himself well : but, the specific gravity of his urine remained above 
1030. 

In about half a year afterwards, he went one evening to Hyde Park to see some 
fire works, got wet feet, and began to cough. The diabetic symptoms returned 
more severely than ever ; and he soon died. I found his lungs stufied with tubercles. 

In furtherance of the principle upon which the use of the hot bath is recom- 
mended, the other well-known methods of promoting the natural functions of the 
skin should be followed ; friction, and more especially warm clothing. 

Steel is sometimes singularly beneficial in repairing the strength, and enlivening 
the spirits ; as indeed it is well known to be in other forms of disease attended with 
a copious and permanent drain upon the system, and with a diminution of red blood. 
Of course it may be combined with opium, or with any other medicine which the 
circumstances of the patient may render needful. 

I scarcely need say that the bowels require attention. Not that active purgation is 
advisable, but simply their regulation. Castor oil, rhubarb, aloes, lenitive electuary, 
are more appropriate in these cases than the purgative salts, which are apt to be 
diuretic also. 

There is one other drug from which I think I have seen the happiest effects, 
i mean the creasote. I first became acquainted with its virtue, from prescribing it, 
almost accidentally, until a consultation could be arranged with Dr. Prout, for a 
child, eight years old, in whom the disease was well-marked, and who had been 
brought to London from the country for advice. She had been rapidly wasting away 
for ten weeks, was extremely feeble, soon tired, very thirsty, especially at night, and 
had (what was also new to her) an enormous appetite. She was passing from three 
pints to two quarts daily of pale urine, having a specific gravity greater than 1040. 
I desired that her diet should be as exclusively animal as she could bear, and that 
she should take one minim of creasote, suspended by means of mucilage in an ounce 
and a half of water, three times a day. Curiously enough, the child liked the tarry 
flavour of the medicine. Upon this plan, with gentle aperients occasionally to regu- 
late, her bowels, she remained for upwards of a twelvemonth. Her urine soon fell in 
quantity within the limits of health, and in density to about 1030. She regained her 



876 



CHRONIC DIURESIS. 



lost flesh, strength, complexion, and spirits, and grew considerably. At length she 
suddenly sank under an obscure affection of the chest. A brother of this httie girl 
has lately manifested unequivocal signs of the same complaint ; and in him it appears 
to have been equally checked by the same method of treatment. I have detected 
sugar in the urine of another boy belonging to the same family. 

There were two points in this young lady's case which deserve a passing remark. 
As her urine diminished in quantity it began to deposit the lithates. This Dr. Prout 
considered a very promising earnest of a return to a better diathesis : and I find that 
in cases which have crept on insidiously from the first, he is accustomed to date the 
malady from the time when lateritious sediments, previously common, disappeared 
from the water. 

The other point was, that calomel always sickened this child, and aggravated all 
the diabetic symptoms. This is consistent with Dr. Front's experience, who tells us 
that he has never seen mercury do good in diabetic disease ; but on the contrary 
almost invariably do mischief. I would advise you to read his judicious observations 
upon the too common abuse of that mineral. 

I am quite aware of a possible fallacy in the case I have been mentioning, with 
respect to the efficacy of the creasote. With the use of that drug was associated a 
stricter adherence to a purely animal diet ; and it is impossible to estimate with pre- 
cision the separate effects of these two remedial measures. I am, however, disposed 
to believe that the creasote, by its well-known preservative property, checks the con- 
version of the food into sugar. And I think it is a mistake to go on increasing the 
dose. To most stomachs it proves irritating and hurtful when pushed beyond a cer- 
tain small amount. Dr. Maclntyre tells me that he has found the creasote very 
useful in diabetes. I must, however, acknowledge that, in common with others, I 
have sometimes been totally disappointed by it. 

For many years of my professional hfe I had not met with an instance of what 
has been called diabetes insipidus: from which I infer the rarity of that disorder. I 
shall use the term chronic diuresis to express this affection. 

Very recently a marked instance of such chronic diuresis has presented itself in 
the hospital. A boy, eleven years old, not unhealthy looking, but lean, was 
admitted there under my care. He was much troubled by thirst ; and by frequent 
micturition, which, even in the night, disturbed'^him many times. His bowels were 
costive, he had a capricious appetite, and his skin was dry. He voided during the 
twenty-four hours several pints, seldom less than nine or ten, of simply dilute urine, 
of a faintly yellowish hue, and having the specific gravity of 1002. Sometimes, 
indeed, it was found to be scarcely heavier than distilled water. In other respects 
he appeared tolerably well. It was supposed that he had been affected in this 
way for about twelve months ; his desire for drink having been the first symptom 
noticed. 

During his residence, of many weeks, in the hospital, under my observation, I 
made trial of every plan and drug that I could think of, for repressing the unnatural 
flux of urine. Nothing did him any good: some things, I fear, by disturbing his 
stomach and bowels, did him some temporary harm. He went out much as he 
came in. 

Although I can tell you neither upon what this disorder depends, nor how it may 
be remedied, I mention the case because it afforded me a proof that liquid may be 
absorbed into the body from the atmosphere ; either by the external skin, or by the 
pulmonary mucous membrane, or by both these surfaces. Dr. Prout, to whom I 
showed both the urine and the patient, advised that, for a time, his supply of drink 
should be limited. Accordingly, very much to the poor boy's sorrow, he was put 
upon a daily allowance of a pint and a half. 1 have no doubt that my injunctions 
were strictly observed, both by himself and by the nurses. Nevertheless, without 
losing flesh or weight, he passed, during the corresponding twenty-four hours, ten 
pints and a half of urine. 

I got evidence of the same fact in another way also ; namely, by weighing the 



ALBUMINOUS URINE. 



877 



boy at short intervals : although the experiment was not repeated so often as I wished 
it had been. I give you tiie results of one of these trials. 

Immediately after he had emptied his bladder he was found to weigh 3 st. 8 lb. 
0 oz. 3 dr. Three hours subsequently, having taken nothing in the interim, he 
weighed 3 st. 9 lb. 0 oz. 2 dr. Then he voided 16 oz. of urine : after which his 
weight was again 3 st. 8 lb. 0 oz. 3 dr. So that he must have imbibed about a 
pound of liquid in that brief space of time.* 

In this instance there was merely an excess in the aqueous ingredient of the urine ; 
the solid matters were apparently there, in their due proportion to each other, but in 
a very small ratio to the water. 

But the aqueous ingredient may be in excess, while the absolute quantity of urea 
is deficient. On the other hand, with an excess of the watery material, there may 
be an excess also in the quantity of urea it contains. 

Dr. Willis has distinguished these three varieties of chronic diuresis by the terms 
hydruria, anazoturia, and azoturia, respectively. Although I am no friend to the 
multiphlf^tion of technical names, I must tell you that the distinctions expressed by 
these terms are real, and of some importance. Anazoturia we shall find to be often 
symptomatic of a peculiar organic disease of the kidney, which I hope to describe 
in the next lecture. 

Azoturia, which is accompanied by an unnaturally high specific gravity of the 
urine, is apt, on that account chiefly, to be mistaken for diabetes. As recoveries 
from it are not uncommon, it may be suspected that some of the boasted cures of 
diabetes were cures of this less serious disorder. In the one case, the yeast test 
detects the presence of sugar in the superabundant urine ; in the other case it fimds 
none. 



LECTUEE LXXVIII. 

[j 

Albuminous Urine. Means of detecting the Jilbumen. What it imports. JlnatO' 
mical characters of Bright' s Kidney. Symptoms to which this renal disease 
gives rise. Nature of the affection. 

Another morbid condition of the urine, imperatively demanding your attention, 
is that in which it is habitually impregnated with albumen. This albuminous con- 
dition is much more common, and in general not less serious, than the saccharine 
condition which I described yesterday. 

There is no albumen in healthy urine. Neither can we recognize its presence, 
in any urine, by mere inspection. We detect it by certain tests : and I will tell you, 
in the first place, what these are ; and how to use them. 

Albumen — of which we have so familiar an example in the " white" of eggs- 
begins to pass from the flui^ to the solid state at the temperature of 1G0° Fahrenheit. 
\ When diluted it may require for its complete coagulation the heat of 212°. Hence 
one simple and easy test of its presence. We discover that albumen is contained 
in the urine, by heating that fluid to the boiling point. This is most conveniently 
done in a small glass tube, by the flame of a spirit lamp. It is seldom that any pre- 
j paration of the suspected urine is requisite. It may, perhaps, be hazy in conse- 

iquence of its containing mucus ; and if its transparency be much troubled, it will be 
well to filter the fluid before testing it. When, as sometimes happens, albuminous 
I urine is already turbid from the presence of the hthates, these dissolve as the heat 



* This boy lived morp than two years afterwards, and continued to yield an excessive 
quantity of pale, neutral urine, scarcely heavier than distilled water. After death, scrofu- 
lous tubercles were found in his brain and in his lungs. . His kidneys were gorged with 
venous blood, but of healthy structure. There was nothing wrong, apparently, in his organs 
■of digestion. 

3y 



1 



878 



bright's kidney. 



IS applied, and the urine first becomes clear ; and then, as the temperature rises, the 

albuminous opacity begins to be visible. 

The phenomena observable in the heated urine vary in different cases, chiefly by 
reason of the variable amount of albumen. The whole is sometimes converted into 
one gelatinous mass : but this is uncommon. Usually the albumen first appears in 
the form of a whitish cloud, of which the constituent particles multiply, and collect, 
in proportion as the quantity is considerable, into small curdy fragments or flakes. 
These soon subside to the lower part of the tube, leaving the supernatant liquid 
clear. The amount of albumen is of course to be estimated by the portion of the 
tube that it occupies. 

Now this test, by heat, is not conclusive, nor sufficient. There are circumstances 
that may impede or prevent its effect in coagulating albumen, which, nevertheless, 
is present. On the other hand it may, under other circumstances, produce a falla- 
cious appearance of albumen where none exists. 

Albuminous urine has often a less acid reaction with litmus paper thaq^healthy 
urine. The reason of this I will explain presently. When recently discharged from 
the bladder, the urine may be neutral or even alkaline ; or it may become neutral or 
alkaline, by spontaneous decomposition after it has left the bladder. In any case, 
the urine, thus alkaline or neutral, will not coagulate when heated, even though it 
may be full of albumen. Again, although there may be no albumen, heat may 
cause a flaky precipitate, consisting of the earthy phosphates. 

We avoid, or remedy, these sources of fallacy, by testing the suspected urine 
with nitric acid also, which has the property of precipitating the albumen in a flaky 
or pulpy form. It will thus detect albumen when the tested urine is alkahne ; and. 
by restoring its acidity, it would make the albumen discoverable by the test of heat. 
It has likewise the effect of redissolving the spurious precipitates which may be 
thrown down by the application of heat, and consequently of showing that they are 
spurious. 

Nitric acid alone, however, is not, any more than heat alone, an unequivocal 
touchstone of the presence or absence of albumen ; for it may occasion a flaky 
precipitate of lithic acid, when there is no albumen. But this defect is compen- 
sated by the complementary criterioA of heat; the precipitate being redissolved 
by raising the temperature of the urine, while any coagulated albumen remains 
insoluble. 

Dr. Christison states that, in his experience, "sometimes nitric acid added in. 
excess did not separate albumen which had been present in large quantity" — a fact 
which he thinks " is probably to be ascribed to the albumen itself having undergone 
more or less decay, along with the other principles of the urine." Hence the urine 
should, if possible, be examined before it has become decomposed by lapse of time. 
If, however, you employ both these tests Avith different portions of the same urine 
at the same time, and with the same portion in succession, you will avoid all risk of 
mistake. 

Other tests there are, frequently spoken of, and sometimes recommended ; particu- 
larly the ferrocyanate of potass, corrosive sublimate, creaSote, and oxalic acid. They 
are unnecessary, in addition to heat and nitric acid ; and they are liable to fallacies 
from which these last, when combined, are free. Unless you are expert chemists, 
you had better avoid them. 

Now it is quite certain that the presence of albumen in the urine does often accom- 
pany and bespeak a very serious organic disease of the kidney. For this disease 
we have no appropriate name. I wish we had. Some call it granular degeneration 
of the kidney, but the epithet granular is not always applicable. It is most fami- 
liarly known, both here and abroad, as Bright'' s kidney or Bright's disease ; after 
the eminent physician who, in 1837, first described it, and showed its great patholo- 
gical importance. These are odd-sounding and awkward terms ; but in the lark of 
better I must employ them. 

It is very difficult to describe, in words, the anatomical characters proper to this 
renal disease ; for they are neither very definite nor very constant. The description 



bright's kidney. 



879 



that I am about to attempt will be made more intelligible by Dr. Bright's plates, and 
those of M. Rayer, which are both before you. 

The morbid appearances presented by the substance of the kidney are such as 
denote some change in its intimate structure. Its cortical (or secreting) portion is the 
primary and chief seat of this degeneration ; yet what is called its medullary (i. e., 
its excreting) part, is also sometimes implicated, but in a less degree. 

These morbid appearances relate to the size, figure, and consistence of the kidney ; 
to the colour and condition of its surface, and of its interior. With respect to some 
of these points there is much variety in different cases ; and studying this variety 
under the light which is thrown upon it by the clinical history of the disease, we 
have reason to believe that it is connected with different stages of the disorganizing 
process. Thus if we look to the size of the diseased organs, they are sometimes 
much larger than natural, sometimes of the ordinary magnitude, sometimes consider- 
ably smaller. The average weight of the adult human kidney is four ounces. M. 
Rayer has met with some, in this disease, weighing twelve ounces. Both the incre- 
ment and the decrement of the natural bulk belong principally, if not altogether, to 
the outer secreting portion of the gland. If a longitudinal section of the exaggerated 
kidney be made, its cortical part is seen to be unduly broad ; and the same part is 
disproportionally narrow when the whole organ is smaller than common. For this 
reason, in the latter case, the radiating medullary portions approach nearer to the 
surface than they are observed to do in a heahhy kidney. And it furthermore 
appears that the enlargement is most commonly coincident with the earher, and the 
contraction or shrinking with the later stages of the renal disease. 

The consistence of the diseased gland is variable also. Sometimes, and for the 
most part in the earlier periods, it is soft and flabby : sometimes, and especially in 
the later periods, it is remarkably compact and hard. The size and the consistence 
of the kidney are, in most cases, inversely proportional to each other. 

Again, the form of the kidney, in the disease in question, often undergoes some 
modification. As the special change proceeds, the exterior of the gland shows a 
tendency to become indented by linear depressions, and to present a lobular shape. 
This, however, is by no means a constant phenomenon, even in the most advanced 
stage of the malady. * 

W'len its proper investing tunic is stripped off — and Jess distinctly through the 
same tunic, before its separation — the surface of the kidney appears mottled, mar- 
bled, or stained ; of a yellowish-gray colour in one place, and of a dark or purple 
tint in another. Occasionally it is pale throughout its whole extent ; more commonly 
of divers hues, and variegated with httle streaks, which are portions of vessels con- 
taining red blood. Sometimes the surface is curiously speckled ; often uneven as 
if strewed with prominent grains ; in some instances quite rough and scabrous. These 
several unnatural appearances are usually the more conspicuous, in proportion as the 
complaint is the more advanced. 

The most uniform, however, and the most characteristic of the morbid appear- 
ances, are those presented by the cut surface of the kidney, when it has been divided 
into two symmetrical portions by a longitudinal incision. We then perceive that the 
cortical substance is the main seat of the morbid alteration. It has lost in a greater 
or less degree, its proper red colour and uniform aspect. Sometimes it puts on a 
speckled or granular appearance ; but this, in my experience, is less common than a 
pale, nearly homogeneous surface, somewhat like the section of a parsnip. Its na- 
tural strisB are confused or obliterated. The incised surface gives one the notion of 
some deposit, whereby the original texture of the part is obscured. The blood- 
vessels seem, many or most of them, to have been emptied by compression, or to be 
blocked up by yellowish solid matters ; while the healthier pyramidal masses belong- 
ing to the medullary portion of the kidney are displaced, and pushed aside, or 
encroached upon by the same yellowish matter, which sometimes interposes itself 
between, and opens out, their tadiating tubuli. Together with these changes of 
appearance and structure, I have several times found the veins that emerge from the 
kidney firmly plugged up by coagula of blood. 

In some rare cases the kidney is studded, both on its surface and throughout its 



880 



SYMPTOMS. 



interior, with numerous small cysts or cells, contaming a tliin transparent liquid. 
These cysts have been inaccurately termed hydatids. It is not at all uncommon to 
meet with one or two such cysts in this diseased state of the organ. 

It has been made a question whether the various appearances which I have been 
attempting to describe, and which sensibly differ in degree and combination in dif- 
ferent cases, are characteristic of different morbid conditions, or merely of different 
stages and varieties of the same essential change. Our knowledge of the subject is 
scarcely sufficient to supply a positive solution of this question. Excepting perhaps 
the cyst, my own opinion is, that they are all accidental forms and effects of one and. 
the same morbid process. At the same time I ought to tell you, that both Dr. Bright 
and Dr. Christison appear to incline to the opposite conclusion. 

There is still another state of the kidney, very different to the eye from any that 
I have yet mentioned, but which has been thought, and which I think, to be, in 
some cases at least, the first stage of all in the disorganizing process. This state, 
which I referred to when speaking of suppression of urine, may be briefly described 
in two words — sanguine congestion. The whole organ is gorged with blood, which 
sometimes drips freely from it when it is cut open. The kidney is in general large, 
somewhat flabby, of a deep dark red, even of a chocolate or purplish colour, nearly 
uniformly diffused, .except that the cut surface is usually diversified by still darker 
tuft-like spots, which have been ascertained to be the Malpighian bodies filled with 
blood. This change from the natural appearance of the kidney is evidently of a 
recent kind ; and the symptoms that have been observed to belong to it are these :— 
Fever preceded often by rigors ; uneasiness or dull pain in the loins; nausea and 
vomiting ; a very scanty secretion of urine, which is sometimes tinged with blood, 
and always albuminous ; occasionally complete suppression of urine. To these 
symptoms there is presently added, in most cases, sudden and general anasarca — 
what is commonly called inflammatory, active, or febrile dropsy. If the secretion 
of urine be entirely suspended, death soon ensues by coma, as I explained to you 
yesterday ; but if not, the disorder is frequently fatal by the supervention of some 
acute internal inflammation ; pleurisy, or pericarditis, or pneumonia, or peritonitis. 
Many persons recover completely from the condition expressed by this combination 
of pneumonia. Many seem to recover, but bear about with them the germs or 
beginnings of those more chronic and latent changes which constitute " Bright's 
kidney." 

And what are the signs which indicate, to an instructed eye, the presence of those 
changes ? Some of them are precisely the same, in kind, as those which denote 
the acuter disorder ; only mitigated in degree, and of slower march and succession. 
The patients are subject to obscure lumbar pains : to sickness from time to time, 
and retching ; and their urine is apt to be red, brown, or dingy, as well as albumin- 
ous, from the intermixture of some of the colouring matter of the blood. They are 
obnoxious to inflammations of the serous membranes also ; and more particularly 
to head affections, of which they often die ; drowsiness, convulsions, apoplexy. 
And, to finish the resemblance, many of them, a}^ most of them, become at length 
anasarcous. Besides these symptoms there are others which are not seen in the 
acute malady ; because it is acute. Gradually increasing pallor is almost constant ; 
disease of the heart is common ; and the skin, in general, even in the absence of 
fever, is remarkably dry and unperspiring. The patients are troubled by a frequent 
want to make water ; by flatulence of the stomach and intestines ; and by caprice 
of the bowels, which are sometimes obstinately costive, sometimes prone to diar- 
rhoea. 

Now it is worth your while to remark, with respect to this category of symptoms, 
that (the state of the urine excepted) they have no special prima facie reference to 
renal disease. They are all common enough in various other complaints. In truth 
they are mere secondary consequences of Bright's disease ; and in so far as they are 
symptoms of it, they are indirect symptoms. Before Dr. Bright, no one perceived, 
in such symptoms, any indication of disease of the kidney. The primary and fun- 
damental organic malady reveals itself by no direct symptoms, excepting those which 
are furnished by the urine. 



STAGES OF THE DISEASE. 



881 



Seeing, then, that this pecuhar disease of the kidney is coupled with effects so 
grave and perilous, and seeing that one of its most positive and distinctive marks is 
an albuminous state of the urine, two questions of great interest at once present 
themselves. 

1. Does albuminous urine always imply the presence of Bright's disease ? 

2. Is Bright's disease, when present, always accompanied by albuminous urine ? 
To both these questions the answer is — no. 

It is certain that some articles of food have the effect, in some persons, of render- 
ing the urine for a time albuminous: perhaps it would be more correct to say that 
certain forms of indigestion cause this change. Albumen has also been detected in 
the urine under that general state of irritation produced occasionally by mercury, or 
by a blister to the skin. In the crisis of some febrile disorders, and in some cases 
of pregnancy, the same phenomenon has been observed. Whenever blood, pro- 
ceeding from any part of the long tract of mucous membrane which lines the urinary 
organs, mingles with the urine, that fluid of necessity contains albumen, and coagu- 
lates if tested by heat or by nitric acid. 

On the other hand, when the kidney is really affected in the way already described, 
the admixture of albumen with the urine is apt to disappear, for a while, even sud- 
denly. I have known it vanish for several hours, immediately after the effectual 
application of a hot-air bath ; and after profuse purging by a full dose of elaterium. 
Sometimes it is absent for a longer period. 

Another important question, therefore, now arises. Finding albumen in the urine, 
how are we to know whether it does-, or does not, indicate the presence of Bright's 
kidney ? 

We may judge, in part, by frequently testing the urine, and noticing whether the 
albuminous impregnation be transitory or persistent. In part also we judge by the 
absolute amount of the albumen in a given measure of urine. If the water be deeply 
charged with that unnatural ingredient, the presumption is strong that the kidney 
disease is in progress; and when that disease is confirmed, another remarkable 
change is found to have taken place in the urine. Its specific gravity is very low ; 
and strikingly in contrast with that of diabetic urine. This is therefore a very strong 
additional diagnostic circumstance. 

1. On Dr. Prout's authority we have assumed the specific gravity of healthy urine to 
range between 1015 and 1025. Other writers make it higher. But the urine voided 
in Bright's disease is sometimes as low as 1004 ; and its mean specific gravity does 
not exceed 1013. 

I need scarcely again remind you, that the question of specific gravity must always 
be viewed in relation to the absolute quantity of urine secreted. The specific gravity 
depends, of course, upon the proportion of the sohd constituents of the urine contained 
in a given quantity. If the aqueous portion be augmented, the effect upon the abso- 
lute density will be the same as if the solid contents were proportionally diminished. 
But when, as frequently happens in certain stages of this renal disease, the specific 
gravity decreases while the quantity of the urine decreases also, that conjunction of 
phenomena becomes especially significant. 

The density of the urine being thus unnaturally low, notwithstanding the addition 
of the new substance albumen, it follows, as a matter of inference, that the solid con- 
stituents proper to healthy urine must be sensibly diminished : and they are found, 
in fact, to be so. These solid ingredients consist mainly of urea, and of certain salts. 
The aggregate solid contents amount, in health, to sixty-seven or sixty-eight parts in 
every 1000. In Bright's disease the amount has been ascertained to be diminished 
to twelve or fourteen parts, and even, in an extreme case, to less than this — to about 
six parts. 

The urine contains, then, albumen : and it is deficient in urea. These two facts 
suggested, naturally enough, to M. Solon, and to others, the notion that the albumen 
might be formed, by a sort of conversion, at the expense of the urea ; since these 
substances, by a slight alteration in the ratio of their elements, pass respectively each 
into the other. But it is not so. Dr. Christison had observed many years ago, that 
when the urine was deprived of the greater part of its urea, the quantity of album.ea 
56 3y2 



882 



bright's kidney. 



contained in it was small ; and, on the other hand, in cases where the urea was con- 
siderable in quantity, the albumen was plentiful also. In a recent work on this 
subject, the same ph3^sician states that the whole of his subsequent experience has 
been in conformity with this observation. 

It being certain, therefore, that the albumen is not vicarious of the urea, what 
(you may ask) becomes of the urea ? It is detained in the blood ; and may readily 
- be recognized there in considerable quantity : and herein hes, as I conceive, the secret 
of the secondary affections which belong to this disorder, and of its great fatality. 
The body is poisoned in detail by the retention of its own excrements. The blood 
not being duly purified through that great emunctory, the kidneys, is spoiled for its 
purpose of nutrition. Besides containing urea, it undergoes other and more mani- 
fest changes. Its proportion of fibrin varies ; and it gradually becomes poor ia 
colouring matter ; the serum is less albuminous also, and of a lower specific gravity, 
than in health. The quantity of albumen in heahhy blood averages from sixty-five 
to sixty-nine parts in 1000. In this malady Dr. Babington has found it reduced to 
sixteen parts. The average specific gravity of healthy serum is 1030; but in 
Bright's disease it descends to 1024, 1020, and even to 1013. Now Dr. Christison 
has made out the very interesting fact, that there is a definite inverse ratio between 
the coagulabihty of the urine, and the density of the serum. The more albumen 
there is in the former of these fluids, the less is there in the latter, and the lower 
is its specific gravity. So that the deficiencies of the one fluid balance the super- 
fluities of the other. All this is very different from what takes place in diabetes, in 
which sugar is excreted with urine that is otherwise healthy : w^hereas, in Bright's 
disease, urea, which ought to be discharged, remains in the blood ; and albumen, 
which ought not to be separated, is taken from the blood and carried out with the 
urine. 

I have now described the changes presented by the kidne^^'s in this disorder, the 
symptoms which attend it, and the morbid conditions both of the urine and of the 
blood. But these all vary and fluctuate at different periods of the complaint, i 
must next, therefore, endeavour to state what has been ascertained of its course and 
progress. 

When the chronic disorder is not a legacy left by the more severe and acute form 
of disease which I have termed febrile dropsy, it is apt to creep on very insidiously, 
and to escape our notice : and its history is not yet fully known. It will be enough 
if I distinguish two stages of the malady — the early, and the advanced. 

In the early stage the urine is generally scanty. Instead of about 40 ounces in 
the twenty-four hours, the patient voids 16, 12, 8, or even so little as 2 or 3 ounces. 
Sometimes the secretion is nearly or quite suppressed : and then the head seldom 
fails to become affected in the way already described. The urine has also an un- 
natural appearance. It is red, or dark, obscurel}^ turbid, like muddy beer. It froths 
more than usual : and if you blow into it through a tube, 3^ou raise bubbles similar 
to those which may be formed in soapy water. Its specific gravity is somewhat, 
yet not greatly, reduced ; about 1021, perhaps ; it is seldom at this period so low as 
1016. It contains an abundance of albumen. 

At the same early period, blood drawn from the arm exhibits the huffy coat. The 
serum is much diminished in density, and contains a considerable quantity of urea. 
There is no decrease in the fibrin ; perhaps it is a little augmented : and there is no 
great change in the amount of colouring matter. 

In the more advanced stages of the disease, the quantity of urine is frequently not 
bejow the standard of health ; and it sometimes considerably exceeds that standard, 
so as to constitute one variety of chronic diuresis (anazoturia)-, which some call 
, diabetes insipidus. It is usually pale, slightly opaque, and of a very low specific 
gravity; 1014, 1010, 1007. Once, when the quantity of the urine was not in 
excess, Dr. Christison found the specific gravity to be no more than 1004. There 
is a corresponding reduction in the natural solid ingredients of the urine. Albumen, 
too, is present, but more uncertainly than in the earlier periods : fluctuations in this 
respect are more common than before. It is a mistake to suppose that the amount 
of albumen increases as the disorder advances. The contrary rule would be more 



SECONDARY AFFECTIONS. 



883 



near the truth. Tn general the albumen is plentiful and almost constant in the outset 
of. the malady; less surely present as it proceeds; and sometimes entirely absent 
in its latter periods ; and it is of importance to remark that the alteration in the 
specific gravity follows the opposite law. The declension of density, so far from 
being corrected, augments with the progress of the disorder. Hence the one of 
these morbid phenomena is a valuable check upon the other, considered as an index 
of what is going on in the kidney. 

And another fact, which it is essential for you to know and to remember, is, that, 
in any stage of the disease, the supervention of febrile disturbance, from local inflam- 
mation or whatever other cause, tends to renew, for the time, those qualities of the 
urine which belong to the early period. 

Meanwhile, the disease advancing, the serum of the blood recovers more or less 
its lost specific gravity, in proportion to the decrease of albumen in the urine. The 
quantity of fibrin seems, in some cases, to diminish. But the striking and most cha- 
racteristic change is the rapid disappearance of the colouring matter, the hematosin, 
as it is called. This may at length be so much reduced, as to form less than a third 
of the healthy average. If venesection be occasionally employed, this process of 
depravation is accelerated ; but it takes place whether blood be artificially withdrawn 
from the system or not. " I am acquainted," says Dr. Christison, " with no natural 
disease, at least of a chronic nature, which so closely approaches hemorrhage in its 
power of impoverishing the red particles of the blood. Hence the peculiar pallid 
or dingy hue of the patient's skin • the leucophlegmatic and even waxy aspect which 
invariably stamps the victims of this complaint. 

These characters, then, of the urine and of the blood, when rightly compared and 
interpreted, reveal not only the existence of the renal disease, but also, with much 
probability, the stage or degree that it has reached. 

Let us next review, a little more in detail, those secondary affections which I have 
already pointed out as being incidental to the subjects of this renal malady. They 
are of much consequence : for in the course of the disease, more or fewer of them 
are almost sure to occur ; most of them are productive of very serious distress ; and 
some of them place the patient's life in immediate jeopard}', and often bring it to a 
premature end. Moreover, it is by these secondary affections that our suspicion of 
the primary disease upon which they depend is, in general, first awakened : and it 
is to the prevention or the removal of these same secondary affections that our cura- 
tive endeavours must chiefly be directed. 

The most common, and practically the most important, of them all, is anasarca ; 
but of this, akhough I mention it first, I shall postpone, for a while, the further consi- 
deration. 

Another very common, and very important secondary compfication, is the occur- 
rence of what we compendiously call head-symptoms : various manifestations of 
derangement in the cerebral functions; headache, drowsiness, delirium, epileptic 
seizures, apoplexy. So frequently indeed is the death of the patient preceded by 
coma, with or without convulsions, that Dr. Christison considers this to be the " natu- 
ral termination " of the disease, or " the mode in which it proves fatal when life is 
not cut short by some other incidental or secondary affection." Of seventy fatal 
cases observed by Dr. Bright, death was ushered in by well-marked cerebral symp- 
toms in thirty. 

I have already told you the circumstances under which these affections of the brain 
usually arise. They almost always follow any great diminution, .or the entire sus- 
pension, of the secretion of urine. But this rule is not so strict as to admit of no 
exception. Occasionally, but I believe very seldom, the urine, in this disorder, is 
reduced to a very small amount, while the head remains undisturbed. Of this Dr. 
Christison has recorded a remarkable instance. One of his patients voided no more 
than two ounces of fight urine daily, for nine days before his death ; yet he continued 
sensible to the very last minute of his existence, and died simply of inanition. Some- 
times apoplectic symptoms occur, and carry the patient off, akhough there has been 
no extreme or material reduction in the quantity of urine. 

Now when death has thus taken place in the way of coma, and the case had beerv 



884 



bright's kidney. 



complicated with anasarca, and serous liquid is found accumulated in unnatural 
measure in the cerebral ventricles, and in the tissue of the pia mater, it seems rea- 
sonable to ascribe the coma to the presence and the pressure of that liquid. The 
dropsy has extended to the brain. And this view of the matter is strengthened by 
the connection which may sometimes be noticed between the accession of coma and 
the visible increase of the dropsy in other parts of the body. My own experience 
accords entirely with that of Dr. Christison as expressed in the following statement. 
" If the dropsical fluid be allowed greatly to accumulate, drowsiness, the first symp- 
tom of the affection of the head, very soon makes its appearance in the generahty of 
cases, and it will speedily pass to fatal coma if not controlled, but the removal of the 
dropsy will usually remove the drowsiness." 

To many cases, however, this explanation will not apply, there being no morbid 
collection of water within the skull, nor any other appreciable change there ; nor, 
perhaps, any dropsy elsewhere. In such cases we refer the uhimate symptoms, the 
stupor and the death, to the poisonous influence of the urea in the unpurified blood 
upon the organs of animal life. Yet this explanation also has its difficulties. Urea 
must often circulate with the blood wnthout affecting the brain. Dr. Christison 
states that he has repeatedly known the daily discharge of the solids of the urine to 
be reduced, for weeks together, to one-fourth of the natural amount, while, moreover, 
analysis of the blood showed that it was loaded with urea, without the appearance 
of any head-symptom. Dr. Bright also relates a case to the same purpose. A per- 
son labouring under this disease of the kidney lived for four or five years under his 
occasional observation. The blootl was analyzed in the earlier stage, and found to 
contain a large quantity of urea ; as much as the urine itself contained. Yet this 
patient had no Jits till towards the close of his life. 

I have sometimes fancied that the pale and watery condition to which the blood is 
at last reduced, may have something to do with the stupor and coma. I showed you, 
some time ago, when speaking of spurious hydrocephalus, that similar symptoms are 
apt to ensue, in conjunction with a similar defect of hematosin. It would seem that, 
under such circumstances, the functions of the brain are exercised irregularly, lan- 
guidl}^, and at length, not at all, in consequence of the faihng supply of its appro- 
priate stimulus through the arteries. 

Another striking circumstance observable in this disease, is a readiness of various 
organs of the body to inflame, and particularly of the serous membranes. According 
to M. Solon, who has lately published a thick volume on Mbuminurie, this disposi- 
tion has not been so manifest in France ; but of its frequent appearance in this 
country I can add my own testimony to that of Dr. Bright, of Dr. Christison, and of 
Dr. Gregory. Such intercurrent acute inflammation is not an uncommon cause of 
the patient's death. The pleura appears to be much more often affected in this 
manner than either the peritoneum or the pericardium. 

It follows from this tendency that when we come to inspect the dead body, we 
seldom find the kidney to be the only part in which structural changes are plainly 
visible. Most commonly evident traces of disease are met with in various organs. 

Disorder of the stomach and bowels is, certainly, a frequent companion of the 
renal malady : nausea, vomiting, flatulent distension, diarrhoea. 

It would appear, however, that these incidental and secondary complications pre 
vail with irregular frequency in different places. They are probably determined, in 
some measure, by local and peculiar agencies. Thus vomiting and diarrhoea have 
been more famihar to the Edinburgh observers than in London to' Dr. Bright, or in 
Paris to M. Solon: while the headaches and coma, so often witnessed by the British 
physicians, have been comparatively uncommon in France. 

Disease of the heart, if not a secondary consequence, is a very frequent accompa 
niment of Bright's kidney. It is probable that the cardiac disease, and the renal 
disease, have sometimes no connection in respect to cause and effect, but are both 
results of some common cause ; of habitual intemperance, for example. 

I am, however, of opinion that the renal malady has a direct tendency, by its effect 
upon the blood, to generate disease of the heart. It induces anaemia ; and anaemia, 
as I showed you on a former occasion, implies debility of the muscular texture of the 



NATURE OF THE DISEASE. 



885 



heart, and leads to dilatation of its cavities ; and the weak muscle, becoming irritable 
also, grows thicker as it labours more. In fact, this is the kind of cardiac disease 
which, more than any other, has been found coincident with the pecuhar change in 
the kidney. Among 100 cases, recorded in a tabular form by Dr. Bright, there are 
27 in which no affection of the heart could be detected. In 52 instances the heart 
presented the characters of hypertrophy, and of these no fewer than 34 were free 
from any trace of valvular disease. Among the 34 there were 11 cases of disease 
affecting the aorta : in the remaining 23 no cause for the existing hypertrophy and 
dilatation could be found in the heart itself, or in the great blood-vessels. The true 
cause may therefore be reasonably supposed to have been the renal disease, ope- 
rating upon the involuntary muscle through the quahty of the blood. 

Whether the renal disease be ever produced by the cardiac, is more questionable. 
In the acute renal affection, when it proves early fatal, the kidney is always found 
to be gorged with blood. And the customary intermixture of blood with the urine 
warrants the belief that the same condition was present in the patients who have 
recovered. From this state of engorgement springs, apparently, the subsequent 
series of changes. It is therefore a plausible conjecture that whatever tends to pro- 
duce congestion of the kidney, tends also to aggravate, and may even cause, the 
peculiar changes in question. I need not now tell you that disease of the heart does 
frequently occasion congestion of the venous system, and gorge the viscera with 
blood. Under this influence the Hver often enlarges. On the other hand, disease 
of the heart, even such as gives rise to venous congestion and to dropsy, often lasts 
long, and proves ultimately fatal, without the occurrence of albuminous urine, and 
without any appreciable change of structure in the kidney. 

Pain or tenderness of the loins, is sometimes, and sometimes only, an accompani- 
ment of the renal disease. This symptom is more often present in the early than in 
the later stages of the malady. It occurred in one-third of twenty-eight cases 
narrated by M. Solon. Dr. Gregory noticed it in the half of his patients. 

The causes of the disease of which I have been endeavouring to sketch the out- 
line, are often obscure. Its more obvious symptoms, in the chronic form of the 
malady, have been observed, in very many inst&,nces, to begin soon after the ex- 
posure of the body to wet and cold under unfavourable circumstances. But it is by 
no means certain — indeed the probabilities preponderat# on the other side — that, in 
these instances, the renal disorder had not previously existed in a latent state. 

It is certain, however, that the acute kidney affection, which may be considered 
identical with febrile dropsy, does often ar.se under similar circumstances of ex- 
posure, and is attended with a marked disturbance of the functions of the kidneys. ' 
And Bright's disease, in its chronic form, has been noticed as occurring in persons 
who had previously suffered, and had apparently recovered from, an attack of febrile 
dropsy. Are we not warranted in believing that the recovery was imperfect in such 
cases? that the kidney had sustained irretrievable injury? and that the disease, 
akhough from the treatment employed, or by lapse of time, it had become tranquil 
or latent, was ready again to give indications of its existence upon any repetition of 
its exciting cause ? 

Again, it is matter of common observation that intemperate habits have often pre- 
ceded the development of this disease. Yet we may conclude that intemperance in 
drinking is rather a predisposing than an essential cause, from the fact that the 
malady is not unknown among children, and other persons whose manner of life has 
been strictly sober. I had lately an example of this in a young girl, fifteen years 
old, who had never menstruated. And this leads me to remark that the renal disor- 
der has been known, in many instances, to follow a sudden check or suppression of 
the catamenia. It has sometimes seemed to owe its origin to blows received upon 
the loins. 

The complaint happens at all ages : less often, however, in extreme youth than 
afterwards. Sabbatier records that he saw, while in the service of M. Baudelocque, 
a young infant affected with anasarca and albuminous urine. The first case described 
by M. Solon is that of an infant, seventeen months old, in whom similar symp- 
toms appeared shortly after exposure to cold and wet. In 1838 a boy between* 



886 



bright's kidney. 



five and six years old, anasarcous and passing bloody and albuminous urine, was in 
the Middlesex Hospital, under the charge of my colleague, Dr. Wilson. M. Con- 
stant, in the Gazette Medicale for 1835, cites the case of a child of five years of age ; 
and M. Rayer gives two plates, representing the kidneys of two children, the one 
five and the other six years old, who both died of dropsy with albuminous urine, the 
sequel of scarlet fever. In each of these the changes described by Dr. Bright were 
well marked, and the bulk of the kidney was considerably increased. 

The malady is, however, much more common in adults : not, in all probabihty, 
because the kidney is more readily susceptible of it at one period of hfe than another, 
but because, as life advances, the circumstances which tend to produce or to foster it, 
become of more frequent operation ; intemperance, exposure to great vicissitudes of 
temperature, and (perhaps) disease of the heart. 

It occurs, I presume for the same reasons, oftener in men than in women. 

Dr. Christison suspects that Bright's kidney happens chiefly in persons of scrofu- 
lous habit ; and he found it, in several instances, coincident with phthisis pulmonalis. 
My own experience would not have led me to that opinion. I partake of M. Solon's 
doubts, whether the co-existence of pulmonary consumption and of this renal malady 
is more than casual. Dr. Bright tells us that " the instances in which phthisis, or 
any form of scrofulous or tubercular disease, has been connected with the renal affec- 
tion, have been decidedly rare." 

What, after all, is the true character and essence of the organic metamorphosis 
which constitutes this formidable disorder, Bright's kidney ? All that has been as- 
certained of its early stages, of its course, and of its causes, furnishes to my mind a 
strong presumption that the structural change, in all its varieties of aspect, may be 
ultimately traceable to an undue accumulation and stagnation of blood in the blood- 
vessels of the kidney. Those curious arterial bunches, the Malpighian bodies, ap- 
pear especially to be over-filled and obstructed. Rayer calls the complaint albumi- 
nous nephritis ; and perhaps the congestion (which unquestionably is present in 
what I consider the acute form of the malady) may sometimes pass into chronic in- 
flammation. We do not, however, find that it ever terminates in suppuration : yet 
suppuration is no uncommon event of true inflammation of that part, excited by vio- 
lent injuries, or by the lodgment of calcuK within it. It seems to me more probable 
that the mischief done to y^e kidney is owing to extreme congestion, and its usual 
consequences — the oozing forth of the blood in substance, or of some of its constitu- 
ents, into the interstitial textures, as well as into the excretory tubes of the kidney. 
The appearance of these ingredients of the blood, and even sometimes of blood itself, 
in the urine ; the increased size of the gland in the earher stages ; the various shades 
of colour which its surface and parts of its interior present, as the colouring matters 
of the effused fluids are more or less absorbed ; the impermeabihty of those altered 
parts by artificial injections ; the ultimate shrinking and hardness of the organ, as the 
disorder becomes chronic, and absorption proceeds; these are all consistent with this 
theory. It is plain that the morbid conditions of the urine depend, in part at least, 
up5n the mechanical transudation of certain portions of the blood, which pass through 
the kidney unchanged, as through an inert filter. Mixed with the urine we find 
serum, with its albumen, and its salts, vv'hich diminish the acidity of the mixture, or 
even render it neutral ; and in many cases we find more or less of the colouring mat- 
ter also of the blood. Those portions of the extravasated fluid which have no outlet 
of escape, solidify, and thus obliterate the natural texture of the part they have in- 
vaded. The obstruction of the emergent veins of the kidney by firm clots of blood 
is in harmony with the same supposition. 

When the kidney is thus spoiled, its natural function is imperfectly or but partially 
performed. The change which it should effect upon the blood by purifying it from 
urea, fails to be accomplished. The albuminous impregnation, and the other altered 
qualities of urine when voided, maybe explained either by supposing that the secret- 
ing pov/er of the whole gland is interfered with, but not absolutely suspended ; so 
that the urine is incompletely elaborated: or, by supposing that portions of the gland 
are spoiled, and portions remain sound and effective ; that true urine is formed by 
^the heakhier portions, and mixes with the constituents of the blood which pass, as 



ANASARCA. 



887 



such, througli the diseased portions. The latter of these hypotheses is most in ac- 
cordance with the fact, that in the advanced stage of the disorder (when we may- 
conceive the spoiled parts to have become mere solid unchanging masses) the albu- 
men is apt to disappear from the urine : and also with the fact, that complete recovery 
does, sometimes, appear to take place ; in which cases we may imagine that, although 
a small portion of the substance of the gland has undergone irremediable change, 
enough of it remains healthy to serve the wants and purposes of the economy. 

I have yet something to say respecting the dropsy, which is so common an ac- 
companiment of these renal changes ; but I must defer it till to-morrow. 



LECTURE LXXIX. 

Anasarca; its consideration resumed. Distinction of chronic Genercd Dropsy 
into cardiac and renal. Characters and signs of each of these varieties. Treat- 
ment, 

We were yesterday occupied with the circumstances of that remarkable disease, 
which has never received a good distinctive name, but which is sometimes called 
Brighfs disease, after the distinguished living physician who first recognized and 
described it, sometimes yellow degeneration of the kidney, sometimes granular dege- 
neration. I endeavoured to represent to you by words and by drawings, the morbid 
appearances that are most commonly noticed in the several stages of the complaint : 
which morbid appearances may, one and all of them, be traced (as I think) to con- 
gestion of the kidney ; to the detention of blood in that organ, and to the physical 
consequences of such detention. T spoke of the symptoms which appear essential 
to the malady, and which consist in certain striking changes in the urine and in the 
blood of the patient. I mentioned also the symptoms which are incidental to the 
renal disease. Bat of one of those incidental symptoms, or secondary consequences, 
.1 postponed the full consideration till to-day ; I mean the anasarca, with which, most 
commonly, yet by no means always or necessarily, it is compKcated. 

This is, for several reasons, a very important symptom. It is usually the first 
thing that prompts us to suspect, and to inquire after, the renal malady. It was 
through his researches into the relation subsisting between chronic dropsy and the 
.conditions of the urine, that Dr. Bright was led to the discovery of the associated 
affection of the kidney. The dropsical accumulation adds greatly to the patient's 
distress, and sometimes constitutes nearly the whole of it. It adds proportionally to 
his danger. Moreover, it is that consequence of the renal disorder over which our 
curative measures have the most control. Indeed, under this complication we have, 
practically, to consider the remedies of the dropsy, distinct from the remedies of the 
renal change. 

In most cases, at the outset at least of the dropsy, the skin is dry, and the urine 
is scanty : and the anasarca is observed to increase, or to decrease, as the quantity of 
,urine diminishes or augments. The aqueous fluid, which should escape from the 
surface and through the kidneys, collects in the subcutaneous areolar tissue. As the 
disorder advances, the tendency to effusion of serum through the sides of the blood- 
vessels is probably increased, not only by the sluggish movement of the blood in the 
veins, from progressive debility of the heart, but also by the cause of that debility, 
the thin and watery condition of the blood itself; a condition which I yesterday 
pointed out to you as one of the most uniform and striking effects of the primary 
disease. 

And here I again take up the subject of anasarca and general dropsy. You will 
remember that, in the earlier part of the course, I entered somewhat fully into the 
general pathology of dropsies. At the same time I promised you that I would after- 
wards, and when you were better prepared to understand them, endeavour more fully 



888 



ANASARCA. 



to explain some grand distinctions which have been found to exist between different 
forms of general dropsy. Having now, at last, brought before you all the organic 
changes which are apt to give rise to anasarca, I am in a condition to redeem that 
promise. In doing so, I shall probably have to remind you of some things which 
you have already heard from me. 

Anasarca^ you will please to recollect, signifies the filling up of a considerable 
part, or of the whole, of the subcutaneous areolar tissue, with serous or watery fluid ; 
and when to this is added a collection of liquid in the large serous cavities also, we 
call the complaint general dropsy. 

It is obvious that this condition may exist, and in nature it does exist, in various 
degrees : from slight infiltration of the areolar tissue, scarcely noticeable until, after 
some hours passed in the upright posture, it accumulates in visible cedema about the 
ankles — to the other extreme, in which the integuments are everywhere stretched to 
the utmost, even to bursting; the insteps bulging upwards; the legs and thighs 
enormously enlarged, cyhndrical, unshapely, 'and exhibiting partial vesications; the 
surface of the trunk of the body capable of being kneaded and moulded like dough ; 
the skin of the penis distended, and, in consequence of its confinement by the frse- 
num, twisted and circumvolved so as materially to impede the outward passage of 
the urine ; the scrotum, as big as a child's head, preventing the miserable patient 
from approximating his thighs, and from lying upon either side ; the hands swollen ; 
the face and neck bloated. With all this, the peritoneum is generally full of hquid, 
and at length the pleurse ; and as the scene is about to close, there is water in the 
ventricles of the brain, and an anasarcous pia mater. 

Now, from whatever cause this watery condition of the whole body may arise, the 
effects resulting from the presence of the water are the same. And of what do 
patients in this state usually complain ? Why, of shortness of breath, and palpitation 
of the heart ; of a sense of impending suffocation if they intend to he down, or 
actively to bestir themselves ; of tightness and distress across the epigastrium, re- 
lieved somewhat by eructation, augmented by food and drink ; of weight and stiff- 
ness of their hmbs ; and, sometimes, of drowsiness. 

The explanation of all this is easy and obvious. The shortness of breath may be 
accounted for on various grounds : by oedema of the lungs themselves, a state that is 
revealed to us through auscultation ; by water in the pleura ; by the pressure up- 
wards of the diaphragm, which embarrasses still more the labouring heart and lungs ; 
and ihiii upward pressure is increased by any kind of distension or repletion of the 
stomach — diminished when the stomach is collapsed, and the upright position is 
maintained. The heaviness and want of pliability of the unwieldy limbs are, like 
the rest of these phenomena, purely mechanical. All parts are oppressed by the 
unnatural load of water. 

But we must look beyond the dropsy, and inquire w^hether the complaint has set 
in suddenly, and simultaneously with febrile disturbance, invading all the districts 
of the body at once, and quickly reaching its present degree ; or whether it has crept 
upon the patient slowly and by stealthy steps : whether it has had any obvious or 
probable exciting cause ; or whether it has approached insidiously, we know not 
whence or why : whether (in a word) the case be one of active and febrile dropsy, 
or of chronic and passive. 

Now, setting aside, for the present, any more particular consideration of the acute 
or febrile form of general dropsy, and contemplating those forms only which are 
chronic, we find that all, or nearly all of them, may be arranged in two great classes ; 
those which depend upon disease or debility of the heart forming one class, those 
which depend upon disease of the kidney constituting the other. To these classes 
we accordingly apply the terms cardiac dropsy and renal dropsy. They are often 
combined in the same individual ; but, taking the pure cases of each form, we may 
proceed to inquire into their peculiar features, how they may be distinguished, and 
what differences of treatment they may require. 

And first of cardiac dropsy. 

The mode in which disease of the heart may occasion general dropsy has been 
sufficiently explained already. We infer that the dropsy, in a given case, hus this 



CARDIAC DROPSY. 



889 



origin, if we find that thoracic symptoms, such as cough and dyspncea, preceded the 
dropsy : or if we perceive direct signs" of cardiac disease, such as distended jugular 
veins, irregular movements of the heart, unnatural impulse, altered sounds; or, if 
we trace the history of some previous acute disease, affecting especially the left side 
of the thorax : or if we learn that the patient has formerly suffered acute rheuma- 
tism : or if the patient's age is so much advanced as to make it probable that some 
of those organic changes in the heart and large blood-vessels are in progress, which 
are almost natural in the decline of Hfe. And our inference is confirmed if there be 
no discoverable indication of renal disease. 

But we see many persons who labour unequivocally under organic disease of the 
heart, yet who survive, even for many years, without becoming dropsical. The 
interesting question therefore arises, of what kind of heart-disease is dropsy a conse- 
quence and symptom ? You already know the answer. It is such disease as offers 
a certain amount of permanent obstruction to the passage of the venous blood. 
Hence, dropsy is especially associated with dilatation of the right chambers of the 
heart. It would not be correct to say that the anasarca is dependent on such dilata- 
tion, for the dilatation itself is at once an effect and a sign of impeded transmission 
of blood from the right side of the organ. Nor is such dilatation a necessary attend- 
ant on the general accumulation of water. The impediment may be sufficient to 
gorge the right cavities, while it is yet too slight in amount, or too recent in dura- 
tion, to have dilated them. 

What, then, are the physical conditions which oppose to the blood in the veins 
such an impecj^ment as we are now considering ? The two great vital organs con- 
tained within the thorax, the heart, namely, and the lungs, form different parts of 
one common mechanism, the object of which is to supply every tissue of the body 
with blood that has recently been purified by exposure to the air ; and these organs, 
thus closely related in their functions, are moreover so reciprocally dependent, that 
structural disease occurring in the one, tends to produce disease, sooner or later, in 
the other also. 

And I wish you again to observe the order and direction in which disease is, 
almost always, propagated from one part of this apparatus to another. It is a back- 
ward direction — opposite, I mean, to the course of the blood. There are, strictly 
speaking, two hearts, which he side by side in respect to their anatomical position, 
but which, reference being made to their vascular inter-communication, are really 
separated from each other by the lungs. The great veins precede, and the great 
arteries follow, this chain of connected organs. Disease occurring in any one part 
of the chain becomes a cause of consecutive disease in the part immediately behind 
it. And this law obtains, as I have shown you before, in regard to the several 
chambers of the heart, considered as a single organ. 

Thus, structural disease situated at the aortic outlet of the heart, and of such a 
kind as to hinder the exit of the blood from the left ventricle, gives rise to permanent 
changes in that ventricle ; to hypertrophy with, or less commonly without, dilatation. 
The hypertrophy is strictly a compensating and conservative change ; and when it 
is exactly proportioned to, and keeps pace with, the impediment which has given it 
birth, so as precisely to balance and countervail it, no delay takes place in the 
stream of arterial blood, and the injury is, as yet, confined to the left ventricle. That 
chamber is remodeled, and adapted to its purpose by the vis medicatrix naturx ; 
and no other evil manifests itself than, perhaps, some shght encroachment and 
pressure upon the neighbouring parts, in consequence of the augmented volume of 
the heart. 

So long as the mitral valve remains healthy and effective, it offers a barrier of pro- 
tection against the extension of the disease in the direction which is retrograde to the 
course of the blood. But at length, in most instances, the stress becomes sensible 
further back. The left auricle and the pulmonary veins become choked and dis- 
tended ; the blood is detained in the lungs. Then commences dyspnoea : at first 
occasional only, whenever the heart is tasked with the conveyance of a greater quan- 
tity of blood in a given time than usual, as in brisk movements of the body, or sud- 
den emotions of the mind ; or when it is oppressed by circumstances that diminish 

3z 



890 



ANASARCA. 



the capacity of the chest ; by a full meal, therefore, by flatulent distension of the 
stomach and intestines, by the recumbent posture. Afterwards the shortness of 
breath becomes more or less constant and distressing. 

Now this loaded and embarrassed state of the lungs, even when it is permanent 
and has reached a considerable degree, may exist without materially interfering with 
the functions of the right or venous heart: for the pulmonary plethora may be 
relieved by increased secretion from the bronchial mucous membrane. Dyspncea, 
even when it has become habitual, may precede for some time any appearance of 
dropsy. 

■ At last, however, the effects of the original evil augmenting and extending, the 
right ventricle also becomes unable duly to propel its contents into the pulmonary 
vessels; it continues morbidly full, is first distended occasionally, then permanently, 
and at length really dilated ; and with that dilatation we have a turgid venous sys- 
tem, of which we see a part in the prominent veins of the neck. 

In this way then may be explained a series of symptoms which you will often 
witness, and be consulted about, in persons who are growing old. You will find 
irregularity of the pulse ; preternatural impulse perhaps of the heart ; occasional 
shortness of breath ; large crepitation, habitually audible in the lower portions of the 
lungs ; more or less expectoration, sometimes tinged, sometimes even loaded, with 
blood. Eventually the ankles begin to swell ; and the patient (if his life is not cut 
short earlier in some other way) becomes by degrees decidedly and universally 
dropsical. 

Many of the direct signs of diseased heart may exist, therefore, w^ile there is no 
anasarca : intermissions and irregularity in its movements, palpitation, the impulse 
proper to hypertrophy. But when dropsy has supervened, we may expect also the 
signs which denote dilatation of the right chambers. The heart is heard and felt to 
beat beyond the prsecordial limits ; the pulsations become feeble and unequal, if they 
were not so before ; the patient is liable to fluttering palpitations, to extreme and 
panting dyspnoea on the slightest exertion, even on taking food into the stomach, or 
adopting the recumbent posture ; his skin assumes a dusky hue, and his lips and 
extremities are apt to be hvid. 

In these cases the anasarca first becomes manifest about the ankles. During the 
earlier stages the oedema disappears in the night, and returns towards the next even- 
ing. It is sometimes confined, for a long while, to the legs ; but ultimately it creeps 
up towards the trunk of the body ; the loins and flanks become doughy, the scrotum 
fills, and water collects in the serous bags of the abdomen and thorax. In extreme 
cases the dropsy is universal, pervading the areolar tissue of the head and face and 
upper limbs. 

As the accumulation of serous liquid is commonly gradual, the reticular tissue, 
partly perhaps through maceration, but chiefly from continued pressure and stretch- 
ing, loses its elasticity ; and the oedema is soft, and pits readily. 

Sometimes, the fluid continuing to increase, the cuticle is raised by it, and large 
vesications take place on the limbs ; or some part of the areolar tissue sloughs, and 
a breach of surface is made, and the fluid drains off by this vent in great abundance, 
to the signal reHef of the patient. This beneficial accident furnishes us with a 
valuable practical hint. 

Such, then, is the consummation of disease commencing in the left heart, and 
working its gradual way, through the lungs to the right heart. But the obstacle may 
originate at a less distant link in the chain. The circulation may be checked, first of 
all, in the intermediate lungs : and it may be worth our while to consider, for a moment, 
the relations which subsist between general dropsy and certain pulmonary diseases. 

Whenever, in pneumonia, a large portion of one or of both lungs becomes imper- 
vious to air and to blood — or when pleurisy fills one side of the thorax with liquid, 
which, by its pressure, shuts out both air and blood at once from one-half of the respi- 
ratory apparatus — the egress of the blood from the right heart, and, therefore, from 
the venous system, must be checked. We might expect that dropsical effusion would 
be the result of these changes ; and in truth it does sometimes occur. That it does 
not happen more frequently is to be attributed, I believe, to the free evacuations, and 



RENAL DROPSY. 



the strict abstinence, which are early put in force in those complaints, and which 
relieve the venous plethora before it produces effusion. 

So, again, lungs that are hollowed out in large cavities or rendered sohd over a 
wide space by numerous tubercles, are manifestly incapable of admitting into their 
vessels from the right ventricle the ordinary quantity of venous blood. In these 
cases, however, the whole mass of blood is diminished, and kept within the hmit 
which does not imply distension of the veins, by the constant agency of various 
causes ; by the imperfect nutrition consequent upon abdominal disease ; by the some- 
times copious expectoration ; by the wasting diarrhcea ; by the profuse nocturnal 
sweats. Accordingly anasarca is an unusual symptom in pulmonary phthisis, or 
shows itself in the latter periods only of the disease, in the form of oedema of the 
legs : and its occurrence then is mainly owing to the debihty which affects, in com- 
mon with the other muscular parts of the body, the moving organ of the blood. 

The pulmonary disease which more commonly and certainly than any other, 
though often very slowly, leads to dropsy, is emphysema of the lungs. I showed 
you, some time ago, that in this morbid condition many of the smaller blood-vessels 
of the lung become gradually obliterated ; and when the disease is extensive and 
advanced, large portions of the organ are visibly white and bloodless. Meanwhile, 
the nutrition of the body is not impaired ; the same quantity of blood continues to be 
returned towards the heart, but it finds not a ready entrance into the pulmonary 
blood-vessels, when delivered from the right ventricle. A certain amount of accu- 
mulation becomes habitual in that chamber, and in the great veins ; and at length 
the capillary vessels feel the mechanical congestion, and more or less anasarca ensues. 

So much for dropsy that is purely cardiac. Let us next consider the circumstances 
• from which, during the hfetime of the patient, we draw the conclusion that the 
dropsy he exhibits is of renal origin. 

There is nothing, that I know of, very peculiar or distinctive in the characters of 
the anasarca itself. When the renal complaint sets in suddenly, and with acute 
symptoms, dropsy usually supervenes soon. So also, during its more chronic pro- 
gress, anasarca is apt to show itself, or to increase, whenever local inflammation, or 
febrile disturbance, happens to arise. The more rapid and copious the effusion, the 
less do the dropsical parts pit upon being pressed. It may be said also of this renal 
form of dropsy, that accumulation in the larger serous cavities is not, in general, a 
prominent feature. 

If we find, upon due scrutiny, no material or adequate embarrassment of the 
respiratory functions, no deviations from the natural sounds of the heart, no derange- 
ment of its regular movements, no alteration in the force of its pulsations, or in the 
space over which they can be felt and heard, no distension of the large veins of the 
neck — then we have reason for suspecting that the anasarca is connected with some 
vice of the kidney. 

But we cannot infer from the presence of heart-symptoms, that the kidney is free 
from disease. 

Our judo-ment is guided, or assisted, in some degree, by the complexion of the 
patient. When general dropsy depends upon disease of the heart, the cheeks and 
lips are occasionally florid, often purplish or Kvid, frequently dusky and loaded. 
Sometimes (as in chlorotic women, where the heart may be temporarily distended 
without any positive organic disease, and the blood is thin and poor) the face and 
mucous membranes are pale : but in the renal variety of dropsy there is a very cha- 
racteristic hue ; an evident lack of red blood, indeed, in the capillaries, but withal an 
unhealthy dingy sallowness, significant, to a practised eye, of some deep-seated al- 
teration of structure. 

Our suspicion that the kidney is the organ primarily in fault is strengthened, if 
we trace certain accidents in the history of our patient. An attack, for example, of 
illness, attended perhaps, with temporary swelling of the body and disturbance of 
the urinary functions (acute dropsy, in short), soon after some exposure, under un - 
favourable circumstances, to the influence of cold ; either apphed to the external 
surface, or to the stomach by a draught of cold drink. For, as I told you yesterday, 
there is reason to believe that in acute dropsy is often laid the foundation of those 



892 



ANASARCA. 



peculiar changes in the kidney which, since they were first pointed out by Dr. Bright, 
have been chiefly studied in their connection with chronic dropsy. That as rheu- 
matic carditis may occur, and become latent as to its effects for some time, and yet 
implant the germs of future cardiac dropsy, so the stress or strain which befalls the 
kidney in cases of febrile anasarca, may set on foot a morbid process that long works 
silently and unobserved, but at last declares its operation by symptoms ; the repro- 
duction of the dropsy in a more chronic form being the most significant symptom of 
all. The acute attack may have been forgotten ; there may have been no obvious 
(though there may have been ill-understood) indications of the renal affection ; and 
its existence has been, therefore, unsuspect-ed. 

The discovery of intemperate habits would also be of importance in aid of our di- 
agnosis, if these same habits had not a like influence in causing disease of other organs 
as well as of the kidney, and especially of the heart. There may, however, be no 
such episodes as these in the patient's history. The dropsy may have come on im- 
mediately after some exposure, or obviously injurious influence, yet not with acute 
symptoms, and in a temperate subject : in which case it is probable that the renal 
disease had pre-existed in a latent state. Or the anasarca may have stolen on by 
degrees, without any apparent cause. 

But the most conclusive evidence of the renal disease is to be found in the condi- 
tions of the urine : which were fully explained to you in yesterday's lecture. I shall 
therefore only add four rules upon the subject, which have been laid down by Dr. 
Christison, and generally acquiesced in by Dr. Prout. These rules assert that or- 
ganic disease, or granular degeneration, or granular disorganization of the kidnej^— 
all which phrases we may condense into the compendious expression " Bright's kid- 
ney" — is present : 

1. In most cases of febrile dropsy, including those which are consequent upon 
scarlet fever. To this proposition I have already given my full assent. 

2. In all cases of anasarca, wherein the osdematous parts are elastic, and do not 
pit upon pressure. I am not so sure of this rule. I believe that the firmness of the 
cedematous parts has relation rather to the rapidity v/ith which the effusion has taken 
place, than to the local origin of the dropsy. In proportion as the accumulation in 
the areolar tissue has been chronic and gradual, does the sweUing receive and retain 
indentation from external pressure. 

3. In most, or all cases of dropsy attended with diuresis, provided the urine be 
not saccharine. Such cases. Dr. Christison truly remarks, are far from being un- 
common. Of course the diuresis here spoken of is such as occurs independently of 
diuretic remedies. 

4. In all dropsies associated with urine of a very low specific gravity (say below 
1010), and not exceeding the natural standard of quantity, whether it be albuminous 
or not. To the last two rules there are probably very few exceptions. 

The dropsy which is dependent upon " Bright's disease" yields, not unfrequently, 
to treatment ; but it is prone to recur. Of the renal disease itself the prognosis is, 
no doubt, very unpromising. Yet I do not think so despairingly of these cases as I 
once thought ; and as many think. I have known a few instances of what seemed 
complete recovery after well-marked symptoms of the disorder. Certainly success 
enough has followed careful treatment to encourage us to use all diligence in prose- 
cuting such remedial measures as are already known, and in devising new ones. 

I have been speaking of dropsies that are purely cardiac, and of dropsies that are 
purely renal. But I have already told you that disease of the heart and disease of 
the kidnejr, frequently go together; and I have endeavoured to esiimate their relation, 
in such cases, to each other. When both organs are structurally affected, the dis- 
position to dropsical accumulation must evidently be augmented. What share they 
have, respectively, in producing the dropsy, it would be very difficuk, and practically 
it is not very important, to determine. 

In chronic general dropsy of a purely cardiac origin, the kidneys, being sound, 
offer the most convenient and eligible channel for carrying off the superfluous water. 
Diuretic medicines, therefore, rank among the most important of our curative expe- 
dients. When they fail to act, or prove insufficient for the purpose sought, we next 



RENAL DROPSY. 



893 



have recourse, the state of the bowels permitting, to drastic or hydragogue purga- 
tives. 

Diuretics are notoriously of most uncertain operations; sometimes completely 
answering our wishes, oftener perhaps disappointing them altogether. When the 
urine is strongly acid, and deposits, on coohng, a sediment like brick-dust, it may be 
well to try, at first, the alkaline diuretics, and particularly the salts of potass. Nitre 
added to the common saline draught ; or a combination of the acetate and bicarbon- 
ate of potass; or the bitartrate in small doses ; or the iodide of potassium: or the 
liquor potassEe. In my own experience the tincture of squills also has seemed to 
correct this superacid and turbid condition of the urine, while it increased its quantity. 

The benzoate of ammonia is another salt which I have found to operate very 
powerfully, in several instances, as a diuretic. 

Digitalis sometimes promotes, in a remarkable degree, the flow of urine ; and this, 
in my judgment, is its most useful and manageable property. Small quantities of 
the tincture, or of the infusion, may be added to other formulae. Or the powdered 
leaves may be combined in pills. But one of the best modes of exhibiting digitalis 
for this purpose is to give larger doses of the infusion, half an ounce, for example, in 
some cordial water, at intervals of four or six hours, till three doses have been taken 
in succession ; and then to pause and note its effects ; and to repeat the three doses, 
or not, accordingly. 

The spirit of nitrous aether, and the compound spirit of juniper, have both of them 
well-marked diuretic properties, and may, with propriety, be added to most of the 
liquid formulae for augmenting the discharge of urine. And, as vehicles for more 
active, or more concentrated ingredients, those vegetable infusions or decoctions should 
be chosen which are reputed to possess similar virtues ; such as the decoction of 
broom-tops, or of juniper-berries, or of winter green, or the infusion of buchu. 

Squills, turpentine, the tincture of cantharides, are drugs of a more stimulant nature, 
more pecuHarly adapted to cases in which there is no febrile disturbance, and the 
kidneys are obstinately inactive. 

Sometimes a combination or farrago of diuretic substances proves more efficacious 
than larger doses of any of the ingredients administered singly : and the operation 
of some of these combinations is undoubtedly quickened and exalted, in many in- 
stances, by the addition of mercury. A fluid drachm of the officinal solution of the 
bichloride in each dose of a mixture; or small quantities of calomel or of blue pill 
when the medicines are given in a solid form. A very useful pill of this kind, much 
recommended by the late Dr. Baillie, consists of three or four grains of the pilula 
hydrargyri, mixed up with one grain of the dried powder of squills, and half a grain 
of the dried leaves of digitalis ; to be given twice or thrice a day. Dr. Baillie states 
that squills and digitalis are much less effectual by themselves, than when combined 
with mercury. 

Tn choosing purgative drugs to aid the effect of diuretics in carrying off the drop- 
sical fluid, or to take their place when these fail to act, we select those which produce 
copious and watery discharges from the bowels. A combination of jalap and cream 
of tartar has been long and deservedly esteemed for its excellent operation in this 
way. Gamboge is also a good cathartic. It may be given two or three times daily, 
in grain or two-grain doses, with a drachm of cream of tartar, suspended in two 
ounces of peppermint water. Or half an ounce of cream of tartar, mixed in six 
ounces of peppermint water, may be administered in one dose every morning. 
Cfoton oil, and elaterium, are still more powerful evacuants of serous liquid from 
the intestines. One or two drops of the former, or frofh a quarter of a grain to a 
grain of the latter, will be about a proper dose. It is astonishing how much relief 
to the feehngs of the patient, and how great" a diminution of the dropsical symptoms, 
are sometimes obtained by these active cathartics. Patients will earnestly beg for a 
repetition of them, even when their operation is attended, for the time, with consi- 
derable pain or sickness, and -much general distress. 

In addition to these measures for the removal of the collected water, attention must 
be paid to the actual condition of the heart. If the dropsy has been the result of 
anaemia, or of cachexy of the system, you must endeavour to strengthen your patient, 

3z3 



894 



ANASARCA. 



and to repair his impoverished blood, by nutritious food and tonic medicine, and 
especially by the administration of steel. 1 told you formerly that preparations of 
iron have an exceedingly good effect, oftentimes, even in cases of organic disease 
of the heart, consisting in dilatation and tenuity, and consequently weakness of its 
muscular parietes. 

On the other hand, if there be violent palpitations of the heart, with a strong 
heaving impulse, you may appease the excessive action, and afford sensible comfort 
to the patient, by applying leeches, from time to time, to the prascordia. 

Of the renal variety of chronic general dropsy, whether pure or mixed, the treat- 
ment is less accurately ascertained. The uncertainty which has perplexed men's 
minds respecting the nature of the renal disorder, has extended, in some measure, to 
their choice of remedies for it. 

Whenever (in renal dropsy) acute symptoms and febrile disturbance occur, much 
relief may be expected from the abstraction of blood. When drawn from a vein, it 
usually shows the huffy coat. The existence at the same time of pain in the loins, 
would indicate the propriety of applying cupping glasses to that part. Nevertheless, 
the impoverishing effect of the disease itself upon the blood, and the probable de- 
pendence of some of the more distressful and alarming symptoms upon the thin 
serous condition of the circulating fluid, as wtII as the increased facility with which 
the dilute blood may transude outwards — these are circumstances which should in- 
duce every cautious practitioner to have recourse to this heroic remedy only when 
it is clearly demanded. 

One definite object, in the renal as well as in the cardiac variety, is to remove the 
dropsical fluid, from whish the danger and the suffering often chiefly proceed. But 
it is a more nice question, when the kidney is involved in the disease, how this is to 
be accomplished. Can we, with the same safety as in cardiac cases, employ diuretics ? 
It has been thought that we cannot. As the primary morbid state of the kidney is 
certainly often, and probably always, a state of congestion, it has been feared that 
direct diuretics, such as are calculated to cause, keep up, or augment congestion of 
the kidney, or to stimulate and irritate that organ, would be hkely to accelerate the 
disorganizing process of which it is already the seat. 

Now, although these views are theoretical, and their justness has not yet been 
established by positive proof, you had better, when you can, observe the caution 
which they suggest. You had better endeavour to empty the distended cavities, 
and to relieve the loaded areolar tissue, through the bowels, or through the skin. 
Sometimes, however, — more often indeed than in cardiac dropsy — we have the 
untoward comphcation of irritable bowels, or habitual diarrho3a ; and then drastic 
cathartics are inadmissible. But when this complication is not present, they are 
eminently useful. 

Much benefit is sometimes derived from measures that act powerfully or steadily 
upon the cutaneous transpiration ; and especially from warm, or hot-air, baths. The 
hot-air bath is, in many respects, preferable to the common warm-water bath, and 
even to the vapour bath. Upon the principle of heterogeneous attraction, the escape 
of the liquid from the surface of the body is more promoted by a dry heat than by 
water artificially raised to a high temperature, and even than by an atmosphere made 
moist, as well as hot, by vapour. The risk, moreover, of exposure to cold, and the 
inconvenience and hazard of fatigues, are much less : for the hot air can be brought, 
with but little trouble or expense, to the patient as he lies in bed. I have often 
applied the sitdatorimn to p*&tients labouring under renal dropsy, and they have ob- 
tained much rehef from it : but the rehef is seldom of itself sufficient, or of more 
than temporary duration. Still it is an expedient that should never be neglected ; 
and in pursuance of the same indication, diaphoretic medicines should at the same 
time be diligently exhibited. Dr. Osborne states that when the renal disease has 
been uncomplicated with other organic mischief, he h»s always found the dropsy to 
disappear upon the re-establishment of the functions of the skin. 

These measures failing — as fail they often will ; and diarrhoea forbidding the use 
of drastic purgatives ; or drastic purgatives and diaphoretics together proving insuf- 



TREATMENT. 



895 



ficient ; we must, even in renal dropsy, choose the least of two evils ; or rather we 
must incur the risk of one possible and contingent evil, for the chance of obtaining- 
what, if obtained, is a certain and positive benefit ; we must endeavour to remove 
the dropsical accumulation by means of diuretics, whether these accelerate the pro- 
gress of the disease in the kidney or not. 

Such diuretics, therefore, are, in the first instance, to be selected, as seem the least 
likely to stimulate the kidneys injuriously. The bitartrate of potass has been found 
one of the most certain and useful. Digitalis also is esteemed safer, and therefore 
more proper for this purpose, than many others : and the simultaneous exhibition 
of these two has, perhaps, the surest effect of all. 

When diuretic medicines act as we intend them to do, and increase the quantity 
of urine, they are commonly of great service by reducing the dropsical swelling. 
But they are apt to be very capricious and disappointing. In some unhappy cases 
of renal dropsy I have tried every known form and combination of diuretics without 
augmenting the secretion from the kidneys. And sometimes, although a plentiful 
discharge of urine takes place, no impression is made upon the anasarca. 

It is yet an unsettled question whether mercury be advisable, or even admissible, 
in these cases. The current of medical opinion sets against it ; perhaps too strongly. 
It has been observed that safivation is apt to be produced by a small quantity of this 
drug; and to be unusually troublesome and severe, without bringing any commen- 
surate advantage. I mentioned to you formerly Dr. Farre's opinion, that mercury 
has the property of rapidly destroying red blood: if so, it must be regarded rather 
as an ally, than as an antagonist, of this malady. On the other hand, some patients 
have appeared to recover altogether, after passing through a furious salivation. One 
of the reputed virtues of the mineral is that it promotes interstitial absorption — a pro- 
perty which the changes apparent in the kidney in renal dropsy would seem to render 
valuable. 

When internal remedies prove ineffectual, and outward applications to procure 
sweating miss their aim, we turn to those mechanical expedients which (in either 
variety of general dropsy) often afford ease, and prolong fife, and may even some- 
times, perhaps, achieve a cure. 

I have told you that the tense and stretched integuments occasionally give way ; 
the areolar tissue sloughs, and from the breach thus made water wells copiously 
forth, and great relief ensues. Sometimes, though very rarely, the whole of the 
accumulated liquid has so escaped, and the dropsy has not reappeared. The sore 
has healed, and the natural cure has been complete. 

This spontaneous mode of draining away the liquid has been imitated by art. For 
the unwieldy legs become painful as well as cumbrous; the integuments threaten 
to inflantie, or to mortify ; and if we can diminish the tension by removing a portion 
of the included fluid, we avert or lessen this danger. The penis and scrotum also 
in the male, and the labia pudendi in the female, become, in many cases, enormously 
swollen, and hinder the exit of the urine, which is therefore spilled upon the tumid 
parts, rendering them erythematous and raw, to the grievous aggravation of the 
patient's sufferings. 

Now, seeing that vesications sometimes form upon the dropsical limbs, and give 
vent, in some degree, to the fluid, practitioners have been induced to follow that indi- 
cation by exciting artificial blisters. But they are highly dangerous ; leading often 
to gangrene of the surface thus inflamed. Within my recollection it was the custom 
to make incisions, with a lancet, in the oedematous legs. These gashes seldom 
healed again ; but degenerated into sloughing sores ; and not unfrequently they 
hastened the dissolution of the patient. 

A vast improvement upon these expedients is the modern practice of acupunc- 
ture, which consists in perforating the integuments here and there with a fine 
needle. 

It is surprising how much fluid may be let out in this way ; and how much relief 
may be bestowed by this trifling operation. The liquid trickles rapidly forth ; and 
I have known it soak through the patient's bed, and form a pool on the floor of the 
room. In one instance, a physician being the patient, the fimpid fluid which thus 



896 



ANASARCA. 



oozed from a puncture in the thigh was caught, and collected in a glass, by means 
of a little gutter of oiled silk. It was found that ninety minims, or a fluid drachm 
and a half, escaped in a minute ; which is at the rate of eleven ounces and a quarter 
in an hour : and this drain went on for upwards of four hours. 

The surface on which punctures of this kind have been made, sometimes becomes 
' red ; erysipelas supervenes, which it is difficult to arrest, and the patient sinks. In 
some of these cases the same event would probably have occurred, even akhough 
no punctures had been made, from mere tension of the integuments, and the pro- 
gress of the disease. When such appearances present themselves, the affected hmb 
should be kept in the horizontal position ; and strips of linen, wetted with a solution 
of goulard, should be applied to the inflamed surface. 

Under the old system of incisions it was found (and reason would teach us to 
expect this) that there was more hazard of sloughing when they were made on the 
legs, than on the thighs. The risk is much less when needles are used. But even 
these punctures are not to be made without attending to certain precautions. They 
should not be too near each other: an inch and a half, at least, should intervene be- 
tween them. Neither should they be too numerous, nor too deep. The depth must 
depend upon the circumstances of the case ; and especially upon the place where 
the puncture is to be made. The needle must not be pushed so deep as to penetrate 
or wound any fascia ; for the danger of subsequent inflammation would thereby be 
increased. 

The peritoneum may, at the same time, require to be emptied in the same 
mechanical way, by help of a trocar. I am always loth to recommend tapping, until 
the symptoms actually call for it, and until all other means of dispersing the water 
have been tried in vain. But the circumstances that warrant or demand the per- 
formance of the operation, the dangers that attend it, and the means of obviating 
these dangers, were fully pointed out when we were on the subject of ascites. 

By whatever means we may succeed in getting rid of the dropsy, there will still 
remain (except in the comparatively few cases that are unconnected with organic 
disease, and depend simply upon debility and an8emia)sthe necessity for guarding 
against the re-accumulation of the water, by remedial measures addressed to the 
faulty organs. You may sometimes keep the disease of these organs in check, even 
when you cannot cure it. 

In cardiac dropsies, besides the medicines already specified, undeviating tem- 
perance and regularity of life must be enjoined ; and the patient should carefully, 
and always, avoid all active motion or exertion of the body, and all strong emotion 
of the mind ; w^hatever, in short, might tend to hurry the circulation. You will 
scarcely be able to enforce this prudence, without plainly showing the patient the 
risk he will incur by its neglect. 

In the renal variety of the disorder, in addition to the appropriate remedies already 
enumerated, particular attention must be paid to the avoidance of all exposure to cold 
and vicissitudes of the weather, and to keeping the surface of the body warm. Such 
patients should be constantly clothed in flannel from head to foot. To those who are 
able to choose their place of abode, I should strongly recommend resort to a warm 
chmate. Some benefit may also be hoped for from counter-irritation — blisters or 
issues to the loins. 

The diet in the chronic forms of the disease should be nutritive but unstimulating. 
M. Solon suggests that if, in the renal cases, urea be detected in the blood, the 
patient should be restrained from too animalized a diet. Dr. Budd has had the 
same thought, and has put to the test, T believe in the Hospital-ship Dreadnought, 
the utility of withholding all articles of food that contain azote. I have found this 
restriction entirely useless in one painful case, in which it was fairly enforced. In 
fact, the principle of such restriction appears to be wrong: the urea is furnished to 
the blood, not in the primary assimilative process, but in that which is secondary 
and destructive. 

One more point, and I have done. Much unnecessary penance used to be imposed 
upon dropsical persons, by stinting their allowance of drink. It was natural to sup- 



CHYLOUS URINE. 



897 



pose that the accumulation would increase in proportion to the quantity of liquid 
swallowed. But experience has shown this opinion to be erroneous, and 

" Crescit indulgens sibi dirus hydrops" 

has ceased to be more than a poetical doctrine. The patient may safely be allowed 
to exercise his own discretion in this respect. When the peritoneum is full, distress 
is apt to ensue upon the distension of the stomach by drinks ; but this source of suf- 
fering is soon discovered and avoided. The sick man is better able than his physi- 
cian to judge which evil is the greatest ; the torment of unslaked thirst, or the dis- 
comfort that may be produced by its immoderate indulgence. 



LECTURE LXXX. 

Chylous Urine. Hematuria ; its diagnosis^ general and particular ; Local dis- 
orders of the Urinary Organs on which it depends ; Treatment. Abdominal 
Tumours. < 



I HOPE I have convinced you that the morbid conditions of the urine are worth 
studying. You have heard, probably, of the quacks who call themselves "water- 
doctors," and who pretend that, by mere inspection of the urine of a patient living 
at a distance, they can tell what is the matter with him, and how he may be cured. 
This skill, which looks like conjuration, the scientific physician of the present day 
does really possess. Of some very important forms of constitutional disorder, and 
of some specific local maladies, he reads the sure evidence in the sensible and 
chemical qualities of the secretion from the kidneys. And I do not hesitate to say, 
that a rightly instructed person might form a more accurate opinion respecting a sick 
man fifty miles off, and prescribe for him more judiciously, upon being furnished 
with a vial of his urine, than some practitioners whom I have known could do, if 
they had the patient bodily before them. You may learn much (and so, no doubt, 
you ought] by prying into the arcana of the night-chair: but you may learn more, 
I am persuaded, by the habitual perusal of the chamber-pot, 

I have not yet quite done with the subject. 

Sometimes urine is voided which appears to contain chyle. It looks white and 
milky, and stiffens as it cools into a tremulous jelly, like blanc mange, and takes the 
shape of the vessel into which it was passed. The coagulum gradually separates 
again into two portions : one of which is liquid and whitish, and when left at rest for 
a few hours, throws up to the surface a sort of creamy matter, containing (as cream 
does) a butyraceous or oily principle : the other is a delicate fibrinous mass, of flesh- 
hke appearance, having a red tinge from the presence of some of the colouring 
matter of the blood. This is the character of the urine passed a few hours after a 
full meal. When the patient has long been fasting, the urine is simply opalescent, 
and the coagulum, small and partial. 

Dr. Prout attributes this curious deviation from the natural qualities of the urine 
to a double fault ; first, in the organs of assimilation ; secondly, in the functions of 
the kidney. The chyle, from some derangement of the assimilative process, is not 
raised to the blood standard ; and being unfit for its purpose, is ejected through the 
kidneys ; and these organs, instead of converting it, as i^ual, into the iithate of ami- 
monia, suffer it to pass through them unchanged. 

Of this rare disorder I have not met with an instance. Dr. Prout has seen more 
or less of thirteen cases. Five of the patients were males, eight females. Two of 
the males, and one of the females, were below the age of puberty. Seven of the 
cases occurred in natives of the East or West Indies, or in persons who had lived 
for many years in hot climates. Mr. Thomas informs me, that during a residence 
of ten years in Barbadoes, he saw at least a dozen well-marked examples of chylous 
67 



808 



fLEMATURIA. 



urine in negroes. It would seem, therefore, that a tropical climate predisposes cer- 
tain individuals to this affection. In one case, drinking cold water while the body 
was warm seemed to have been the exciting cause ; and exposure to cold was thought 
to have had something to do with the attacks in other cases. 

The general health suffers less than you might suppose. Two of the females, 
while labouring under the complaint, became pregnant, and brought forth healthy 
children ; and one of the two lived nearly twenty years, with the disorder upon her 
all the time. 

In the slighter cases there is usually some degree of feverishness, some uneasi- 
ness in the back and loins, some thirst, a dry skin, and torpid bowels. When the 
malady is more severe, the symptoms approach to those of diabetes ; the thirst is 
more urgent, the appetite unnaturaUy craving ; and there is some degree of emacia- 
tion and debility. In this severer variety the urine is apt to coagulate before it leaves 
the bladder ; and the patient experiences difficulty in passing it, the urethra being 
blocked up by the clots. Dr. Prout states that he has known this to constitute the 
most troublesome symptom of the disease. In one of the fatal cases the body 
was examined, and the kidneys found perfectly healthy. Occasionally the com- 
plaint ceases of its own accord, even for years, and then recurs, without any 
apparent cause. We may conclude from these circumstances that it is a purely func- 
tional disorder. 

With respect to treatment, little can be said. Dr. Prout has found several things 
of temporary service, in the chronic state of the affection. The mineral acids ; astrin- 
gents, such as alum, and the acetate of lead ; opium ; counter-irritation. But the 
suspended symptoms have always soon returned. 

Lastly, the urine may contain blood: and I proceed to consider some of the phe- 
nomena that occur in connection with hematuria ^ under, which term I would com- 
prehend every kind of bleeding from the urinary organs. 

Blood alters, of course, the colour of the urine with which it is mixed ; giving it, 
in some instances, a bright red tinge, and causing it, in others, to assume a dark hue ; 
to become brown, like coffee, or even to approach to blackness. Hence we are some- 
times too ready to conclude that urine of a distinctly red colour, or so very dark as 
to appear almost black, derives its pecuhar tint from blood that has somehow mingled 
with it. 

But, in truth, urine may be perfectly red, or nearly black, and yet be quite free 
from blood. There are certain substances which, when taken as food, invariably 
impart a red colour to the urine. One of these is the prickly pear, or Indian fig as 
it is sometimes called, the cactus opuntia of botanists. When the Spaniards first 
took possession of America, many of them were alarmed by observing that they 
passed what they supposed to be bloody urine : but it was soon discovered that the 
red colour of the secretion was owing to the liberal use they made of that fruit. Dr. 
Hennen, in his book on Military Surgery, quotes a precisely similar example from 
Elliot's Journal of his Travels for determining the boundary of the United States. 
He says that " his people ate very plentifully of this substance at an island of the 
Mississippi (Kayo-ani), and were not a little surprised the next morning at finding 
their urine appear as if it had beerf highly tinged with cochineal. No inconve- 
nience resulted from it. It would seem (he continues) that the juice of this plant 
may be analyzed into a crimson dye by other processes besides that of the cochineal 
insect." 

Another vegetable substance with which, in this country, we are more famihar, 
and which will produce the same effect, is beet-root. Desault relates the case of a 
person who noticed that he every morning voided urine of a deep red .colour ; exactly 
such as would result from adding fresh blood to that liquid, except that no deposit 
took place. The man became frightened at this, and consulted M. Roux, who, after 
some examination, began to suspect that the water owed its red appearance to some 
other cause than the admixture of blood. It turned out that his patient was in the 
habit of supping every night upon the red beet-root ; and as soon as, by M. Roux's 
advice, he relinquished this article of diet, he was freed at once from his supposed 
bloody urine, and from his fears. 



HEMATURIA. 



899 



A similar tinge is said to be given ta the urine by the use of madder as food, by 
some species of strawberries, and by drinks made of sorrel. Logwood, which we 
sometimes use in medicine, has the same effect. 

It is right that you should know these facts : for by swallowing large quantities ofi 
such substances, and by complaining of sensations which they do not really feel, 
impostors may endeavour, without any difficulty, or pain, or danger to themselves, to 
deceive others into a belief that they are suffering under some serious and disquah- 
fying disease, and are proper objects of charity. Moreover, a knowledge of the 
effects of these vegetable matters may sometimes enable you, as in the case men- 
tioned by Desault, to remove unfounded anxiety and alarm from the minds of per- 
sons who are innocently and unconsciously giving themselves red urine. 

The natural tint of the urine inchnes towards redness, independently of any 
admixture of blood, in many instances of fever, and of acute inflammation. Occa- 
sionally urine of a pink colour is passed by persons who are subject to obstinate 
dyspepsia connected with organic disease. This pink tint is most apparent when 
the water is contained in an opaque, shallow, white vessel. 

Again, urine of so deep a colour as to be called, in common parlance, black, may 
or may not owe that hue to the presence of blood. When blood is the cause of the 
unnatural colour, the blackness must be ascribed to the chemical action of some free 
acid upon the blood : as I showed you formerly to be the case with blood that is 
vomited in hsematemesis. 

1 also pointed out to you some Httle while since, that the urine, in jaundice, some- 
times, seems to be black, when it is collected in large quantity, and in a deep vessel. 
This colour is merely a concentration of yellowness, as appears at once by diluting 
the urine with w^ater. It then assumes a bright yellow colour. The aspect of the 
skin in icterus will always secure you against mistaking or overlooking this cause 
of black urine. 

There has been observed, also, though very rarely, a form of black urine, de- 
pending upon the presence in that secretion of a pecuhar principle to which Dr. 
Marcet gave the name of melanic acid. The only specimen of really black urine 
that I ever saw, was shown to me by Dr. Prout ; who knew nothing, ho\vever, of 
the circumstances under which it was voided. It appeared to me to be full of coal- 
dust. 

With these two exceptions, almost all urine that is of a very dark or blackish colour 
owes that quality to the circumstance of its containing blood, which has been more or 
less altered, by various causes, from its original appearance. 

When blood is present in any considerable quantity, a portion of it subsides to the 
bottom of the vessel, and may be recognized without any difficulty. And even 
when there is not enough blood to give a marked and characteristic deposit, a very 
small admixture of it will be found to disturb the natural transparency of the urine, 
rendering it of a smoke-brown or dull cherry colour; whereas the reddish or pink 
urine which contains no blood is clear and untroubled ; and if, on coohng, it throws 
down a sediment, that sediment may be redissolved by heating the urine — a result 
which does not take place when a portion of blood has been deposited. Another 
rough test is, that a mixture of urine and blood tinges a piece of white linen dipped 
into it, of a red colour. A better criterion is afforded by gradually raising the sus- 
pected urine to the boiling temperature. If it contains blood, a grayish-brown fioc- 
culent precipitate, consisting of coagulated albumen tinged with the colouring matter 
of the blood, will form, and gradually subside, and leave the supernatant hquid clear, 
and with its natural tint. But if you use the microscope, that will furnish you with 
the best evidence upon this point. If there be blood in the urine, there will be blood- 
corpuscles, turgid or collapsed, diffused through the urine, or collected at the bottom 
of the vessel : and whatever modifications they may present, they may always. Dr. 
Bird says, be identified by "their non-granular surface, uniform size, and yellovir 
colour under the microscope." 

We have by no means accomplished the diagnosis when we have merely ascer- 
tained that there is blood in the urine ; and that the case is a case of hsematuria. 
The question remains, of what is such haematuria a sign. The blood emerges from 



900 



HEMATURIA. 



the urethra, hut it may have heen poured out at any point of a long and somewhat 
complex tract of mucous membrane. It may have proceeded from one or both of 
the kidneys ; from each or either ureter ; from the bladder ; from the prostate gland, 
or from the urethra. 

Hsematuria strictly idiopathic must be very rare. Cullen remarks that neither he 
nor any of his friends had ever met with an instance of it. I shall mention presently 
the only example of hemorrhage from the urinary organs, apparently idiopathic, that 
has fallen under my own notice. 

Blood is excreted with the urine in that acute affection of the kidney which I have 
already spoken of as lying at the root of most, if not all cases of febrile dropsy. The 
albuminous urine proper to the chronic form of Bright's disease sometimes contains 
the colouring matter as well as the serum of the blood. Hematuria is occasionally, 
I believe, vicarious of some other hemorrhage, and especially of bleeding from the 
hemorrhoidal vessels : so that it is always right, in obscure cases, to inquire whether 
the patient has been habitually subject to hemorrhage from the rectum ; and if so, 
whether that hemorrhage is suspended. These cases have even been called hsemor- 
rhoides vesicas. 

Haematuria occurs also, independently of any strictly local complaint, in the course 
of certain disorders which affect the system at large ; especially in scurvy and pur- 
pura hemorrhagica. Bloody urine is sometimes a symptom, and one of the most 
fatal augury, in typhus fever, small-pox, measles, and the plague. 

But setting aside these more general forms of hsematuria, let us inquire what local 
affections of the urinary organs themselves may give rise to hemorrhage ; and how, 
under different circumstances, we are to interpret this symptom. 

One very common source of hemorrhage from the urinary passages, is the presence 
within them of calculous matter. The pressure occasioned by the aggregation of 
the earthy mass, when it is formed in the kidney, or by its accidental change of posi- 
tion, lacerates, or lays open by ulceration, some of the smaller vessels with which 
it is in contact. And in those cases in which a calculus descends into the bladder, 
and is ultimately voided, it may, in succession, give rise to hemorrhage, first from 
the kidney from which it is separated ; secondly, from the narrow tube of the ureter 
through which it is forced ; thirdly, from the bladder, which it enters, and wounds, 
or irritates ; and fourthly, from the urethra in the last stage of its progress out of the 
body. ^ 

There will be the same liability to hsematuria, if the concretion, instead of coming 
down from the kidney, is formed originally in the bladder. The appearance of blood 
in the urine suggests, therefore, in many cases, the fearful suspicion, that there is, or 
is likely to be, a stone in the bladder. Dr. Heberden, in his Commentaries, says, 
" urine made of a deep coffee colour, or manifestly mixed with a large quantity of 
blood, has within my experience been very rarely the effect of any thing but a stone 
in the urinary passages. I therefore suppose a strong probabihty of this cause, when- 
ever I see this appearance." 

Again, blood may proceed from the kidney, or from the bladder, in consequence 
of malignant fungous growths, to which those parts are liable : a disease which, 
though more surely fatal than the stone, is scarcely, to the unhappy subject of it, so 
appalling. 

Hemorrhage may take place from the surface of the bladder from chronic disease, 
not cancerous, of that membrane. Mr. Howship has recorded an instance of this 
kind which occurred in Mr. Heaviside's practice. An old East Indian, who had 
Jong been subject to nephritic complaints, was suddenly seized with what was 
thought to be retention of urine. A catheter was passed, but as no water flowed, it 
was supposed that it had not entered the bladder, in the situation of which there 
was a manifest tumour. The patient died the next day ; and the bladder was found 
distended by a very large coagulum of blood which had come from the diseased mu- 
cous membrane. There was no trace of hemorrhage in the kidneys, nor in the 
ureters. 

I hold in my hand a preparation showing disease of the prostate gland, which had 
been accompanied by haematuria. 



HiEMATURIA. 



901 



Now we judge of the exact seat of the hemorrhage, and of its cause, partly by the 
nature and appearance of the effused blood, and partly by the symptoms that precede 
or accompany the bleeding. 

Dr. Prout states that " when blood is derived from the kidney^ it is in general 
equally diffused throughout the whole urine : on the contrary, when derived from 
the bladder, the blood for the most part comes away in greater or less quantity at the 
termination of the discharge, the urine having previously flowed off nearly pure." 

There are also certain modifications of the sensible qualities of the excreted blood, 
by means of which the same distinguished physician thinks he can pronounce, with 
considerable confidence, that the hemorrhage is owing to malignant disease. " The 
red particles of the blood (he says) discharged in the earlier stages of fungoid dis- 
ease, have often a remarkable appearance, and appear to the eye larger than natural; 
so that after they have subsided to the bottom of the urine, they at first sight some- 
what resemble grains of lithic acid gravel, and, like that substance, when the vessel 
is inclined, may be distinctly seen to roll along the bottom. From this peculiar ap- 
pearance of the red particles of the blood, the presence of malignant disease may be 
often suspected before the symptoms assume a decided character." In a more ad- 
vanced stage of the disease, there is often a dark-coloured offensive bloody sanies in 
the urine, and more or less of mechanical impediment in passing it. I should con- 
ceive that the microscope might aid the diagnosis of such cases. 

There is one phenomenon which, whenever it occurs, is very characteristic of 
hemorrhage frpm the kidney, or the commencement of the ureter. I mean the ex- 
pulsion, with the urine, of slender cylindrical pieces of fibrin, which have evidently 
been moulded in the ureter, and subsequently washed down into the bladder by the 
descending urine. These httle coagula are commonly of a whitish colour, the red 
particles of the blood having been removed ; and they look like slim maggots, or 
small worms. They denote, with much certainty, that the hemorrhage which they 
accompany is renal. 

Such, then, are some of the points of diagnosis furnished by the qualities of the 
excreted fluid itself. 

The bleeding may be presumed to come from the kidney, or from the upper part 
of the ureter, when it is accompanied or preceded by a sensation of heat, or of 
weight, or by some degree of pain, in the situation of the kidney ; especially if these 
uneasy feehngs are confined to one side of the body. This presumption will of 
course be strengthened if calculi have been known to descend from the kidney ; and 
converted into certainty if the patient suffers, together with the hcematuria, a fit of 
the gravel ; and if there be no symptom of stone, or of disease, in the bladder. 

On the other hand, when no symptoms referable to the kidney or the ureter are 
present, while there are signs of stone, or of disease of the bladder, or of a diseased 
prostate — a mixture of mucus with the blood ; occasional retention, or a sudden stop 
in the stream of urine ; pain referred to the glans penis immediately after the 
bladder is emptied — then we conclude that the blood proceeds originally from that 
receptacle. 

When pure blood comes away, either pruttatim, or in a stream, unmixed with urine, 
and neither preceded nor accompanied by any desire to make water, it is probable 
that the urethra is the locus of the hemorrhage. 

Bleeding from the surface of the urethra doubtless niay, and commonly does, pro- 
ceed from some mechanical injury done to that channel : as in the passage outwards 
of a fragment of stone, or inwards of a surgical instrument. But it is probable that 
blood is sometimes exhaled from the same membrane in considerable quantity, under 
circumstances which favour or produce a strong determination of blood to the genital 
organs. A young man came to the Middlesex Hospital with hemorrhage from 
the urethra, and said that he had lost a considerable quantity of blood in this way, 
within a few hours. The hemorrhage appeared to have been the consequence of 
excessive indulgence in sexual intercourse. His own account of the matter was 
that he had passed the night with a female, in whom the monthly period had just 
returned ; and he ignorant ly fancied that the hemorrhage from his own person was 
the result of a sort of contagion. However, the bleeding was permanently arrested 



903 



HiEMATURIA. 



by the introduction of a bougie, which was allowed to rernaiij for a short time in 
the urethra. This was the solitary instance to which I alluded just now, of (perhaps) 
idiopathic hemorrhage, occurring within my own knowledge. When the hemor- 
rhage comes originally from the urethra, the blood may regurgitate into the bladder, 
and coagulate there ; and. mislead an observer into the belief that the hemorrhage 
was vesical. 

It appears, then, that, in many instances, certain local symptoms are associated with 
hsematuria, and point distinctly to the part of the urinary apparatus whence the blood 
proceeds. 

But many cases are very obscure. Blood sometimes appears, mixed in greater or 
less quantity with the urine, when there is no pain, nor any other sign which would 
lead us to fix upon one part rather than another as the source of the hemorrhage. 
Now I believe that hsematuria, bearing this indeterminate character, will generally 
turn out to be renal, and to depend upon earthy concretions in the kidney. It is 
true that the hemorrhage which results from cancerous disorganization, whether of 
the kidneys or of the bladder, may also be painless. But cancerous disease of 
these organs (unless it extends from parts in the neighbourhood, as from the rectum, 
or from the uterus, to the bladder) is very rare ; and when it does occur, the nature 
of the case may usually be ascertained from those peculiar qualities of the effused 
blood which I have mentioned as beings characteristic of mahgnant growths. 

A calculus can seldom remain long in the bladder, at any rate will seldom cause 
bloody urine, without giving some other notice of its presence there : .but concretions 
form in the kidney, sometimes in great numbers, and reach a considerable size, and 
remain therfe long, without furnishing any signal from which we might suspect their 
existence ; except (perhaps) the occurrence of haematuria. We know this, because 
calculi are frequently met with in the kidneys of persons who had never suffered 
any pain or obvious derangement of the urinary organs during hfe ; and because, in 
other persons, in whom such calculi pass down from the kidney towards the bladder, 
the first notice of their existence is often given by the acute suffering they inflict 
daring their transit through the narrow ureter. 

Yet though calculi may lodge in the infundibula, or in the pelvis of the kidney, 
without manifesting their presence by exciting pain, it is very conceivable that, by 
progressive enlargement, they may lay open, or by accidental change of position 
they may wound, some of the smaller blood-vessels of the part, and so give rise to 
painless hsematuria. It will strengthen the presumption that such is the source of 
the bleeding, if it has succeeded (as hemorrhage from the urinary passages often 
does succeed) to a fall ; a shock, or jar of the body ; or jolting on horseback or in a 
carriage. Similar movements may occasion bloody urine when there is stone in the 
bladder; but then the irritation will he felt in that sensible part; the haematuria will 
not be painless ; the bleeding will not be the only symptom. 

It is, then, I say, my behef that very many of the obscure cases of hsematuria may 
be referred to renal calculi : and if this view of the subject be correct, it will render 
it probable that the alleged instances of idiopathic hemorrhage from the kidneys 
ought thereby to be reduced in number. 

The expulsion of the blood in hsematuria, whether it be painful or not, is sometimes 
attended with severe rigors. I mentioned before, that, in some persons, almost any 
irritation of the urethra, the passing a bougie, for example, will bring on a shivering 
fit. I had some time ago a patient under my care in the hospital, who had heema- 
turia of an obscure kind, and the discharge of blood was always marked by a smart 
rigor. Dr. Prout speaks of an instance of obstinate haematuria in which a shaking 
fit constantly preceded hemorrhage. Dr. Elliotson, too, in one of his lectures, gives 
an account of a case of intermittent haematuria. The patient was under his care 
in St. Thomas's Hospital, and had formerly had the Walcheren fever. He was 
admitted for ague, and every time that the cold stage of his attack came on, he voided 
a quantity of pure blood from the urethra. He was cured, by quina, both of his ague 
and of his hemorrhage. 

If we may trust to the records of physic, instances of periodic haematuria are not 
uncommon. 



HiEMATURIA. 



903 



One circumstance yet remains, worth noticing, in respect to hsematuria ; and it 
depends upon the hemorrhage itself rather than upon the disease of which the bleed- 
ing is a sign. I allude to the coagulation of the effused blood in the bladder, how- 
ever it may have got there. This circumstance is sometimes the source of much 
inconvenience, and suffering, and even of danger, to the patient. It may cause reten- 
tion of the urine and all its evil consequences ; and a still worse event is, that the 
coagulum. sometimes supphes a nucleus, around which calculous matter is deposited, 
and thus lays the foundation of that horrible malady, " the stone." 

You will perceive, from what I have said, that the treatment o( hsematuria resolves 
itself, in most cases, into the treatment of the disorder, or bodily condition with which 
the hemorrhage is associated, and of which it is merely a symptom. 

Sometimes, however, the bleeding itseJf is so profuse, or so long-continued, as to 
require direct efforts on our part towards its restraint. 

" When (says Dr. Prout) the bladder becomes distended with blood, and complete 
retention of urine in consequence takes place, recourse must be had to a large-eyed 
catheter, and an exhausting syringe, by the aid of which, and the occasional injection 
of cold water, the coagula may be broken down and removed. If the hemorrhage 
be so profuse that the bladder becomes again distended with blood in a very short 
time, the injection of cold water into the rectum or bladder is sometimes of great use ; 
and should these means fail, from twenty to forty grains of alum may be dissolved in 
each pint of water injected into the bladder ; a remedy that seldom fails to check the 
bleeding, even when the cause is mahgnant disease. I have never known any 
unpleasant consequences follow the use of this expedient, and have seen it imme- 

I diately arrest the most formidable hemorrhage, when all other means had failed ; 
and when the bladder had repeatedly become distended with blood, almost imme- 
diately after its removal." 

Among remedies given by the mouth, the same physician thinks highly of the 
acetate of lead. I have mentioned before, in these lectures, a nostrum called, after 
the name of its inventor, Ruspini's styptic. This has often been known to put a 
stop to hemorrhage which had resisted other remedies. I will read you one example 
of this from Sir Benjamin Brodie's published lectures. Speaking of hsematuria, 
dependent upon disease of the prostate glatid, he says: "Those medicines w^hich 
operate as styptics when taken internally, and which are useful in cases of hemor- 
rhage from the lungs, are also useful in hemorrhage from the prostate. I had a 
patient with very diseased prostate. A frightful hemorrhage took place. The usual 
methods of treatment were adopted, but were of no avail. The skin became pale, 
the pulse became weak, and the patient was exhausted ; yet the bleeding continued. 
Large quantities of blood were drawn off with the catheter: nevertheless the bladder 
continued to become more and more distended with blood, and was felt prominent in 

j the belly as high as the navel. All other remedies having failed, I gave the patient 
a dose of the nostrum known by the name of Ruspini's styptic, and repeated the dose 
two or three times in the course of the next twelve hours. In about half-an-hour 
after the first dose was taken the hemorrhage ceased ; and it never returned. The 
patient lived a year and a half afterwards, and there was no reason to believe that 
any ultimate harm arose from the bleeding." 

I For a long while this nostrum seems to have baffled analysis. The late Dr. 

I Maton told me that Dr. Wollaston had examined it, and had arrived at the negative 

I conclusion, that it contained no metallic substance. Dr. A. T. Thomson has since 

I announced that it mainly consists of a solution of gallic acid in alcohol diluted with 

' rose-water. 

I There is no substance more highly spoken of as a remedy for internal hemorrhages 

1 by foreigners, and especially by the French, than the extract of Rhatojiy root, the 
I " Krameria of our Pharmacopoeia. A female was sent to me by my colleague, Mr. 
j Arnott, complaining that for some weeks she had been passing bloody urine. She 
I had gone through the ordinary routine of treatment without benefit. There were no 
I symptoms present which threw any light on the precise source or cause of the 
hemorrhage. I recommended a tHal of the rhatany, and she began to take a scruple 
of the extract, mixed with water, three times a day. As in Sir Benjamin Brodie's 



904 



ABDOMINAL TUMOURS. 



case, the hasmaturia ceased after the first dose, and it did not return for many months. 
I mention this instance the rather, because the gallic acid enters into the composition 
of this vegetable extract also. 

Now the galhc acid is one of those substances which, when introduced from the 
digestive organs into the blood, passes through the round of the circulation unchanged, 
and reappears in the urine. We may conceive, therefore, that it stays internal hemor- 
rhage by exciting its astringent property upon the ultimate capillary blood-vessels in 
its passage through them. It certainly is apphed, in solution, after its elitnination 
from the blood, to the urinary passages : and thus, in hsematuria, it may be presumed 
to produce its styptic effect upon the bleeding surface. 

To the same principle are owing, I believe, the astringent and styptic virtues of 
the uva ursi, bistort, tormentil, the pomegranate, kino, catechu, and the several pre- 
parations of gall nuts. I am sorry that I have not had much opportunity of trying 
the gallic acid itself, in its separate state ; for I have heard of several instances of its 
successful employment in cases of internal ..hemorrhage. If, as I believe, it really 
has this power, it is very desirable that it should be prescribed in a more definite and 
precise manner than is afforded by its natural combinations with so many different 
vegetable matters. 

I am unwilling to take leave of the cavity of the abdomen, without saying a few 
words (very few they must be) respecting the various kinds of tumour to which it 
is obnoxious. It may seem strange that the diagnosis of abdominal tumours, which 
manifest themselves to the touch, and to the sight, should be so difficult and puzzhng 
as it often is. I mentioned some reasons for this before : the loose and shifting man- 
ner in which some of the viscera of the belly are packed and fastened ; their liability 
to enlarge beyond their natural hmits ; their accidental dislocations under disease. It 
would be vain to attempt even a sketch of the infinite variety of these deviations 
from the healthy state. Every case of abdominal tumour forms a separate object of 
study, and must be judged of by its proper circumstances. All that I can profess to 
do, is to offer you some rough hints on this interesting subject. 

Some kinds of tumour result from morbid growths; such are all the varieties of 
cancer: some from the presence and rrfUlti plication of parasites; of which we have 
examples in collections of hydatids : some are produced by the distension of hollow 
organs ; as when concretions, or fecal matters, or gases, lodge in the intestines ; or 
when urine accumulates and is pent up in the bladder: some consist in the mere 
enlargement of parts. 

Let us enumerate the principal of these ; that you may know what chiefly to 
expect. 

1. There are, I say, tumours from lodgments in the bowels; and these are more 
hopeful than most kinds of abdominal tumours. Sometimes the stomach, or some 
part of the intestinal canal, is distended in consequence of a mechanical impediment 
to the course of its contents : and this impediment may be invincible. 

2. Ovarian tumours are very common. Of these I spoke at some length in a 
former lecture. 

3. The liver is very liable to enlargement: either from simple congestion of 
blood; or from the interstitial deposit of adipose matter; or from the intrusion of 
malignant growths ; or from colonies of hydatids. 

4. So also the spleen swells, from fullness of blood, or from specific deposits in its 
substance. 

5. The kidneys sometimes attain a vast size ; being occupied by malignant disease, 
or swollen by pus that finds no vent. 

6. Enlargements of the mesentenc glands ; cancerous degeneration of the peri- 
toneum, especially where it forms the omentum ; tumours connected with the uterus ; 
aneurisms of the aorta; vast distension of the gall-bladder; constitute other species 
of abdominal sweUing, which I simply mention without further comment. 

Now our judgment of the character of a given tumour is naturally influenced by 
its place. In the right hypochondrium, we suspect the liver; in the left, the spleen ; 
jn the epigastric region, the stomach ; in the hypogastric, the womb, or the bladder ; 



ABDOMINAL TUMOURS. 



905^ 



in either flank, an ovary, or perhaps a kidney ; in the track of the colon, we guess 
at fecal collections. 

But sometimes the situation of the tumour fits more than one, or than two, sup- 
positions. Between the ribs and the ilium on the right side we may have an 
enlarged ovary, a tumid kidney, a distended caecum. A prominence in the epigas- 
trium may be due to cancer of the stomach, to an infarcted transverse colon, to a 
ventral aneurism. Above the pubes, the distended bladder, or the enlarged uterus, 
may equally project. The sigmoid flexure of the colon loaded with feces, the left 
kidney exaggerated by disease, a bulky ovary, may either of them occupy the same 
sinistral space. 

Moreover, the colon deviates strangely, and not seldom, from its natural course and 
position : and the magnified viscera may invade, by their displacement, or by their 
irregular expansion, the regions that are proper to other organs. 

Our conjectures are assisted by the associated symptoms, and by observation of 
the regular performance, or of the disturbance, of particular functions. Yet here, 
also, we meet with continual sources of fallacy. Pressure from a tumour without 
may, as well as infarction within, impede the passage of alimentary matters through 
the bowels, of urine through the ureters ; and cause, in the one case, flatulence and 
tormina, in the other, retention or suppression of urine. Growths foreign to the liver 
may, nevertheless, press upon its excretory ducts, and occasion jaundice. And so of 
other parts and functions. I mean, that the functions prominently deranged are not 
always the functions of the part occupied by the tumour, but of organs which are 
secondarily and accidentally subjected to its disturbing influence. Your sagacity 
will be abundantly tried in balancing the evidence of different symptoms in these 
obscure, yet palpable, forms of disease : and after all you will often doubt ; and often, 
when you do not doubt, you will mistake. 

Enlargement of the fiver may usually be distinguished from other tumours of the 
right hypochondrium, by percussion. Try from the clavicle downwards. At first, 
you get a hollow sound. Then, a little below the nipple perhaps, (for the spot varies 
much in different subjects,) the sound begins to grow dull. If this dullness be trace- 
able, without change or interruption, to the tumour, the inference is strong that the 
tumour is hepatic. Any other tumour there situate leaves, most commonly, when 
the patient is recumbent, a palpable sulcus above it : or a space in which the sound, 
upon percussion, is different from that which is yielded by the liver. 

Percussion helps us to discriminate an ovarian from a renal tumour. When the 
swelhng is large, the intestines lie behind the one, in front of the other : and the 
sound is affected accordingly. 

Tumours that are readily movable, are generally intestinal, omental, or ovarian. 

A pulsating tumour is not necessarily an aneurism. The healthy artery will fift 
almost any sort of hard swelling that happens to lie directly over it. 

The occurrence of haematemesis or melasna would corroborate your belief that a 
tumour in the right hypochondrium was hepatic — in the left, was splenic. 

Even when you are satisfied as to the organ affected, there comes another ques- 
tion, scarcely, in some cases, less difficult than the first — What is the nature of the 
tumour ? 

Suppose, for the sake of illustration, that your inquiry relates to the liver. If the 
tumour be large, smooth, roundish, of slow growth, and the general health be not 
materially deranged, it is most likely an hydatid tumour. If, along the edge and 
upon the surface of the augmented liver, you can feel large inequalities and projec- 
tions, and if the complexion and general state of the patient are expressive of faihng 
health, the enlargement is, in all probabihiy, cancerous: and if there be other traces 
of carcinoma in the system, this conclusion becomes almost certain. Small hard 
irregularities betoken the hobnail fiver ; which is, sooner or later, accompanied by 
ascites. When, without pain or jaundice, the liver of a phthisical patient trans- 
gresses its natural boundaries, it is, presumably, a fatty- liver. 

By applying a similar method of investigation to other ventral enlargements, yoa 
may frequently hit the right scent, and trace the mischief to its true source. To 
treat the subject in detail would require a volume. I may refer you to a series of 

4a3 



906 



ACUTE RHEUMATISM. 



papers by Dr. Bright, in the Guy's Hospital Reports ; where you will find a host 
of examples, and much valuable informalion, concermng the most common and the 
most important kinds of " abdominal tumours and intumescence." 



LECTURE LXXXI. 

Jicute Rheumatism ; Symptoms; Varieties; Treatment. Chronic Rheumatism ; 

Phenomena : Plan of Cure. 
Gout: Description of a Paroxysm; Progress of the Disease ; General state of 

the Health in Gouty Persons ; Causes of the Disease ; Diagnosis between Gout 

and Rheumatism. 

I PROCEED, this afternoon, to the consideration of that very common, very painful, 
and sometimes very perilous disease, rheumatism. There are two species of it, the 
acute and the chronic. They graduate, however, insensibly into each other ; and 
the chronic is often a sequel of the acute form. Yet this is not necessarily so. 
Chronic rheumatism occurs in persons who have had no preceding attack of the 
disorder in its acute stage or degree. 

Rheumatism implies inflammation: but as I mentioned in an early part of the 
course, it is inflammation of a pecuHar or specific kind. In the first place, it is in- 
flammation of a particular tissue — the fibrous tissue: and it may, therefore, manifest 
itself wherever that tissue is employed in the fabric of the body. No doubt the in- 
flammation does involve other tissues also : but it is always, probably, by extending 
to them through what has been called contiguous sympathy. Thus we have the 
synovial membrane of a joint inflamed in many cases, the inflammatory action having 
spread from the fibrous textures around the joint: or, as I formerly pointed out to 
you more in detail, the serous surface of the pericardium, and the serous surface (or 
what is analagous to a serous surface) of the inside of the heart, and especially that 
part of it which is carried over the valv«e — each and all of these serous membranes 
are extremely liable to be affected with inflammation in the acute form of rheumatism: 
but in all of them it is probable that the fibrous tissue was the first to suffer. The 
pericardium is, as you know, a fibro-serous membrane ; and fibrous tissue is inter- 
posed between the folds of the serous membrane, in the cardiac valves. 

Rheumatism, therefore, is essentially inflammation of the fibrous tissue : and it 
most commonly seizes upon the fibrous parts that lie round the larger joints ; the 
ligaments and the tendons : and in this respect you may almost consider the perpe- 
tually moving heart as one of the large joints. Yet this inflammation, when confined 
to the fibrous tissues, is not common inflammation. At any rate, it does not reckon 
among its events (as common inflammation does) either suppuration or gangrene. If 
suppuration sometimes occurs (and it certainly occurs very rarely) it is because the 
rheumatismal inflammation has extended to contiguous textures, and then has run 
the ordinary course of inflammation. Inflammation of the areolar tissues around a 
joint may thus inflame and suppurate. . The inflammation of the synovial membrane 
may be of sufficient intensity to give rise to the formation of pus. When, however, 
the inflammation extends to the serous tissues within and around the heart, the pro- 
ducts of the inflammation are just the same as when inflammation of the same tex' 
ture, of the common kind, is any how produced. 

Acute rheumatism, then, consists in redness, heat, pain, and swelhng (that is to 
say, in inflammation) of the parts lying around, or entering into the composition of, 
one or more of the larger joints of the body ; generally of several at the same time, 
or in succession ; with a disposition to shift from one joint to another, or to certain 
internal organs, and especially to the membranes of the heart ; and with fever. 

This tendency to shift its place — to what is usually called metastasis — is a very 
remarkable feature of the disease. The inflammation will appear in one joint sud- 



ACUTE RHEUMATISM. 



907 



denly, and as suddenly subside in another which it previously occupied ; and then, 
perhaps, it will jump back again to its old quarters. In many instances, however, 
it invades fresh joints without wholly ceasing, and sometimes even without diminish- 
ing at all, in those formerly affected. It may visit in this way every large joint in 
the body, and even seize upon some of the smaller ones ; or it may possess nearly 
all of them at once. It is most commonly seen to affect the ankles and knees, the 
knuckles, wrists and elbows. It is often seated in the shoulders, also, and in the 
hips. The joints of the fingers frequently suffer ; and I have seen one instance in 
which the joints of the jaws were manifestly imphcated in the rheumatic inflamma- 
tion. But by far the most serious and dangerous leap which the diseased action is 
apt to take, is to the membranes of the heart. 

But I pointed out *to you, in a former lecture, the symptoms of rheumatic car- 
ditis, its consequences, the various ways in which it connects itself with the joint 
affection, and the treatment by which we are to attempt to moderate it. I dismiss, 
therefore, this, the most momentous complication of acute rheumatism, from the pre- 
sent discussion, and shall confine myself solely to the disease as it manifests itself 
externally. 

The shifting and migratory inflammation of the textures lying round or composing 
the larger joints, is attended with high inflammatory fever ; with a remarkably full, 
bounding pulse ; with flushed cheeks ; headache ; profuse, drenching, sour-smelhng 
perspirations, which distress and weaken the patient, but bring no relief to his pain ; 
with a white-coloured, dirtyish, thick fur on the tongue, which is red, however, at its 
tip and edges ; with turbid and acid urine. But this severe and inflammatory fever 
(synoc/ia, Cullen calls it) has no tendency to degenerate into a typhoid form ; and 
that is a striking feature in the complaint. Neither is the intellect affected, except 
when carditis takes place ; and then, as I stated formerly, violent delirium is apt to 
ensue, misleading the practitioner, drawing his attention away from the chest, where 
fatal changes are in progress, and fixing it upon the head, where no inflammation at 
all exists, but which is disturbed through sympathy with the cardiac disorder. 
With this exception, we do not find patients in acute rheumatism delirious. Through- 
out all this febrile disturbance, there is no coma, no marked trouble of the stomach 
or of the bowels, no vomiting, no diarrhea, no petechias, no aphtha3, no sordes about 
the mouth, all which are of ordinary occurrence in the course of common continued 
fevers. 

The joints are exquisitely tender, as well as painful. The fibrous tissues, which 
are endowed with but little sensibility in their sound and heakhy state, become 
acutely painful when occupied by inflammation. The pain is increased by pressure, 
and therefore by whatever imphes pressure ; by movements of the joints, conse- 
quently. The patients are reduced to perfect helplessness by the pain. Their com- 
mon phrase is, that they have entirely lost the use of their limbs ; and this is true 
enough in fact, but not true in the medical sense of those words. They have not 
lost the jooz^^e?^ of moving them; there is no palsy ; but they i/m-e no^ move them, 
because the effort gives them so much torment. 

Pain in the affected joints is more constant than sweUing, and swelling more con- 
stant than redness. The swelhng differs also, in different cases, in rather a remark- 
able manner. In fact, two varieties have been made of acute rheumatism. The 
distinction was first drawn by Dr. Chambers, at St. George's Hospital, and after- 
wards made public by Dr. Francis Hawkins, in his Gulstonian lectures. The vari- 
eties are spoken of under the names of fibrous or diffused rheumatism, and synovial 
rheumatism. I will briefly state their distinctive characters. 

In the one, then, the inflammation commences in the immediate neighbourhood 
of one of the larger joints : not in the joint, but near it. It attacks the tendons, 
fascise, hgaments, and possibly also the muscles. There is not at first much redness, 
or swelling ; but after the pain has been of some duration, there is a pufliness around 
the parts affected, caused apparently by turgescence of the blood-vessels, and at 
length slight pitting, or oedema, may supervene, from effusion into the surrounding 
areolar tissue ; and what redness is present is disposed in streaks, following the 
course of the tendons. 



908 



ACUTE RHEUMATISM. 



On the other hand, in the synovial variety, which shows itself more frequently 
and more plainly in the knee than anywhere else, the pain which marks the onset 
of the complaint does not last long before some degree of swelling is perceptible, 
together, in most instances, with shght redness of the skin ; and this swelhng is not 
due so much to turgescence of the blood-vesseJs, or to oedema of the areolar tissue, 
as to fluid poured into the cavity of the joint. And the form and character of the 
swelling indicate that it is the result of the fullness and distension of the synovial 
membrane. It is tight and elastic, and protrudes, as it were, through the spaces that 
intervene between the tendons and hgaments by which it is in other parts bound 
down and restrained ; and fluctuation is often distinctly perceptible in the superficial 
joints, when both hands are apphed to them. 

These are the local differences between the two forms of the disease. And there 
are differences equally well-marked between the constitutional symptoms that attend 
them. 

It is in that form which xat' i^oxrjv is called fibrous rheumatism, that the inflam- 
matory fever runs so high ; that the tongue is so thickly furred ; that the round, full, 
bounding pulse occurs ; that the profuse, spontaneous, acid perspirations break out, 
w^hich exhaust the patient's strength without alleviating his sufferings ; that the urine 
is high-coloured, and deposits a copious sediment hke brick-dust. 

In the synovial form, the fever is either less intense from the beginning, or soon 
moderates after the joints begin to swell ; the tongue is less foul ; the patient sweats 
much less. It is to this form that the term rheumatic gout is often apphed. And 
growing experience has led me to beheve, that in this popular appellation the real 
nature of the complaint is most truly expressed. Gout and rheumatism are very 
similar in kind ; and what has been called synovial rheumatism, while it forms a 
connecting link between the two, and partakes of the characters of both, is more 
nearly allied to gout than it is to rheumatism. 

Conformably with this belief, it has been noticed that the tendency of the inflam- 
mation to settle upon the cardiac membranes is much greater in the fibrous than in 
the synovial disease. This is a most important difference. 

I know of no other exciting cause of acute rheumatism than exposure to cold, and 
especially cold combined with moisture. And this is the reason why the disease is 
very common among the poorer classes of society, who are more in the way of that 
cause, and cannot guard against it so effectually as their wealthier brethren ; among 
whom it is comparatively rare. 

Acute rheumatism is principally a disease of youth, prevailing most, I believe, 
from the age of puberty to that of thirty-five or forty. I have repeatedly, however, 
seen it in children ; sometimes as early as the third or fourth year ; and I stated to 
you some time ago, that the chance of the joint affection being complicated with 
rheumatic carditis is the greater in proportion as the patient is the younger. With, 
perhaps, one exception, I never knew the disease occur in an unequivocal form before 
puberty, without its being attended with inflammation of the fining or investing 
membranes of the heart. 

I have already told you what I beheve to be the proper plan of treatment to pursue 
when rheumatic carditis is present: in that case, the affection of the hmbs is of 
secondary consequence. But what are we to do when there is no complication of 
the joint disease ; no invasion of any of the viscera ? 

Why, if you seek for instruction upon this matter in books, or even among prac- 
tical men, you will meet with a very perplexing diversity of opinion. Apart from 
the cardiac affection, acute rheumatism has no danger about it ; and the articular 
inflammation usually terminates, sooner or later, in recovery, whether the heart be 
implicated or not. And most persons who have been for any considerable time in 
■practice have their own favourite method of conducting the disorder to its termina- 
tion. While many employ free blood-letting, and other active antiphlogistic reme- 
dies, some, on the contrary, even in the present day, put their trust in bark. Some 
give large doses of calomel in the outset of the disease, such as half a scruple or a 
scruple, with or without a grain or two of opium ; and they repeat the dose dail3\ 
or oftener, till the urgent symptoms give way ; and in this manner I have seen the 



ACUTE RHEUMATISM. 



909 



disease apparently cut short. But I have also known many instances in which the 
disease was painfu], and protracted, and obstinate, although this practice was adopted 
early, and fairly prosecuted. Some physicians, again, give smaller and more fre- 
quent doses of calomel and opium ; and some think opium alone to be as useful as 
this connbination. Others depend mainly upon colchicum ; others, upon large and 
repeated doses of conium; and some attempt the cure of acute rheumatism by 
sweating the patient by means of guaiacum, and similar stimulant medicines, and a 
profusion of bed-clothes. 

Now you may be sure — when men's opinions, concerning the treatment of a dis- 
ease which is of common occurrence and easy recognition, are thus unsettled and 
diverse — you may be sure, first, that no specific for that disease has yet been disco- 
vered ; and secondly, that the disease is not very obedient, or not steadily obedient to 
any remedial plan. When I first began to practise, I pleased myself, now and then, 
with the belief that T had ascertained the best cure for acute rheumatism : so rapidly 
and decidedly did the disorder recede and cease upon the administration of such or 
such a remedy. But, on the next trial of it perhaps, my expectations have been 
miserably disappointed. This marked improvement has happened under the use of 
colchicum, of conium, of calomel with opium, of alkahes. I did not, in the prosperous 
cases, mistake spontaneous recovery for cure. The change was too great and imme- 
diate, and the instances of success were too numerous, to admit of that explanation. 
4 Whether it be (as I suspect) that shghter diagnostic marks have been overlooked, 
and that sometimes gout has in reality been cured under the semblance of rheuma- 
tism — whether bodily idiosyncrasies have withstood the influence of remedies — or 
whether atmospheric agencies have kept up the disorder in spite of proper treatment 
— I cannot tell: certain it is that we are occasionally baffled, and the patient con- 
tinues to suffer, notwithstanding the diligent enforcement of all the approved reme- 
dies and plans of treatment, one after the other. I am far, however, from thinking 
that remedies are useless : and I do by no means assent to the dictum of the first Dr. 
Warren, who, when asked what was good for acute rheumatism, answered " six 
weeks." 

In the fibrous or genuine form, with the bounding pulse, the flushed face, the high 
inflammatory fever, you may bleed your patients from the arm ; especially if they 
are young and robust. They will bear to lose a large quantity of blood without 
fainting; and you will always find the blood drawn to be remarkably buffed and 
cupped. The pain and inflammation are local ; but the case is not adapted to local 
remedies. We may, by leeches, or cupping, or cold apphcations, be able perhaps 
to subdue the inflammation in a knee or an elbow : but from the migratory character 
of the disorder, we incur the risk, by such topical measures, of giving the inflamma- 
tion a new and a more serious location. ^ 

Venesection will, almost always, afford a marked degree of relief to the sufferings 
of the patient : but the relief will seldom be complete or permanent : and we may 
sometimes with propriety repeat the bleeding. In very few instances, however, can 
we hope to extinguish the disease by blood-letting. And this is one of the cases in 
which you must not take the state of the blood' already drawn as a criterion of the 
propriety of abstracting more. The blood will remain ready to show the buffy coat 
long after the use of the lancet has ceased to be available or safe. 

The advantages of blood-letting in this complaint are, first, the partial relief which 
it bestows. It is seldom that the pain is not sensibly mitigated, and the fever calmed, 
provided the bleeding has been carried to a proper extent, sufficiently soon. Secondly, 
free and early venesection may sometimes perchance (but not often) cut short the 
attack. This, however, is a favourable effect which you must not reckon upon, and 
which I would not advise you to aim at. But, in the third place, blood-letting may 
be serviceable, by preparing the body for other remedies : for calomel, opium, pur- 
gatives, colchicum. 

Yet, looking to my own practice in acute rheumatism, I find that although I am 
in the almost daily habit of treating it — for it is a disorder from which our wards are 
never perhaps entirely free — I rarely prescribe phlebotomy. Many of the patients 
come under our care at an advanced period of the disease ; when the time for bleed- 



910 



ACUTE RHEUMAVTSM. 



ing with any prospect of benefit has gone by. Some have been bled before their 
admission. Others, in whom the rheumatic diathesis has become inveterate, are 
suffering recurrences of the malady: and neither does the recurrent disease require, 
nor would the system bear, active and repeated depletion. In many instances, acrain, 
the constitution has been battered and broken by a London life : while in others there 
is no great infensity of febrile disturbance from the first. So that the cases in which 
I am tempted to employ the lancet are really few and far between. At the same 
time I can well believe — what I have often heard — that in the countr}^ in young 
persons of unimpaired vigour, in the first attacks of the disorder, and when the in- 
flammatory sym.ptoms run high, venesection may be of much service in mitigating 
the sufferings of the patient, and in facilitating his cure. 

I beheve few persons now adopt the plan of forced perspiration for the cure of 
acute rheumatism. Formerly it was the fashion to give powerful sudorifics : Dover's 
powder, or antimony, in large doses ; and the patient was " accinctus ad sudorem ;" 
covered up in bed between thick blankets, with a hot bottle or brick at his feet. But 
in the severe, unequivocal fibrous form of rheumatism the perspiration is profuse 
without any artificial means being used to excite it, and it is not accompanied by the 
smallest alleviation of the pain : nay sometimes the patients will tell you that they 
are worse, in that respect, while the sweating continues. 

The preparations of colchicum have sometimes, whether venesection has been pre- 
mised or not, an almost magical effect in quelhng the disease. Frequently, when 
most successful, (though that is by no means a necessary condition of their success,) 
they exercise some marked influence upon the stomach and bowels. Colchicum is 
very apt to occasion deadly nausea and vomiting, griping, and diarrhoea, and when 
these consequences ensue from its use, the inflammation of the joints often subsides 
entirely. At any rate, if the rheumatism does not give way when the stomach and 
bowels become thus affected, you may be certain that to push the colchicum further 
would be useless. 

Our wishes, however, and our expectations, from colchicum, are often doomed to 
be defeated. I beheve that in proportion as the synovial symptoms predominate, or 
mix themselves distinctly with the fibrous — in proportion as the disease approaches 
in its characters to gout — you may expect to be successful with colchicum. Large 
doses are not requisite. Twenty minims of the wine or of the tincture may be given 
every six hours, until some result is obtained. Or a grain of the inspissated juice, or 
of the acetous extract of colchicum, every four hours. Under this treatment the dis- 
ease sometimes vanishes within three or four days ; the medicine producing sickness 
and purging, and the rheumatism, or the rheumatic gout, rapidly dechning. Occa- 
sionally the same favourable event takes place, although there has been no disturb- 
ance in the stomach or bowels. 

There are some cases which yield readily to calomel and opium : and in the fibrous 
disease I think that calomel and opium are the remedies to which, after sufficient 
bleeding, you will do well tO trust. For it is under this character that the extension 
of the disease to the membranes of the heart is so liable to happen : and if anything 
can protect the patient against this fearful complication of amalady which, previously 
attended by no danger, becomes by this addition almost necessarily fatal — or if any- 
thing can arrest the carditis before it leaves indelible mischief imprinted on the heart 
— it is (in my opinion) mercury. 

Dr. Hope has lately (1837) published an account of a particular mode of using 
calomel and opium in this disease, which mode he learned from Dr, Chambers, and 
which is followed, more or less closely, I fancy, by many other physicians. It is 
said to be so successful that even the details of it ought to be known. The plan is 
described as follows : — After a full venesection, or even two, in the robust, but with- 
out any bleeding in the feeble and delicate, eight or ten grains of calomel, w^ith a 
grain and a half of opium, according to the age of the patient and the severity of the 
case, are administered every night ; and followed every morning by a strong black 
dose, sufficient to ensure four or five stools at least. With this treatment is combined 
thrice a day, a saline draught containing from fifteen to twenty minims of the 
vinum colchici, and five grains of Dover's powder. When the pain and swelhng 



ACUTE RHEUMATISM. 



911 



are greatly abated, if not almost gone (which Dr. Hope affirms to happen often 
within two days, and almost always within four), the calomel is omitted ; or it is 
omitted sooner if the gums become at all tender. The opium, however, is con- 
tinued to the amount of a grain or a grain and a half at bed-time ; and in severs 
cases a grain also at noon is added ; and the colchicum, and the black dose, are 
still given as at first. Dr. Hope considers it a case of exception if the patient be 
not well in a week. 

The following are stated by Dr. Hope as being the great advantages of this plan 
of procedure: — 1. That the patient is generally sound, well and fit for work, in a 
week or ten days after the pains have ceased. 2. That the gums are rarely affected, 
especially if you previously ascertain that the patient has not a morbid susceptibility 
of mercury. 3. That it is rare to see inflammation of the heart if the treatment is 
early begun ; not oftener, he thinks, than in one of a dozen cases. 4. If the slightest 
symptom of endo- or peri-carditis does supervene, a few extra doses of calomel and 
opium, given every four or six hours, will generally affect the constitution in twenty 
or thirty hours, which, with two or three cuppings or leechings on the region of the 
heart, almost always place the patient in a state of safety. 

Now, beheving that some such plan as this, made up of blood-letting in some cases, 
purging, calomel and opium, and colchicum, is as good as can be pursued ; and in- 
deed that, with individual modifications, it is very much pursued, especially in Lon- 
don at present; still I cannot help feeling great doubt — doubt which I would will- 
ingly not entertain — about all the advantages just enumerated. Too often we do 
not see the patient till there is such disease of the heart present as is manifest to the 
ear ; and then, as T stated in a former lecture, perfect recovery and repair seem 
scarcely within the scope of possibihty. Too often, when the patient is seen early, 
the system refuses to admit of the specifi.c protection of the full mercurial action. 
There is a practical objection also to the exaction of four or five motions from the 
bowels of these rheumatic patients every day ; I mean the inconvenience, the increase 
of pain, and the fresh exposure to cold, occasioned by frequently going to stool ; and 
this is a disadvantage likely to be particularly felt in hospitals. 

Bark used to be highly thought of for the cure of acute rheumatism ; but it is only 
beneficial, or safe, during the convalescence. Where the system has been much 
reduced or broken by the complaint, or by the disciphne the patient has undergone, 
1 think that the decoction of cinchona is of service in fortifying the body against the 
renewed agency of those causes on which the original attack depended. 

Cases frequently occur which are neither absolutely acute, nor absolutely chronic. 
The inflammation, without being intense in any one joint, lingers in many ; and the 
fever, though not entirely absent, is moderate. The joints are hot and painful, and 
the skin is dry, and there is some thirst. To this intermediate character the term 
subacute is sometimes apphed ; and it will serve our purpose of distinction. 

In this form of the disease, as well as in the more active form, the urine is almost 
always loaded with lateritious matters, and strongly acid. Looking upon this as an 
indication of treatment, I have prescribed alkalies, and with much success : the 
liquor potassE!, for instance, to the amount of a drachm daily, for several days to- 
gether ; keeping the bowels free by laxative medicine. Under this plan, more surely 
j in my experience than under any other, the urine clears, the pain abates, and the 
I joints are Kberated. Nitre has been praised of late as being eminently successful 
' against rheumatism : I have not had much opportunity of trying it, but I should 
I think it hkely to do good in these subacute cases. 

I There are two kinds of chronic rheumatism : one attended with local heat and 
j swelHng, aUhough the constitution at large sympathizes very little or not at all with 
I the topical inflammation ; the other characterized rather by coldness and stiffness of 
I the painful joints. In the former of these the pains are increased by pressure, and 
j by movements of the limbs, and by external warmth ; the warmth of a bed, for ex- 
ample ; and there may be even some shght degree of pyrexia at night. In truth 
this form of chronic rheumatism claims a near relationship with the acute, i?ito which 
it sometimes passes, and of which it is frequently the sequel. It accordingly requires 

I 



912 



CHRONIC RHEUMATISM. 



antiphlogistic remedies, only less vigorously applied. It is important for you to know 
that, in these cases, you may, with less hesitation, less fear I mean of driving the in- 
flammation to some more vital part, apply leeches, and cold washes, to the painful 
joints. Otherwise, the principle of treatment remains unchanged. The complaint 
is, however, often obstinate, and lingering, and prone to recur. It frequently involves 
and cripples the smaller joints, especially those of the knuckles and fingers ; render- 
ing them knobby, and distorting their form and position. The fingers take a per- 
manently obhque direction, slanting outwards towards the ulna : and Dr. William 
Budd has drawn attention to the curious fact that the corresponding joints of the two 
sides of the body are always affected exactly in the same manner. To use a para- 
doxical expression, the deformity is symmetrical. One crooked joint is just the copy 
of its fellow. Surely this indicates the constitutional origin of the disorder. 

In the other form of chronic rheumatism, what some call passive, the remedies 
that answer best are of a different kind. The pain is alleviated by friction of the 
joint, and the patients are most comfortable when they are warm in bed, and espe- 
cially when moderate perspiration is present. They are singularly benefited also 
by summer weather. Persons who are much troubled by this wearing complaint, 
and who can afford to live where they please, w^ould do well to take up their resi- 
aence in a warm climate. Wherever they may be, such patients should be protected 
against atmospheric vicissitudes by warm clothing : they should be cased in flannel 
from the neck downwards. Warm bathing is of great service ; and especially baths 
of salt water, of a temperature not less than 100°, that they may act as a stimulus to 
the cutaneous circulation ; warm douches ; the vapour bath ; or the hot-air bath, of 
which, as I said before, the patient may receive the benefit lying in bed. And to 
warm clothing, and warm bathing, may be added friction, with some stimulating lini 
ment, and what is called shampooing. It is in these cases that stimulating internal 
medicines are often of use. Turpentine; some of the animal oils, the cod-fiver oil, 
for instance ; guaiacum. Opiates, too, are frequently remedial of the pain : and 
there can be no better form for their administration than that presented to us in the 
celebrated Dover's powders ; the pulvis ipecacuanha compositus of the Pharmaco- 
pceia. 

There is a remedy which has recently come into extensive use, for the relief of 
chronic rheumatism; I mean the iodide of potassium. It is most certain of acting 
beneficially when that fibrous part, the periosteum, is principally affected. Its vir- 
tues in the case of venereal nodes {i. e., in venereal inflammation of the periosteuiaj, 
were first distinctly pointed out by Dr. Williams, of St. Thomas's Hospital. I believe 
it is equally effectual upon whatever cause chronic inflammation of the same part, 
with nodes and thickenings, may depend. 

Some of you probably saw a woman who was lately my patient in the hospital, 
and who had been worn down to a skeleton by the pain she had endured from 
chronic periostitis giving rise to nodes, which did not appear to be traceable to 
syphilis. She had been in the habit of lulhng the pain by large opiates at night, 
and begged to have them after her admission. I gave only the iodide in the ordinary 
dose (five grains thrice daily), and she slept without opium ; and in a week or two 
lost her nodes, and was perfectly well. 

Cfosely allied to acute rheumatism, and yet distinct from it, is the singular dis- 
ease which in this country is popularly called the gout: which Cullen, in the first 
instance, was disposed to term arthritis ; but as arthritis would imply inflammation 
of all or any of the joints, he afterwards adopted the ancient name of podagra (foot- 
pain). 

The same author has given, in his First Lines, an excellent account of the phe- 
nomena which constitute a paroxysm of gout. It is copied from Sydenham, who 
drew from nature : for he had himself suffered frequent and severe visitations of the 
disease during a period of thirty-four years. 

The attack begins, most commonly, an hour or two after midnight. The patient, 
who had gone to bed and to slefep in his usual health, and without suspecting what 
was about to happen, is awakened by a pain in one of his feet, mostly in the first 



GOUT. 



913 



joint or hall of the great toe ; but sometimes in other parts of the foot — the heel, the 
instep, the ankle. With the coming on of this pain there is generally more or less 
of a cold shivering, which gradually ceases as the pain gets worse, and is succeeded 
by heat. The pam grows more and more violent and intolerable ; and is spoken of 
by those who suffer it, as amounting to torture. It is a grinding, crushing, wrench- 
ing pain ; or a burning sensation as if a hot iron were pressed into the joint. Some 
humorous Frenchman described it in this way. " Place (said he) your joint in a 
vice, and screw the vice up until you can endure it no longer. That may represent 
rheumatism. Then give the instrument another twist, and you will obtain a notion 
of the gout." The pain is attended with great restlessness and misery, and exquisite 
tenderness. The patient cannot bear the weight of the bed-clothes upon the affected 
limb ; nor the jar of a heavy foot-fall in his chamber. In a vain search after comfort 
he is perpetually shifting his foot from place to place, and from posture to posture. 
At length, about the ensuing midnight, the pain remits ; sometimes gradually, some- 
times so suddenly that the patient attributes the rehef to his having at last found an 
easy position. He falls asleep in a gentle perspiration, and when he wakes the next 
morning he finds the part, which had been so painful, to be red, swelled, tense and 
shining, surrounded by more or less oedema, and by turgid veins. The same series 
of symptoms recur, in a mitigated degree, for some days and nights ; and then the 
disease often goes entirely off, not to return till after a long interval. 

As the oedema subsides, and the redness fades, the cuticle of the part that has 
been inflamed peels off; and this process of desquamation is generally attended with 
troublesome itching. 

Such is a picture of an attack of gout, occurring in an adult subject, for the first 
time, and in its most regular and genuine form. 

Attacks of this kind are preceded, in most instances, by some marked disorder of 
the functions of the stomach ; diminished appetite, flatulence, heartburn, nausea per- 
haps. And during the paroxysm the urine is very high-coloured, and acid, and 
turbid ; depositing a copious pink, or brick-dust sediment. The stools, also, are un- 
natural ; pale, or of a dark green, and very offensive. After the fit, when the com- 
plaint has ceased entirely, it generally (says Cullen) "leaves the person in very 
perfect health ; enjoying greater ease and alacrity in the functions of both body and 
mind, than he had for a long time before experienced." 

But the disorder, w^hich has thus departed, is very apt — nay, unless extreme care 
be taken to prevent it, and even in spite of all care, it is almost sure — to return. At 
first, perhaps, it recurs not oftener than once in every three or four years ; but after 
some time the intervals are shorter, and the attacks become annual, happening about 
the same time of the year : afterwards they come twice every year ; and at length 
they return several times during the course of the autumn, winter, and spring. And 
as the fits are more frequent, so also are they more protracted, till, in the advanced 
state of the disease, the patient is hardly ever free from it, except perhaps for two or 
three months in summer. I do not mean that all this occurs invariably in all cases 
ahke ; but this is a sketch of the general course of the complaint. 

There are other phenomena also to be noticed as time advances, and as the dis- 
ease is repeated. At first, I say, it commonly appears in one foot only ; afterwards 
every fit includes both feet, the one after the other : and as the disease continues to 
recur, it not only attacks both feet in succession, but after having ceased in the foot 
which was secondly visited, it will return again into the foot first affected, and per- 
haps a second time also into the other. It passes, too, into other joints, both of the 
upper and lower extremities, large as well as small ; so that there is scarcely a joint 
that may not, at one time or another, be seized upon. But as the disease proceeds, 
and the fits get to be more numerous, the pains are commonly less violent than they 
were at first ; the patient is, however, more affected with sickness, and suffers more 
in his general health. 

Again, after the earher attacks, the joints usually recover entirely their former 
strength and pliancy ; but when the disorder has returned again and again, they 
are not so readily nor so completely restored to their previous condition, but re- 
58 4b 



GOUT. 



main weak and stiff : and sometimes they lose at length their capacity of motion 
altogether. 

Also, in many gouty persons, but not in all, after the disease has frequently re- 
curred, what are called chalk-stones form ; concretions that look exactly like chalk 
take place around and outside the joint, filling up the areolar tissue, and lying, in 
general, immediately beneath the skin. The material of these curious concretions 
is deposited at first in a half fluid state, and resembles soft mortar ; but the more 
watery ingredients being afterwards absorbed, it becomes dry and hard. Of course 
when this stuff is deposited in any quantity on the outside of a joint, it must limit in 
a great measure, or entirely prevent, the motion of that joint. And sometimes matter 
of the same kind is effused into the joint itself; as I have once seen in a gouty pa- 
tient who died in the Middlesex Hospital. 

Gout is a disease that was well known, and well observed, by the ancients. In 
its genuine form it could neither be overlooked nor mistaken. Many very interest- 
ing facts relative to this painful disorder have accordingly been ascertained : and I 
proceed to notice the chief of these ; but must do so with as much brevity as I can* 

First, then, gout is an hereditary disease. I do not mean to say that the disposi- 
tion to it is always a transmitted disposition ; but that the complaint is much more 
likely to occur in persons in whose pedigree it can be traced, than it is in other 
persons. It may, I believe, be generated by certain habits of hfe ; and, on the other 
hand, in spite of an inherited predisposition, the disease may be staved off and 
averted. Let the son of a rich and gouty nobleman change places with the son of a 
farm-servant, and earn his temperate meal by the daily sweat of his brow, and the 
chance of his being visited with gout will be very small. Granting this, we see 
reason, independent of the general analogy of hereditary disorders, why the gout 
may be expected sometimes to leap over a generation, just as family hkenesses are 
known to intermit ; while yet the disposition may descend to the children of those 
who, in their own persons, have never suffered the disease. Among 522 gouty 
persons, concerning whom Sir Charles Scudamore had collected information, 332 
could trace their disease to the father, mother, grandfather, grandmother, uncle, or 
aunt. In the remaining 190 the disease was not known to have existed in either 
upward branch of the family-tree. 

2. There is a pattern of body which is behoved to be favourable to the acquisition 
of gout. "It attacks (says CuUen) especially men of robust and large bodies, men 
of large heads, of full and corpulent habits, and men whose skins are covered with a 
thicker rete mucosum, which gives a coarser surface." 

3. Whether, in a given individual, there be an inherited tendency to the disorder 
or not, its access is promoted in a remarkable manner by a full and luxurious mode 
of life, and by sedentary or inactive habits. 

4. It is observed of gouty persons, that they are usually subject to nephritic com- 
plaints also, to fits of the gravel, to renal and vesical calculi. These disorders of the 
urinary organs commonly .begin to manifest themselves after the gout has plagued 
the patient for some time. They do not coincide with the paroxysms of gout, but 
the two happen alternately: or (what is equally expressive of the connection between 
the two forms of disease) the children of gouty and nephritic parents inherit often 
the one or the other of these maladies ; but " whichever may have been the principal 
disease of the parent, some of the children have the one, and some the other. In 
some of them the nephritic affection occurs alone, without any gout ; and this fre- 
quently happens in the female offspring of gouty ancestors." 

The urinary concretions to which gouty people are so subject, and the morbid 
states of their urine generally, belong to the lithic diathesis. Dr. Prout holds that 
"the lithic acid, developed principally during the mal-assimilation of the albuminous 
textures, may be considered as the characteristic feature in gout." And the chemical 
composition of the chalk-stones which sometimes accompany gout, is in accordance 
with this statement ; and illustrates strongly the connection between gout and gravel. 
The so-called chalk-stones consists mainly of lithic acid combined with soda ; of the 
Hthale or superlithate of soda. Sometimes this very hthate of soda, perfectly white, is 
deposited in large quantities in the urine. Dr. Prout says that he has seen it co- 



GOUT. 



915 



piously secreted of the consistence of mortar, so as to block up the urethra in its pas- 
sage outwards. Now this is just the stuff which is deposited around, and sometimes - 
within, the joints, and which hardens as it collects. I may mention here again that 
many persons have the gout long, and severely, without having any of these concre- 
tions. They are incidental to the more chronic forms of the disorder, in which the 
pain and the fever, though of long duration and frequent recurrence, are slight in 
degree. The cuticle at length gives way, and the earthy matter hes bare. A 
namesake of mine, Mr. Henry Watson, describes, in the first volume of the Medical 
Communications, the case of a Mr. Middleton, who was accustomed, when playing 
• at cards, to chalk or score the game upon the table with his gouty knuckles. 

5. Gout attacks especially the male sex. Some few women, however, suffer it, 
in its regular and decided form ; and generally these women are robust and plethoric. 
CuUen noticed its occurrence in " several females whose menstrual evacuations were 

' more abundant than usual." But the disease chiefly happens in women after the 
catamenia have ceased to appear. Heberden knew a female who had numerous 
^ sores from chalk-stones. 

6. Cullen observes that the gout does not usually come on till after the age of five 
and thirty. Heberden, who in his long and extensive practice among the higher 
classes of society in this tov/n saw as much of this disease as any physician ever 
did, says that he never met with a case which he could decidedly pronounce to be 
gout, before the age of puberty. Sir Charles Scudamore has collected a statistical 
account of 515 examples of gout, in which the period of the first assauh had beea 
noted. Of these, 142 began between the ages of 20 and 30 ; 194 between 30 and 
40 ; 118 between 40 and 50. The greater number, you will observe, was between 
30 and 40. 

However, I believe that where the inherited disposition is strong, and the habits 
of living are such as to foster that disposition, gout may show itself, occasioaally, 
even prior to the age of puberty : but this is, certainly, the exception to a very 
general rule. 

7. Gouty persons are subject to various ailments, which spring from the same 
fountain as the well-marked paroxysm : derangements in the functions of the digestive 
organs, of the heart and lungs, of the brain and nerves. 

The most famihar of these ailments is indigestion, with its various circumstances 
of impaired appetite, sickness, vomiting, flatulency, heartburn, acid eructations, gas- 
trodynia. Pains and cramps occur in several parts of the trunk, and shoot thence 
into the upper extremities, and are relieved by the extrication of wind from the 
stomach. The bowels are irregular ; colicky diarrhcea being sometimes the prevail- 
ing fault, but more commonly costiveness. With all this the patient is apt to be ex- 
cessively dejected and hypochondriacal, morbidly attentive to every bodily feeling, 
disposed to exaggerate his sufferings, and apprehensive of the worst event. 

When the viscera of the thorax are affected, the patient has palpitations, fits of 
dyspnoea, faintings, or even pangs like those of angina. 

In the head occur pain, giddiness, transient affections of the vision and of the 
hearing, threatenings of palsy and apoplexy. 

All these, you may say, are feelings and ailments to which any and all persons 
are liable. True : but the remarkable peculiarity which connects them, in some 
men, with gout is this; — that they often all clear away and disappear upon the 
breaking out of a paroxysm of that disease in the foot. 

Hence such symptoms are regarded as indicating one variety of irregular gout. 
Cullen, led by a questionable theory, classes them under the head of atonic gout. 
Sometimes the patient so affected is said to have lurking gout ; or masked gout. 

In another variety of irregular gout, the complaint commences, in the ordinary 
way, in a joint; but the pain and inflammation do not reach the ordinary degree of 
intensity, or at any rate do not continue for the usual time and then recede gradually 
in the accustomed manner, but they disappear abruptly and entirely, while symp- 
toms of severe and alarming disorder arise, as suddenly, in some internal pari. This 
Cullen names retrocedent gout. It affords an example, as I conceive, of true metas- 
tasis. The internal part most commonly attacked is the stomach. It becomes 



1 



916 



GOUT. 



affected with a peculiar feeling of anxiety and distress ; with sickness, vomiting, or 
violent pain, which the patient calls spasm, and which, prabably, is of a spasmodic 
character. More rarely the retrocession is to the heart, when syncope or urgent 
dyspncea ensues ; or to the head, when it may terminate in a stroke of apoplexy, or 
a paralysis. 

In a few cases the disorder, thus ahghting on some other part than a joint, is 
plainly inflammatory. The most common example of this is gouty inflammation of 
the urethra, with scalding and a puriform discharge ; simulating very exactly an 
attack of gonorrhoea. So also there is a gouty form of ophthalmia, or gout in the 
eye ; gout in the testicle ; and a year or two ago an eminent physician of my ac- 
quaintance suffered a violent and dangerous attack of what was considered to be gout 
in the throat. Dr. Cullen speaks of these inflammatory affections under the title of 
?nisplaced gout : but they may well enough be ranked under one of the preceding 
heads of masked, or retrocedent gout. 

The disposition to gout may be engendered, and w^hen inherited will infallibly be 
strengthened and developed, as I have told you already, by certain habits of life : by 
sensual indulgences, and (but in a less degree, I believe) by want of bodily exercise. 
Of this we have the strongest negative evidence in the remarkable immunity from 
the disease enjoyed by the working poor in our rural districts. One never hears of 
the gout among agricultural labourers. Sir Gilbert Blanc states that, during ten 
years in which he was physician to St. Thomas's Hospital, akhough in his private 
practice he reckoned 130 patients who had gout, being about one in twenty-six of 
the whole number, he had not a single case of it among 2406 patients in the hospital. 
This I think strange, for in the London hospitals it is not very uncommon for us to 
meet with gout ; but then it is in persons who have hved fufly and inactively : in the 
servants of wealthy families for instance, butlers, coachmen, porters — men who often 
live more luxuriously, and more idly a great deal, than their masters. And among 
the rich, those who are most subject to gout are notoriously those who indulge most 
in what are called the pleasures of the table ; who eat largely of animal food, and 
drink much wine, especially if they are indolent withal. Such men generate for 
themselves the lilhic acid diathesis ; and if the gouty tendency happens to have been 
born with them, they incur the disease, under these habits, with more or less readi- 
ness, according to the degree of that innate disposition. Strong exercise certainly 
remedies, in some measure, the evil effects of this mode of life, by promoting the 
excretions of the body : but gout used to be exceedingly common in the old-fashioned 
fox-hunter, who "rode hard," while he also "hved hard." Mere sedentary habits 
do not produce gout, as we learn from the comparative exemption of females, and of 
the poor, Avho, following sedentary employments, are yet compelled by their poverty, 
Avhich is so far a blessing to them, to be temperate. Men who eat much meat gene- 
rally indulge themselves in drinking also : the two causes go together, and it is 
difficult to estimate their separate influence. Butchers, who live fully upon animal 
diet, are said to be rarely affected with gout, but then they necessarily take a great 
deal of exercise. It appears that the use of wine, and of malt hquors, fosters the 
disposition to gout much more than the abuse of distilled spirits. The paucity of 
gouty patients among the lower classes in this gin-drinking town suffices to show 
this. I have been told that gout is very little known in Glasgow, where the com- 
mercial men live richly, and lead sedentary lives, but do not drink much wine, their 
favourite beverage being rum-punch, of which they are not at all sparing. Dr. Wil- 
liam Budd says that the disease is common among the " ballasters" on the Thames ; 
that, akhough they are not a numerous body, many are admitted with gout every 
year into the Dreadnought. Now these men being much exposed to inclemencies 
of weather, and using great bodily exertion, which is attended with profuse sweating 
and much exhaustion, think themselves warranted in drinking (besides spirits) two 
or three gallons of porter daily. This shows the effect of malt hquor in producing 
the gouty habit of body. 

On the other hand, the inbred gouty tendency may be so strong, as to be scarcely 
kept in check by the most abstemious regimen. 



GOUT. 



917 



A fit of the gout may be brought on by various circumstances : in other words, 
the possible exciting causes of gout are many. A paroxysm has been frequently 
known to follow immediately upon an unusually severe debauch. Strong mental 
emotion has sometimes the same consequence, especially emotion of a depressing 
kind. Excessive fatigue — more particularly fatigue produced by too much walking 
exercise on any one day — is another exciting cause. And this is unlucky, for it often 
discourages a patient from again making use of a proper and even a necessary amount 
of exercise of that kind. Another exciting cause which frequently operates is ex- 
ternal injury. The first attack of gout often fixes upon the seat of an old hurt : and 
a very slight recent injury is sometimes enough to determine a paroxysm — a trifling 
bruise or sprain, the pressure of a tight shoe ; nay, Dr. Heberden tells us that he 
verily behoves he has seen an attack of gout brought on by the bite of a flea ; show- 
ing how easily the disease may be excited, when there is a strong predisposition to 
it. This it is which makes us so often doubt the accuracy of gouty persons, when 
they tell us that they are lame from a sprain. 

Dr. Cullen enumerates sundry debilitating circumstances, which, as such, appear 
to operate in caihng into action the gouty disposition. And there can be no doubt 
that a state of weakness does often favour the eruption of the malady. A friend of 
my own had lately a most serious attack of continued, fever, in the course of which 
he became hemiplegic, and his life was despaired of. Soon after the fever had left 
him, and while he was yet extremely feeble, he had three attacks of gout in quick 
succession. 

Paias have been taken by several writers, especially by Heberden, to lay down 
the distinguishing characters between gout and rheumatism. A first assauk of gout 
can scarcely be confounded with an attack of acute rheumatism. The limitation of 
the inflammatory redness to one foot, and the restless distress of the gouty patient, 
contrasts strongly with the helpless and motionless condition of the rheumatic, v\^ho 
is pinioned, so to speak, in many limbs. There may be more room for doubt and 
mistake in the advanced state of gout, when many joints have at length become 
involved ; but even then you may generally decide by inquiring into the history of 
the patient, and learning the circumstances of his early attacks. 

The main points of distinction may be broadly and generally stated thus. 

In gout the small joints are first and chiefly aflfected, especially the joint of the 
great toe : in rheumatism, the large. The redness of the gouty inflammation is more 
bright and vivid than that of the rheumatic ; and the fluctuations between agony and 
ease are greater and more frequent. Gout usually affects one joint only at a time : 
rheumatism often many at once. The inflammation in gout is attended with more 
cedema than in rheumatism ; and is followed, in the majority of instances, by de- 
squamation and itching, phenomena which we do not notice at the close of rheumatic 
inflammation. Gout is not attended with those drenching acid sweats which are so 
characteristic of acute fibrous rheumatism. The gout is decidedly hereditary : rheu- 
matism, if hereditary at ah, is much less distinctly so. The gout occurs rarely or 
never, whereas rheumatism is not very uncommon, before the age of puberty. In 
gout, though many functions suffer, there is no tendency to carditis : in rheumatism, 
with far less general disturbance, that tendency is very marked. Gout is the punish- 
ment (some have thought it the privilege) of the rich, of persons who live fully, 
luxuriously, and idly : rheumatism is most frequently the appanage of the poor, and 
of those who toil. 



LECTURE LXXXII. 

Pathology of Gout. Prognosis, Prejudices respecting the diseasfi. Treatment: 
during the paroxysms ; during the intervals. Cutaneous Diseases. 

I YESTERDAY described the phenomena of gout, from its primary outbreak to its 
crippling consummation. I told you what observation has collected concerning its 

4b3 



918 



GOUT. 



causes ; and I pointed out the circumstances which distinguish it from rheumatism. 
Let us look a Httle closer into the essence of this curious malady. 

The pathology of gout has been the theme of endless controversy. Humoralists 
and solidists contend ahke for the triumph of including the disease within the pale 
of their respective theories. The very name, gout, derived through the French 
goutte from the Latin guita, expresses summarily the doctrine of those who imposed 
it : and we trace the same, or a similar idea, in the appellation of the kindred dis- 
order, rAmmatism. 

" The opinion (says Cullen) which has generally prevailed, is, that gout depends 
upon a certain morbific matter, always present in the body; and that this matter, by 
certain causes thrown upon the joints or other parts, produces the several phenomena 
of the disease." 

You will find this doctrine at the bottom of all Sydenham's speculations on the 
subject. But Cullen doubted it, and even endeavoured, in an elaborate argument 
which you may read in his First Lines, to disprove it. He held gout to be an 
aflection of the nervous system. I shall not trouble you by detailing his argument, 
for I consider it an utter failure. I am satisfied that the ancient doctrine, which 
asserts the humoral origm of the disease, is the true one. "Morbific matter" (it 
may well be called a. poison) is generated, of detained, under certain circumstances, 
within the body, and silently collects in the blood ; until, after obscure threats, per- 
haps, and prelusive mutterings, it explodes in the foot ; and then the bodily economy, 
like the atmosphere after a thunder-storm, is, for a while, unusually pure and tran- 
quil. To some such conclusion as this the result of all modern research seems 
clearly and unfailingly to tend. Dr. Holland, for example, in his thoughtful and 
thought-exciting volume, recently pubhshed, expresses his belief in " a tnateries 
morbi, which, whatever its nature, is capable of accumulation in the system, of 
change of place within the body, and of removal from it." In this, and in several 
other propositions relative to gout, enunciated in distinct terms by this learned writer, 
I fully concur. Some speculations still more lately put forth by Dr. Wilham Budd, 
in a communication to the Medical and Chirurgical Society, throw a strong light 
■upon this perplexed subject ; and bring the phenomena, not only of gout, but also 
of many other important complaints, within the operation of one general, compre- 
hensive, and intelligible law. I shall take leave to refer, in a very cursory manner, 
to some of Dr. Budd's positions. 

I need not remind you of the various ways in which extraneous matters find en- 
trance into the blood. Poisons, under their proper shape and name ; medicines, 
which misapplied become poisons ; our natural food and drink, which the folly of 
man converts into poison ; the products or dregs of the secondary assimilative pro- 
cess ; these are common sources of impurities, more or less hurtful, which mix and 
circulate with the vital fluid. Some of these extraneous matters escape harmlessly 
by one or more of the waste-pipes and emunctories of the body. Some are entan- 
gled in its solids : but not indiscriminately ; for different substances have their special 
or their favourite resting-places. All this is well known to persons conversant with 
lexicological researches. 

Now, this doctrine of the elective affinity between certain tissues or parts of the 
body, and certain morbific principles conveyed to them by the blood, is applied by 
Dr. Budd to elucidate the very curious fact of the symmetrical local manifestations 
of many disorders ; which disorders are themselves so far general that they derive 
their origin from the circulating fluids. This symmetry he finds the most exact in 
chronic constitutional complaints, wherein the local morbid changes are eff'ected in a 
manner which approximates closely to the processes of healthy nutrition. He shows 
good reason for believing (what, if the whole theory be true, we should expect) that 
the same symmetrical phenomena are modified by the amount of the poison collected 
in the system. If there be a certain quantity only, it may settle in some favourite 
or congenial spot, on one side of the body. If there be more than enough to satu- 
rate tliat part, it goes next to the corresponding spot upon the opposite side ; or, per- 
haps, to an analogous part of the other limb of the same side. If there be more still 
of the poisonous material, it flies to, and occupies, other parts also, He furtbey 



GOUT. 



919 



shows that the elective affinity is more exclusive, and the bond of union stronger, in 
respect to some morbid principles, than to others : and in proportion as the affinity 
is weak, so is the local manifestation of the disease apt to shift, by metastasis, from 
place to place. When the matter which has thus entered, or combined with, a cer- 
tain tissue or organ, is any how loosened and released from that union, or repelled 
from the part, it is again set afloat in the blood, to " break out" elsewhere ; to tease 
various organs, perhaps, or to derange ihe whole economy. The alternation so often 
to be noticed between certain cutaneous eruptions and internal disorders of function, 
is a striking and famihar example of this. The eruption affords presumptive evi- 
dence of the detention of some pecuHar morbid principle in that part ; and the 
internal affection which succeeds the disappearance of the eruption, denotes that the 
morbid principle has re-entered the blood. Some of these peccant or poisonous 
matters fix permanently in the affected spot or spots ; and some of them may even 
be recovered in substance from the dead tissue by chemical meahs ; the poison of 
lead, for example, from the symmetrically palsied muscles. Others appear to be 
expended gradually in the part, and so eliminated from the system. Dr. Budd 
observes, that the regular arrangement of these local tokens, whether they be out- 
ward or internal, is disturbed by the presence of fever. Probably the febrile tumult 
may itself be owing to the quantity of the noxious matter in circulation within the 
body. He states, also, that, cscteris paribus, this morbific matter is most apt to 
pounce, in the first instance, upon parts which have been previously hurt, or which 
are mechanically irritated at the time. For which reason a part that has once been 
affected by it is more likely than other parts to suffer again. 

Now, see how thoroughly the ascertained phenomena of gout accord with this 
theory. Certain habits of hfe produce fullness, and richness, and impurity of blood ; 
the same habits which breed the hthic acid diathesis. We may even conjecture this 
acid, or some of its compounds, to be the actual inateries morbi. Lithates are 
poured forth with the urine, and sometimes deposited in vast masses around and 
within the gouty joints. At first, after obscurer intimations of the presence of the 
poison in the system, it thunders in the foot; and there, perhaps, is all discharged 
and spent. The chemist, BerthoUet, found that the skin of a part affected with 
gouty inflammation communicated instantly to litmus paper a deep red colour : a 
large quantity of acid was evidently passing off by exhalation from the inflamed 
surface. If the poison be too copious to find sufficient vent in one joint, it attacks 
another, or more than one. "Gluandoque etiara primis morbi diebus, cum materia 
peccans adeo exuberat ut ei capiendee pes unus impar sit, utrosque simul pari vehe- 
mentia fatigat : sed ut plurimum pedes successive, uti diximus, adgreditur." These 
are Sydenham's words. A chain of repeated paroxysms at length purifies the blood : 
" Donee tandem materia peccante prorsus absumta, seger pristinam obtinuerit sani- 
tatem." The descent of the disorder upon a particular joint is often determined by 
a recent blow or sprain, or by the chronic weakness consequent upon an ancient 
hurt. If the inflammation, after thus settling, be repelled from the foot, the poison, 
being driven again into the blood, may fight upon some vital organ, and place the 
patient's life in immediate jeopardy. The late Dr. Parry, of Bath, had at one time 
under his care two patients who- had attempted to cut short or to ease a paroxysm 
of gout by plunging the affected foot into cold water. This gave instant relief to the 
pain, and in both instances the inflammation presently abated ; but in both also, 
hemiplegia occurred a few hours afterwards. 

If these views respecting the pathology of gout be true, it can scarcely be doubted 
that they are applicable, mutatis mutandis, to the cognate disorder — acute rheuma- 
tism. Dr. Prout, indeed, considers the lactic acid, developed chiefly during the 
secondary mal-assimilation of the gelatinous tissues of the body, to have the same 
relation to rheumatism which the Hthic acid, derived from the mal-assimilatian of the 
albuminous textures, has to gout. 

The prognosis of gout may be gathered, without much further suggestion on my 
part, from what has already been said. The inflammation which befalls the joints 
has no worse event than the thickening, or, perhaps, the chalk-like deposit, which it 
produces ; so that gout in the extremities is not a mortal disease. But as it is not 



920 



GOUT. 



always confined to the extremities, the hfe of a gouty person is justly held to he 
insecure. "Lagoutte articulaire (says some French author) est celle dont on est 
malade; et la goutte interne est celle dont on meurt.^' You will find that all insur- 
ance companies exact, cseteris paribus, a larger premium from those who have had 
the gout. When it proves fatal, it is by translation of the disease, or rather of the 
gouty virus, to some vital part; to the stomach, the heart, the lungs, the brain. 

As the early visits of gout are generally followed by a striking change for the 
better in the health and feelings of the patient, it is not to be wondered at that the 
disease, in its genuine and decided form, should' have sometimes been wished for, 
and even courted. It is commonly thought that a fit of the gout clears the system 
of all other disorders. It does, indeed, clear it, for the time, of those disorders which 
resulted from the poison of gout. But this fact has led to great practical mistakes. 
First, to the error of looking on inertly, and doing nothing to remedy the ailments 
which are supposed (often very wrongly) to depend upon lurking gout, and to require 
a fit of the gout for their cure ; and, secondly, to the more dangerous experiment of 
endeavouring to force on such a fit by excess and intemperance. Men forget, or do 
not know, that the enemy thus reinforced, instead of evacuating the fortress by its 
oulports, may retreat triumphant into the citadel. To drop metaphor, such a course 
of living may, indeed, determine an attack of the disease in the extremities, but in- 
volves the fearful peril of some fatal internal seizure. Besides, the benefits expected 
from external gout belong to its earher returns alone. The more numerous the fits, 
the faster does the general health break, and the more stubbornly do the associated 
symptoms cling to the patient : and many persons linger on, martyrs (as they say) 
to the disease, long after they have ceased to be fit for any of the business of life, or 
capable of any of its pleasures. Nevertheless, as Heberden observes, " people are 
neither ashamed nor afraid of it ; but solace themselves with the hope that they shall 
one day have the gout; or, if they have already suffered it, impute all their other 
ails, not to having had too much of that disease, but to wanting more. The gout, 
far from being blamed as the cause, is looked up to as the expected deliverer from 
these evils." 

And this mistaken ambition is heightened, no doubt, by the notion, still more ab- 
surd and ridiculous, yet very generally prevalent, that it is a creditable thing to have 
the gout : a notion which evidently originated in the fact of its being peculiarly inci- 
dental to the wealthy and the great, to men of cultivated minds, and intellectual dis- 
tinction. Nothing can show more strongly the power of fashion than this desire to 
be thought to possess, not only the tone and manners of the higher orders of society, 
not their folHes merely and pleasant vices, but their very pains and aches, their 
bodily imperfections and infirmities. AH this is more than sufficiently ludicrous and 
lamentable : but so it is. Even the philosophic S3^denham consoles himself, under 
the sufferings of the gout, with the reflection that it destroys more rich men than 
poor — more wise men than fools. " At vero (quod mihi afiisque beet, tam fortune 
quam ingenii dotibus mediocriter instructis, hoc morbo laborantibus solatio esse 
possit) ita vixerunt atque ita tandem mortem obierunt magni Reges, Dynastae, exer- 
cituum classiumque. Duces, Philosophi, ahique his similes baud pauci. Verbo dicam, 
articularis hicce morbus (quod vix de quovis alio adfirmaveris) divites plures interemit 
quam pauperes, plures sapientes quam fatuos." 

The treatment of a gouty patient naturally divides itself into. that which is proper 
during the paroxysm, and that which is proper during the intervals between the 
paroxysms. 

It was maintained by the great physician, whose words I have just been quoting, 
that all artificial evacuations during a fit of the gout are useless or hurtful. He, 
therefore, discountenanced blood-letting, purging, and the use of diaphoretic medi- 
cines. It was nature's prerogative, he said, to exterminate the peccant matter in her 
own way ; namely, by depositing it in the joints, whence it might be dispersed by 
insensible transpiration. Evacuant remedies had no other efl^ect than that of recall- 
ing into the blood this peccant matter, which nature had already thrust forth to the 
extremities of the body ; whereby it happened that the virus, which should have 
been eliminated through the joints, fell upon some of the viscera ; and so the patient, 



GOUT. 



921 



who was in no danger before, became in peril of his life. I mention all this to sho'v 
you how entirely identical was Sydenham's theory of the gout with that which is 
now rapidly regaining its lost ground in this country, and which I firmly believe to 
be the true one. After his time, and upon his authority, the treatment of gout lapsed 
into an inert expectancy. Even Cullen came to the conclusion that the best thing to 
be done is to commit the sick man to " patience and flannel alone." Here and there, 
indeed, an advocate of more active measures sprang up. Dr. Rush thought that 
venesection was always safe, and generally serviceable: and some persons, following 
the bad example of the illustrious Harvey, were for extinguishing the inflammation 
• by immersing the affected joint in cold water. Heberden, however, had clearer and 
juster views upon the subject. He perceived that one reason why physicians did 
nothing to checlc the paroxysm was, that they did not know what would check it. 
He agreed with Cullen in thinking " that no medicine for curing the gout had yet 
been found ;" but he did not partake of his behef in " the impossibility of a cure by 
medicines." 

" The itch (he observes) is supposed to be wholesome in some countries, where it 
is endemical ; and an ague has been considered as a minister of health, whose pre- 
sence and stay ought by all means to be courted. These opinions are now pretty 
generally exploded in England ; and I hope the time wifl come when a specific for 
the gout, as certain as those which have been discovered for these two disorders, will 
ascertain the equal safety and advantage of immediately stopping its career, and pre- 
venting its return." 

That time has come : for the colchicum, judiciously employed, may fairly be 
accounted a specific for the gouty paroxysm. And it is remarkable how long this 
truth has been seen, though not distinctly or steadily. The hermodactyl of the 
ancients is the modern colchicum, and was in high estimation among them for its 
efficacy in the same forms of disease as are benefited by the colchicum now. It 
bore, with some, the name of anhna ariiculorum, the soul of the joints, because (as 
Cluincy states) it prevented " the lodgment of such gritty matter as occasions the gout 
and arthritic complaints." And I think there can be no doubt that the active prin- 
ciple of the quack medicine so much in vogue for the cure of gout some years ago — • 
I mean the eau medicinale — was either the same with that of the meadow-saffron, or 
derived from the same family of plants which Decandolle has associated together 
under the title " Colchicaceas." 

This drug has certainly the property of easing, in an almost magical manner, the 
pain of gout. How it operates is not so clear. It is apt to produce nausea, faintness, 
and diarrhoea ; but its curative influence is not conditional upon the occurrence of 
these symptoms. Sometimes the rapid disappearance of the gouty inflammation is 
its only perceptible effect. The patient may be in helpless agony, with a tumefied 
red joint, to-day ; and walking about, quite well, to-morrow. The colchicum is, 
therefore, plainly an anodyne. It also sensibly modifies the condition of the urine, 
rendering it less acid, and even alkahne ; and increasing its quantity. These effects 
are consequent, I presume, upon changes in the blood wrought by this substance, 
which thus, and there, proves somehow an antidote to the poison of gout. 

There are, as you are aware, various preparations of colchicum in use : the wine 
of the bulb : the wine of the seeds ; the vinegar of colchicum ; the acetous extract, 
made by evaporating that vinegar; the inspissated juice of the plant itself. These 
are all of them active and valuable medicines ; and I should pretend to more know- 
ledge than I possess, if I undertook to tell you which of them is the best. 

The mode of administering the remedy, in a regular fit of the gout, is simple 
enough. For example, you may give forty or sixty minims of the vinum colchici, 
in a sahne draught, at bed-time ; and half a drachm more, in a warm black dose, the 
next morning ; and you may repeat this sequence if the gout continues. Some per- 
sons give twenty minims every six hours, with a drachm of Epsom salts, and a 
drachm of syrup of poppies in the draught, till the symptoms yield ; but I prefer the 
other plan. In this way the pain is usually calmed, and the swelling reduced in a 
few days ; or even, as if by a charm, in a few hours. 

But you must not be satisfied with thus quelling the pain and inflammation. A 



922 



GOUT. 



strong prejudice at one time existed, and still exists among some practitioners, against 
the colcliicum. It was said that it had indeed the power of cutting short the paroxysms, 
but that it cut short the patient's hfe also : that they who trusted to it for getting rid 
of the gout, very seldom lived more than two or three years afterwards. How far 
this was true I cannot tell : but even admitting it to be true, it was not, I conceive, 
so much the fault of the medicine as of the patient, or of the medical man who did 
not properly admonish the patient. Men were very glad to get rid of their gout on 
such easy terms ; and they will sometimes say to us now : " I have, as you see, got 
the gout. This is Monday. I must be in the House of Commons, or attend such 
and such a meeting, or be at the head of my regiment, on Wednesday : and I expect 
that you will enable me to do so." Or even sometimes the reason may be that they 
are engaged to some good dinner two or three days afterwards. Now if patients are 
content, or are suffered to be content, with expelling the gout from their toe, Mathout 
observing abstinence more than a day or two, and without any depletion or further 
medication at the time, we can easily perceive the probabihty of their being soon 
attacked by some formidable internal complaint. I apprehend that the proper way 
to eradicate the lurking residue of the mischief is to continue to give small doses of 
the colchicum ; five minims of the wine, for instance, two or three times a day, for a 
while. Moreover, purgatives must be employed, if that remedy does not prove 
aperient. Not violent purgatives, however, which, by weakening the patient, seem 
to strengthen the power of the gouty virus. With mild cathartics, moderate doses 
of mercury will generally be advisable, to correct the subsisting disorder of the 
hepatic functions ; and the patient must adopt and pursue abstinent, or at any rate 
strictly temperate habits, in respect to meat and wine. 

And as I think that the dregs, if I may so speak, left behind it by a gouty 
paroxysm, may be dispersed by the continued use of what, in the usual acceptation 
of that word, I may call alterative doses of colchicum (doses, that is, which produce 
the desired purpose gradually, and by insensible operation), so I think it probable 
that many a fit of the gout might be averted, if the remedy were given in the same 
way upon the first occurrence of the ordinary premonitory troubles. Many of those 
troubles never appear to reach the crisis of a fit. There are headaches, attacks of 
asthma, derangements of the digestive organs, which, occurring in a gouty person, 
are presumed to be fainter intimations of the presence of the gouty poison in the 
blood : and if such symptoms yield (as unquestionably they often do) to colchicum, 
the presumption draws near to proof. Dr. Holland has well remarked that the 
meadow-saffron, by its curative effects, may bring sundry maladies, hitherto thought 
anomalous, under the same law of morbid gouty action ; just as the Peruvian bark, 
has reduced many complaints, that were previously vague in their nature, within the 
same category of aguish distempers. The same author conjectures that as hypo- 
chondriasis is certainly often symptomatic of the gouty poison in the male, so may 
sometimes the kindred disease, hysteria, be in the female. 

Strange stories are recorded — strange, but I believe true — of instantaneous cures 
of the gout by strong mental emotion ; by sudden terror, by violent wrath. Dr. Rush 
relates an instance of this. An old man who for several years had suffered an 
annual attack of gout, was lying in one of these paroxysms, when his son, by some 
accident, drove the shaft of a wagon through the window of his room, with vast 
noise, and a great smashing and destruction of glass. The old man leaped out of 
bed, forgetting his crutches ; and his wife, on entering the apartment, was surprised 
to see him walking up and down, and exclaiming angrily against the author of the 
mischief. The late Professor Gregory, of Edinburgh, was in the habit of mention- 
ing another example to the same effect, authenticated to him by a naval surgeon. 
It occurred to the person of an officer who was freed from an attack of the gout, when 
at sea, by an alarm of fire. Whether this influence of certain states of the mind be 
rightly alleged or not, it is clear that we can never hope to make any practical use 
of such a remedy. Indeed, a fit of the gout has been sometimes brought on by a 
mental shock. 

The treatment of a gouty patient in the interval between his attacks of gout, 
whether regular or irregular, must be chiefly regimenal. The instances are not few 



GOUT. 



923 



of men of good sense, and masters of themselves, who, being warned by one visita- 
tion of the gout, have thenceforward resolutely abstained from rich living, and from 
wine and strong drinks of all kinds, and who have been rewarded for their prudence 
and self-denial by complete immunity from any return of the disease ; or upon whom, 
at any rate, its future assaults have been few and feeble. On the other hand, many 
who are liable to gout are taught by sharp experience that a single debauch, a casual 
glass or two of champagne, even an unusual indulgence in the use of animal food, 
may suffice to bring their enemy suddenly upon them. I am sure it is vvorth any 
young man's while, who has had the gout, to become a teetotaller. But the case is 
different with the and with those whose health has been broken by the inveterate 
disease. They must be allowed a certain quantity of their accustomed good cheer, 
or they become an easier prey to the disease. In such cases you must trim, as well 
as you can, between opposite dangers ; between the Scylla of excess, and the Cha- 
rybdis of debility. 

It is the same with respect to exercise. The young and the hearty can scarcely 
take too much : the old and the dilapidated, by one act of over-exertion, may incur 
the penalty of an attack. Although I can do httle more than point out general prin- 
ciples for your guidance, I may remark, in reference to exercise, that it should 
never be violent., lest it excite a paroxysm by straining any part, or by causing great 
fatigue : that it should be habitual, daily — not used by fits and starts, and interrupted 
by long periods of indolence or inaction : and that it should be active muscular ex- 
ercise, as distinguished from passive exercise or gestation. No mode of exercise is so 
good as that of walking ; and with this may be agreeably and beneficially conjoined 
riding on horseback. 

Early and regular hours are also of much importance ; and the avoidance of severe 
mentaLapplication. Sydenham relates that one of the most atrocious attacks of gout 
he ever underwent was induced by intense thought and study, in the composition of 
his medical works. 

The regimen which I have been recommending may require some power of self- 
control ; yet in reality it implies no severity of mortification. It is perfectly compa- 
tible with life's best enjoyments ; but to be efTectual it must be adopted early, as soon 
as the disease threatens : and steadily persevered in. Gouty persons, however, do 
not like these restraints. They are ready to believe that an attack of gout will do 
them good ; or if they are disabused of that error, they are desirous that some medi- 
cine may be found which will avert the disease, without their being obhged to forego 
their accustomed indulgences. "To gratify this desire (says CuUen) physicians 
have proposed, and to take advantage of it empirics have feigned, many remedies." 
One of these was the famous Portland powder, of which Heberden remarks : " Unura 
est ex multis quse vocantur remedis specifices, quorum ortum, et splendorum, et oc- 
casum vidi." It consisted chiefly of bitters and aromatics, and had descended, with 
some shght v^iations in its composition, from the times of Galen. Another pre- 
ventive has recently been praised by Dr. Graves, of Dublin, as being highly ser- 
viceable, although (what is a suspicious circumstance) it had, like the Portland pow- 
der, fallen out of fashion. These are its ingredients : — Two ounces of orange peel, 
an ounce of powdered rhubarb, and two ounces of the pulvis aloes cum canelld of 
the Dublin Pharmacopoeia, steeped for a week' in a quart of brandy. A tablespoon- 
ful of the strained infusion is to be taken, mixed with two or three spoonfuls of 
' water, night and morning. Sir Henry Halford recommends what I think a better 
j form of prophylactic remedy ; viz., a few grains of rhubarb, with double the quantity 
of magnesia, every day : or some light bitter infusion, with tincture of rhubarb, and 
I about fifteen grains of the bicarbonate of potass. 

j Now what has been observed respecting preventive remedies of this kind is, not so 
I much that they are inefficacious, as that, when exclusively trusted to, they are unsafe. 
I I believe that they are often useful by improving the digestive process ; but they are 
I dangerous substitutes for a course of temperance and exercise. 

' When gout attacks the stomach, either by retrocession or primarily, it often proves 
rapidly fatal. The gastric affection is not, in general, inflammatory ; so we judge, at 
least, from the juvantia. The attack, which consists of violent pain, and a sense of 



924 



CUTANEOUS DISEASES. 



weight or of constriction in the epigastrium, with sickness, vomiting, and a disposi- 
tion to faint, is often reheved by the employment of stimulants. But such remedies 
would be likely to aggravate inflammation. It will always be well when symptoms 
like these occur, to inquire whether any indigestible food has been lately taken ; for 
gout (so called) in the stomach has sometimes turned out, under the test of an emetic, 
to have been nothing more than pork in the stomach. In the true gouty seizure, 
antacids will frequently remove the pain ; magnesia, in full doses, with rhubarb. If 
this does not succeed, opium may be resorted to ; and if it should be vomited, opiate 
enemata may be injected. Dr. Heberden thought that opium, and hot spices, were 
more efficacious and less inconvenient, in these cases, than wine and spirits ; but 
when they fail, a glass of brandy will often allay the pain completely. The mus- 
tard poultice, or the turpentine stupe, apphed over the epigastrium, has been follow- 
ed by strikingly good effects. And it is in these emergencies, contingent upon 
retrocedent or misplaced gout, that we are justified in the endeavour to induce gout 
in the extremities ; not, however, by internal stimuli, but by enveloping the feet in 
a mustard poultice, and so enticing or provoking the foe to quit his hold of the inte- 
rior, and to appear at the outposts. And this expedient should be practised, what- 
ever may be the internal organ upon which the gouty disorder has settled. 

Sometimes, but much less commonly, actual gastritis does seem to ensue ; and 
therefore all these cases are anxious and alarming cases. I do not know how the 
inflammatory affection can be discriminated from the non-inflammatory, unless it be 
by the occurrence of tenderness with the pain, and of fever. You must treat such 
cases as you would treat an ordinary case of gastritis, taking no further heed of the 
gout, except by the application of stimulating cataplasms to the feet. 

This concludes what I proposed to say respecting gout and rheumatism ; diseases 
of which the local seat is not exactly external, nor yet do they belong strictly to the 
interior of the body, except in their accidental complications. They form a hnk of 
connection between the internal and external disorders which fall to the care of the 
phjT^sician ; and I proceed, in the next and last place, to speak of those complaints 
which either concern the integuments alone, or which, at any rate, are attended with 
some notable affection of the skin. 

Under the general head of cutaneous diseases, are included maladies of very dif- 
ferent kinds, and of very different degrees of importance. Some are attended with 
fever, and run a definite course, and are often dangerous to life. Others are chronic, 
irregular in their progress, troublesome perhaps, and obstinate, and disfiguring, yet 
implying no peril to the existence of the patient. Some again are contagious, while 
many are not so. But before I enter upon any further account of these divseases, I 
wish to make you acquainted with the names by which the various morbid appear- 
ances presented by the skin have been known, since the time of Dr. Willan. 

That author — whose works have been augmented by Dr. Bateman, so that per- 
haps I ought to say those authors— divides cutaneous diseases into eight orders, dis- 
tinguished from each other solely by the appearances upon the skin. I shall omit 
the last of these orders, the order of maculse, such as freckles, and congenital spots 
and discolorations, because in fact these are not diseases at all. 

The first, then, of the appearances described by Dr. Willan are papidss; pimples. 
These are little elevations of the cuticle, of a red colour, and solid ; not containing, 
I mean, any fluid. They are of uncertain duration, and often terminate in scurf. 
They are supposed to denote inflammation of the papillas of the skin. If you wish 
for an example of a papular eruption, look at that of small-pox, at its very earliest | 
outbreak. • 

The second are squamse; scales. These are small, hard, thickened, opaque, j 
whitish patches of unhealthy cuticle. The subjacent surface is red. They are well | 
seen in lepra and psoriasis, and are very common in syphilitic eruptions. | 

The third are exanthemata; rashes. They consist of superficial red patches on | 
the skin, variously figured and irregularly diffused, and of all sizes. We have exam- 
ples of them in some of the most important febrile cutaneous diseases ; scarlet fever, 
measles, and others. 



EXANTHEMATA. 



925 



It is a pity that some other technical denomination was not chosen to express these 
rashes ; for the term exanthemata has long been familiar to the profession as the title 
of an order of diseases in Cullen's Nosology. 

The fourth are bullx; blebs, miniature bhsters. Large portions of cuticle are 
detached from the subjacent skin, by the interposition of a thin transparent liquid ; 
with inflammation beneath them. Such occur in erysipelas sometimes, and in 
pemphigus. 

The fifth are pustulse; pustules. Circumscribed elevations of the cuticle, con- 
taining pus, and having red inflamed bases. We have instances of these in common 
boils, and in the eruption of small-pox when at its height and maturity. 

The sixth are vesiculx; vesicles. Small elevations of the cuticle, covering a 
fluid which is generally clear and colourless at first, but becomes afterwards whitish 
and opaque, or pearly. These are exemplified in the eruption of cow-pox, and in 
the chicken-pox. You will observe that these vesiculsB differ very little, except in 
size, from the bullse, or blebs. They often terminate in small scabs. 

The seventh are tuber mix; tubercles. This also is an unlucky appellation, since 
the word tubercle is almost appropriated, in the present day, to the scrofulous depo- 
sits which infest the lungs, and other parts of the body, in pulmonary phthisis. 
However, these cutaneous tubercles are small, hard, superficial tumours, circum- 
scribed and permanent ; or, if they suppurate at all, ihe suppuration in them is par- 
tial. Sometimes they slowly ulcerate at the summit. The imperfectly suppurating 
pustules of the modified small-pox, and certain red spots which are apt to haunt the 
face, particularly of young persons, furnish examples. 

Now, it is very convenient, for the purpose of distinguishing different diseases, 
and of describing them, to know these outward marks when you see them, and to 
use these names. But they form a very unfit basis for the classification of diseases. 
Maladies may usefully be classed according to their causes ; according to their inti- 
mate nature ; according to the general plan of treatment they may require. But 
the superficial markings of disease have no definite relation to any of these heads. 
Besides, a complaint which is papular to-day, may be vesicular to-morrow, and pus- 
tular next Saturday. Yet the classification most commonly followed in this country, 
and in France, is that of Willan and Bateman. Here we find collected under one 
and the same division, maladies which nature has stamped with broad and obvious 
marks of distinction : the febrile with the non-febrile ; contagious complaints with 
those which have not that property ; ailments that are local and trivial, with diseases 
of grave import, and deeply rooted in the system at large. And, on the other hand, 
distempers which nature has plainly brought together, and connected by striking 
analogies and resemblances, this methodical arrangement puts widely asunder. I 
point out, without professing to remedy, these imperfections. I cannot even under- 
take to give you any full or systematic account of the many disorders comprised in 
this classification. There is, however, one group so remarkable, so important, and 
so highly interesting, that I shall consider it as much in detail as I can. I allude to 
the group which CuUen comprehends under the title exanthemata. With this 
exception, the advancing year warns me that I must contract what I have to say 
respecting diseases of the skin within very narrow limits. 



LECTURE LXXXIII. 

Exanthemata. They are contagious ; sometimes epidemic. Period of the Erup' 
tion; Period of Incubation. Theory of Contagious Febrile Diseases. Conti- 
nued Fever. 

Of the numerous complaints which are ranked among the diseases of the skin, 
some, I observed in my last lecture, are attended with fever, and some are not. 

4c 



926 



EXANTHEMATA. 



Among the former there is a highly interesting group, distinguished by other and 
more important characters than the mere presence of fever, or pecuhar marks upon 
the skin ; dharacters that enabled Cullen to collect these diseases into a separate 
order, to which he gave the name of exanthemata. This is his description of them : 
" Morbi contagiosi, semel tantum in decursu vitse aliquem afficientes ; cum febre inci- 
pientes ; definito tempore apparent phlogoses, saspe plures, exiguas, per cutem spar- 
sae." Contagious diseases ; attacking a person once only in his life ; beginning with 
fever. At a definite period small eruptions appear, often numerous, scattered over 
the skin. These, you will allow, are very remarkable characters. They are not 
all strictly and universally true, perhaps, of all the forms of disease which I propose 
to bring now under your notice ; but they apply with more or less exactness to con- 
tinued fever, to the plague, to small-pox, chicken-pox, measles, scarlet fever, and 
erysipelas. 

Hooping-cough, and the mumps, might be placed in the same catalogue, although 
there is no specific eruption on the skin in them: but I have already spoken of these 
two disorders. 

Before I take up the consideration of any one of these diseases in particular, I shall 
premise a brief survey of certain circumstances that are more or less common to them 
all. This preliminary examination of the exanthemata as a class, will give you, I 
trust, clearer ideas respecting them : at any rate it will enable me to dispense with 
much needless repetition afterwards, and so to save both your time and my own ; a 
matter of some consequence at this advanced period of the session. 

In the first place, then, the diseases comprehended in this group are contagious 
diseases. You will hear persons disputing about the term contagion ; but such dis- 
putes can only arise from the want of a distinct definition of the sense in which it 
is employed. I understand a disorder to be contagious, when it is in any way com- 
municable from one person to another. Some would restrict the word contagion to 
the cases, in which there must be absolute contact of the healthy body with the 
sick body, or with its visible offscourings. When the disease can be conveyed 
through the medium of the atmosphere, or by means of other intermediate substances 
called fomites, they would call it infectious. And there is no objection to such a 
distinction, provided it is understood by the reader, or hearer, as well as by the writer 
or speaker. But since in all cases the disease is conveyed to the person of the reci- 
pient by particles of matter proceeding from the person of the sick, and since it 
seems very unimportant whether those particles are in a solid or in a gaseous form, 
whether they are imparted by direct contact of the two human bodies, or by being 
wafted through the air, or carried upon articles of clothing, I shall include both and 
all these modes of communication under the single term, contagion. This, in fact, 
is what is done in common discourse : all disorders that are " catching," I shall take 
leave to consider contagious. 

In this sense I believe that all the diseases just now enumerated are contagious ; 
some, no doubt, much more strongly and distinctly than others. Some of them, 
indeed, are undeniably contagious. For example, we are privy to, and sometimes 
willing agents in, the communication of small-pox from one individual to another. 
There are others concerning the contagious nature of which medical opinion is less 
settled and unanimous. Many persons deny that continued fever is communicable 
from person to person. The evidence from which I conclude that it is so, I will lay 
before you when I have described that disorder. Even they who admit that it is 
contagious, are of opinion, manjr of them, that it sometimes breaks out spontaneously, 
without the intervention of any specific virus. No one questions, I fancy, the con- 
tagious properties of measles; or of scarlet fever. Whether the plague, and whether * 
erysipelas, be always or ever so produced, has been thought more doubtful. There 
is every reason for believing that the small-pox, at least, has now no other source than 
contagion. How it first arose, it may be difficult to conjecture ; but it is never known 
to originate spontaneously now-a-days. 

Small-pox may in truth be regarded as the rtopo^fty^a, or type, of this group of 
diseases. I shall, therefore, take by anticipation, some well-ascertained facts in its 
history, for the sake of illustrating the general subject. It is a malady which could 



EXANTHEMATA. 



927 



iscarcely be mistaken for any other ; and of which the horrible aspect and fatal 
tendency are so strongly marked, that its appearance has always been watched 
with affright by mankind in general, and with intense interest by the philosophic 
physician. 

In the acme of this disease, when it is severe, the whole surface of the body is 
covered with innumerable little pustules. A minute portion of the matter contained 
in any one of these pustules, jiist so much as may suffice to moisten the point of a 
lancet, is inserted, we will suppose, beneath the cuticle of a healthy man, who has 
not been near the sick man. What follows this engrafting? Nothing, apparently 
for several days : but then febrile symptoms burst forth : and by and by a crop of 
papulse appear sprinkled over the skin : and these gradually ripen into pustules pre- 
cisely resembling that from which the engrafted drop was taken. 

The very same phenomena ensue, if a healthy man enters the chamber of a small- 
pox patient, and breathes, for a certain time, an atmosphere tainted with the emana- 
tions from his body. 

The points to be noticed here are — 1, the manifest introduction of the virus into 
the system : 2, its dormancy for a while, in other words, the occurrence of a period 
of incubation : 3, the breaking out, at length, of a disease identical in its symptoms 
and in its character with that of the first patient : and 4 (most surprising of all), the 
enormous increase and multiplication of the poisonous matter. 

I say the history of small-pox leads to the settled behef that this disorder, of which 
few persons are not readily susceptible, never occurs, except from contagion. It 
was quite unknown in Europe till the beginning of the eighth century. No men- 
tion of any such malady is to be found in the Greek or Roman authors of antiquity. 
Now whatever may have been the deficiencies of the ancient physicians, they were 
excellent observers, and capital describers of disease : and it is impossible that a 
disorder so diffusive, and marked by characters so definite and conspicuous, should 
have escaped their notice, or have been obscurely portrayed (if known) in their 
writings. 

On the other hand, Mr. Moore, in his learned and interesting History of Small- 
pox, has shown that it prevailed in China and Hindostan from a very early period • 
even more than 1000 years before the time of our Saviour. That it did not sooner 
extend westward into Persia, and thence into Greece, may be attributed partly to the 
horror which the complaint everywhere inspired, and the attempts that were conse- 
quently made to check its progress by prohibiting all communication with the sick 
partly to the limited intercourse which then took place among the eastern nations, 
but principally to the peculiar situation of the regions through which the infection 
was diffused ; separated as they were from the rest of the world by immense deserts 
and by the ocean. 

The disease is said to have broken out in Arabia at the siege of Mecca, in the 
year in which Mahomet was born ; ^. e., in the sixth century. It was widely pro- 
pagated by his wars, and by those of the Arabs afterwards ; and, as I said before, 
it is generally believed to have first found entrance into Europe at the time of the 
overthrow of the Gothic monarchy in Spain by the Moors ; when to avenge the well- 
known outrage upon his daughter, " Count Julian called the invaders." Whensoever 
and wheresoever it came, it spread with fearful rapidity and havoc. 

What I wish you to remark is this : that while almost all men are prone to take 
the disorder, large portions of the world have remained for centuries entirely exempt 
from it, until at length it was imported; and that then it infallibly diffused and esta- 
blished itself in those parts. 

Of the more modern history of the disease our knowledge is more precise and 
sure. It tends uniformly to the same conclusion. 

There was no small-pox in the New World before its discovery by Columbus in 
1492. In 1517 the disease was imported into St. Domingo. Three years later, in 
one of the Spanish expeditions from Cuba to Mexico, a negro covered with the pus- 
tules of small-pox was landed on the Mexican coast. From him the disease spread 
with such desolation, that within a very short time, according to Robertson, three 
millions and a half of people were destroyed in that kingdom alone. Small-pox was 



928 



EXANTHEMATA. 



introduced into Iceland in 1707, when 16,000 persons were carried off by its ravages ; 
more than a fourth part of the whole population of the island. It reached Green* 
land still later, appearing there for the first time in 1733, and spreading so fatally ay 
almost to depopulate the country. 

Evidence to the same effect is furnished by the results of vaccination in some 
countries. In Mr. Cross's History of a Variolous Epidemic which occurred at 
Norwich in 1819, it is stated, upon good authority, that vaccination was adopted in 
Denmark, and made compulsory, in 1800. After the year 1808, small-pox no longer 
existed, and was a thing totally unknown. Whereas during the twelve years pre 
ceding the introduction of the preventive disease,* 5,500 persons died of the small- 
pox in Copenhagen alone. Statements corroborative of this account have been made 
to me in the present year (1638) by Dr. Blick, an intelligent Danish physician, who 
was on a visit to London. 

Now it is a very instructive fact respecting this disease, thus rankly contagious, 
and arising from no other source than contagion, that when it is epidemic in any 
places, many instances of it occur which we can by no means trace to contagion. 
Dr. Gregory tells us that of the numerous cases received into the Small-pox Hospital 
(to which he has long been physician) not one in twenty is capable of being referred 
to any known source of infection ; the disease being ascribed by the patient to cold, 
fatigue, change of air, or some other innocent circumstance. A prisoner shut up in 
soHtary confinement in the Penitentiary at Milbank was seized with small-pox. 
Surely this should warn us against inferring of analogous disorders (of continued 
fevers, for example) that they are necessarily not contagious, because we often fail 
to discover any way in which the poison could have been apphed. If small-pox be 
produced by contagion alone, and yet the mode in which the contagious matter has 
been communicated eludes sometimes our closest scrutiny, then we must conclude 
that the same thing may happen in other contagious diseases, of which the contagious 
property may not be so strong or so obvious. Nay, the argument from analogy will 
lead us a step further. If once a disorder of this kind is decidedly proved to be 
sometimes the effect of contagion (and this I think I shall be able to prove to you of 
continued fever) — we cannot help entertaining a doubt whether the disorder in ques- 
tion really ever has any other cause. It is chiefly with a view to the fight which 
they throw upon the obscurer subject of continued fever, that I am thus anticipating 
some points in the history of the contagious nature of small-pox. 

Again, it is noticed of small-pox — and it is the same with the other diseases in 
this group — that the human body is not always equally susceptible of its contagious 
influence. Some individuals are more readily affected by it than others : and the 
same individual more so at one time than at another. There are even some who 
seem to be incapable -of taking the small-pox — ^just as some, who are quite as much 
perhaps in the way of it as their neighbours, never become infected with the great- 
pox. Of 215 persons who had not been vaccinated, nor had the small-pox, and who 
were hving at Norwich in the same houses with persons ill of that disease, fifteen 
did not become affected with it ; and of these fifteen it was ascertained that ten had 
escaped under similar circumstances of exposure before. I mentioned, on a former 
occasion, the fact that a certain dog, in Paris, could not be made to take the conta- 
gion of rabies. 

It is not at all uncommon for persons to resist the influence of contagion at one 
period, and to yield to it at another, even when the exposure has appeared to be 
Jess complete. Mr. Cross gives a striking example of this. A man, who believed 
that he had had the small-pox, Uved for twelve years as a nurse in an estabhshment 
for the reception of persons inoculated with that disorder. At the end of that time 
he caught the small-pox, which proved fatal to him. Now this might have been, 
and probably was, as the man supposed, a second attack. ,^ The late Mr. Lockley 
told me an instance still more remarkable, as being free from that ambiguity. Nearly 
the first patient he ever attended, if not the very first, was an old woman, who for 
years had been in the habit of going from village to village as a nurse ; and of nurs- 
ing a great number of persons labouring under small-pox, which she had never had, 
and against which she (naturally enough) believed herself proof. At length she 



EXANTHEMATA. 



929 



was taken ill, and died of small-pox, under Mr. Lockley's observation, at the age of 
eighty-four. 

In many cases we can assign no reason for these variations and differences. Age 
seems to have something to do with them. Infants are but little susceptible of the 
operation of contagions. Debihty, howsoever produced, certainly augments the dis- 
position to be affected by this, as by other causes of disease. The dose and strength 
of the poison must also be taken into account. As some men can drink a much 
larger quantity of wine (which is an alcohohc poison) than others, without being in- 
toxicated, and are differently influenced by the same quantity at different times, so is 
it also with the animal poisons we are now considering; so is it, as I showed you 
before, with the mineral poison of mercury. 

This fluctuating power to resist contagion is most conspicuous, perhaps, when 
viewed in reference to scarlet fever. After the very earliest periods of life, children 
catch infectious disorders of all kinds readily enough ; more readily than in mature 
age. The poison of scarlet fever operates with less certainty upon adults than the 
poisons of small-pox, or of measles. Some medical men escape scarlet fever alto- 
gether, although brought much into contact with it by their vocation. I do not know 
that I ever had scarlet fever. 

Another fact, well worthy of notice, is, that small-pox, which is so rankly conta- 
gious, and which has at present no other source besides contagion, has its alternate 
periods of slumber and of activity. This metropolis, and most of our large towns, are 
never entirely free from it. Scattered cases occur here and there ; and when thus 
thinly disseminated, the disease is said to be sporadic. But there are seasons in 
which it spreads rapidly and extensively, and assumes the form of an epidemic dis- 
temper. We are now living (1838) in the midst of one of these epidemics of small- 
pox. The same is equally true of the other complaints included in this group. 
Sometimes they are confined to single families ; sometimes they pervade a whole 
district. 

Hence you can never infer that any febrile disorder is not contagious, merely be- 
cause it prevails epidemically. Many epidemic diseases are not contagious. But 
the two properties may and do meet in the same malady. They are not to be set in 
opposition to each other, or regarded as incompatible properties, as they have been, 
by some ingenious writers. 

With respect to these epidemic visitations of the exanthemata, certain general facts 
have been ascertained, very useful and necessary to be known, 

1. The strength of the contagion, and the severity and fatality of the disease, vary 
at different periods of an epidemic. In general the contagion is the most active, and 
the disorder the most fierce, at the outset of the epidemic. By degrees its violence 
slackens, and it ceases to spread. This is partly to be explained by the circumstance 
that the number of persons who are susceptible of the disease, and who have not yet 
been attacked, are fewer and fewer as the epidemic proceeds. The fire langfuishes 
for lack of fuel. But this does not seem to be all. The disease dies out before it 
has affected all those who are capable of receiving it. We might, I think, expect, 
prior to experience, that the earher cases would usually be the severer: for the 
weak, who are less liable to struggle with the complaint, and those who, by pecu- 
liarity of constitution, are most susceptible of the morbific influence, are likely to be 
the first to suffer. 

2. There are great varieties also in the general character of the symptoms that 
occur in different epidemics of the same disorder. At one time, or in one place, in- 
flammatory symptoms run high; in another place, or at another time, there is an 
early tendency to debihty and sinking. One epidemic is more malign than another. 
And the practice varies accordingly ; so that these are facts of the greatest importance. 
The prevailing character of the malady is attributed to what is called the epidemic 
constitution of the season. And when we have made out, by observation, what this 
epidemic constitution is, we have obtained a clue to the proper management of the 
disorder. Thus continued fever, as it has appeared in London during the last twelve 
years, has required and borne far less depletion than it did for the preceding twelve* 
years or more. 

59 4c 3 



930 



EXANTHEMATA. 



You may Jearn from this how dangerous it is to apply indiscriminately in one 
epidemic the remedies that may have been found useful in another : and also how 
foolish and unfair it is to censure the practice employed and recommended by others, 
merely because it differs from that which we, in other epidemic visitations of the 
same disorder, have considered fitting and beneficial. 

These differences in the pre valency of the disease, and in the character of its 
sym.ptoms, are not to be explained by any variation in the exciting cause, which is a 
definite animal poison ; nor can they be reasonably ascribed to any appreciable 
quality or agency of the weather at the time. They must depend upon chang-es 
that have been slowly wrought upon the human body : and those changes, consti- 
tuting an acquired predisposition, are probably due to previous conditions of the 
atmosphere, which have exercised a long and gradual influence upon all the indivi- 
duals of a community. 

After stating, in the first clause of his definition, that the exanthemata are conta- 
gious diseases, Cullen announces, in the next place, the very curious fact, that they 
occur but once in a person's hfe. " Semel tantum in decursu vitee aliquem afii- 
cientes." In this they offer a remarkable contrast to inflammations, which, having 
happened once, are, for that very reason, more apt to happen again. 

You will take care to observe, that it is not the mere circumstance of the disease 
being contagious that makes the difference. Those disorders which shield the sys- 
tem against their own future recurrence are, all of them probably, contagious ; but 
the converse does not hold. It is not true that all contagious disorders protect the 
constitution from their own return. Syphihs, purulent ophthalmia, the itch : these 
not only do not secure a patient from a repetition of the disease, but perhaps they 
even render him more hable to it in future. 

Neither is the proposition absolutely and invariably true of any disease. Like 
most general rules, it admits of occasional exceptions. There is not one of the group 
enumerated in the beginning of this lecture, which has not been known to occur 
more than once in the same person. Small-pox has, in many instances, affected the 
same individual twice ; even when the first attack had been so severe as to have 
engraved deep traces of its visit upon the skin. There are a few instances recorded 
of its third recurrence. It was believed, at one time, that whenever the disease was 
thus repeated, it was always, in the first instance, severe, which, taken in conjunc- 
tion with the repetition, was thought to indicate a strong natural susceptibihty of the 
disorder. But it has since been noticed that the primary visit is sometimes unusu- 
ally mild : and this fact (so powerful is the love of theory) has led to the supposition 
that the first attack was not sufficiently intense to affect the whole mass of blood, and 
to exhaust the inborn susceptibility. I believe that the two attacks have always been 
separated by a considerable interval of time. I have myself known one very strik- 
ing instance, about which there could be no mistake, of the recurrence of measles in 
several children of the same parents. This proclivity to be again affected by the 
specific poison seems to run in families. It is less uncommon for scarlet fever to 
happen a second time in the same individual. No contagious disease therefore fur- 
nishes complete future protection against itself. But that this privilege belongs, as a 
general rule, to small-pox, to measles, and to scarlet fever, there can be no doubt : 
and the vahdity of the rule is applicable in the order in which I have here mentioned 
them. It applies, also, though less uniformly, to the other exanthemata. A person 
who has suffered a well-marked attack of continued fever is far less liable than ano- 
ther, according to my experience, to have that disease again. The plague is said to 
afford a temporary safeguard against itself. Very few persons have it twice in the 
same season. During one epidemic Dr. Russell found that, among 4,400 individuals 
who underwent the disease, only twenty-eight contracted it a second time. The 
singular property we are considering is less plainlj'- visible in erysipelas than in any 
other malady of the group. 

The next clause in Cullen's definhion asserts the supervention of the cutaneous 
marks, in technical language, of the eruption, at fixed times {definito tempore) after 
the commencement of the general fever. It is clear, therefore, that the cutaneous 
inflammation cannot be the cause of the fever, but is itself an effect of the contagious 



EXANTHEMATA. 



931 



poison. Here again we have a mark of distinction between febrile exanthemata 
and inflammatory fevers, or what C alien calls the phlegmasisB, in which the local 
inflammation commonly precedes the pyrexia. 

In point of fact, the circumstance to which I have just referred shows the impro- 
priety of ranking these diseases under the head of cutaneous diseases. They would 
more rightly be called blood diseases. The disseminated cutaneous inflammation is 
a curious and an important circumstance ; and it is the symptom which, in the ma- 
jority of cases, is most distinctive of the disorder : but it is not an essential circum- 
stance. Thus, although there often is a manifest eruption (quite independent of 
common petechias) in the eadier stage of continued fever, a lenticular mottling, some- 
what like that of measles, yet it is often absent altogether. And the very same 
thing happens in other diseases of the same group — diseases which all the world 
considers and calls cutaneous. A febrile affection, often a fatal one, but attended 
with no rash, proceeds sometimes from the contagion of scarlet fever. The fever — 
or rather the patient — is not scarlet. The worst form of cynanche maligna is of 
this kind. It is just the same in measles. Authors speak of morbilli sine morbillis ; 
of scarlatina sine scarlatina ; and even of variolas sine variolis. Catarrhal symp- 
toms certainly occur sometimes in weakly children who have been fully exposed to 
the contagion of measles ; and the complaint has proved fatal, without there having 
been any eruption at all. So in the plague : certain cases occur in which there are 
no buboes nor carbuncles, yet which undoubtedly originated from the common con- 
tagion of the prevailing epidemic. 

The time at which the eruption comes out differs in the different diseases ; and 
even in the same disease, it is subject to occasional variation. The rule with re- 
spect to small-pox is, that the spots begin to be visible on the third day ; that on 
which the sickness and fever commenced being reckoned the first. As far as I 
have observed, this rule is a very constant one. It has been noticed, however, that 
when the disease is confluent, and therefore severe, it occasionally shows itself in 
eruption on the second day ; and when quite distinct and mild, sometimes not till 
the fourth. 

The regular period for the outbreak of the cutaneous affection in measles is the 
fourth day : it scarcely ever begins sooner; but it is often later — on the fifth or the 
sixth day, or even later than that. 

Cullen assigns the fourth day for the ordinary appearance of the rash in scarlet 
fever also. But in this he is decidedly wrong. Sometimes it is, I beheve, percepti- 
ble on the first day ; but its most general period is the second day. In severe and 
unfavourable cases it may be postponed till the fourth day, or longer. 

The eruption, which is tolerably constant in some varieties of continued fever, 
observes less regularity in the time of its arrival. 

The period which intervenes between the reception of the poison, and the super- 
vention of distinct symptoms — the period during which the virus, though doubtless 
at work, seems to lie dormant in the system — the period (in one word) of incubation, 
differs also in the different diseases of this group, and varies even in different cases 
of the same disease. Although no marked changes occur during this period, I be- 
lieve that some slight deviation from the usual condition and feehngs of the patient 
might often be observed, if they were expected and looked for. 

The period of incubation in continued fever is very uncertain. In a paper upon 
this curious subject, published in the ninth volume of the Medical Gazette, Dr. 
I Gregory states it as his opinion, derived from much inquiry, that ten days is the 
I average period. Dr. Haygarth reckoned the minimum period at seven ; the maxi- 
j mum at seventy-two days. Sir William Burnett, in his Account of a Contagious 
I Fever at Chatham, gives the history of a party of men belonging to the *S'/. George, 
j lying at Spithead, who were sent, on the 3d of January, 1811, to assist in navigating 
I the Dolphin troop-ship ; the crew of which were affected with typhus fever. On 
I the 10th (seven days after exposure) fourteen of these men were sent to the Hos- 
pital-ship from the St. George, ill with the fever ; and many subsequently, up to 
the 21st of January (the eighteenth from exposure), after which period no cases 
occurred. 



! 



932 



CONTAGION. 



The period of dormancy is more definite, yet still liable to some variation, in most 
of the oiher exanthemata. "At the Small-pox Hospital," says Dr. Gregory, " abun- 
dant evidence has been afforded that the period of incubation is usually about twelve 
days." It is a remarkable fact that, " when the small-pox is received into the system 
by inoculation, seven days only elapse between the insertion of the virus and the 
establishment of the fever." 

Dr. Bateman puts the period of incubation in measles at " from ten to fifteen 
days." I have known several instances in which the date of a single short exposure 
was exactly ascertained, and in which the disease commenced precisely a fortnight 
afterwards. In scarlet fever, the average period is shorter ; not more than from four 
to six days. In the plague it is, I beheve, more variable ; but generally not exceed- 
ing a few days. Dr. Russell tells us that, among those inhabitants of Aleppo who 
shut themselves up after having been in the way of the contagion, no instance 
occurred of the appearance of the malady later than the ninth or tenth day. 

To say that a febrile disorder is contagious, is the same thing as to say that it is 
produced by an animal poison. Now, there are many poisons, very deadly poisons 
too, which cause diseases that are not communicable from person to person. That 
particular poison, the malaria, is of this kind. 

Of the inorganic poisons, some are taken into the blood, and emerge again from 
the body, unaltered, with one or more of the ordinary secretions ; chiefly with the 
urine. They may induce changes in the body as they pass ; and if these changes 
be salutary, the substances so inducing them become medicaments. If the changes 
be destructive or injurious, they are strictly poisons. 

Other of the inorganic poisonous substances do not find so ready an exit from the 
body. They enter into permanent chemical union with the constituent tissues of 
particular organs. In this way, to use the words of Liebig, they deprive the organs 
of the principal property which appertains to their vital condition, viz., that of suf- 
fering and of effecting transformations. If the organs of which the functions are 
thus destroyed he vital organs, these poisons are fatal. 

But the animal poisons, those at least with which we are now concerned, act in a 
totally different manner. They effect changes in the blood, whereby they are them- 
selves abundantly multiplied or reproduced ; and the eruptive disease that ensues 
seems to be the mode provided by nature for the escape or the expulsion of this 
newly-formed morbid matter from the system. This is the old-fashioned humoral 
pathology, founded on bold, unproven speculation ; and it is most curious to see 
these very doctrines, which had sunk into universal discredit and contempt, now 
again assuming their places, as scientific truths, upon the secure basis of organic 
chemistry. A wonderful specimen this of the sagacity of the older physicians — of 
the despised wisdom of our forefathers. 

The ancients attributed various disorders to a fermentation of the animal fluids. 
The cause of fever, according to Hippocrates, was some morbid matter in the blood. 
This matter, by a process of concoction, was brought, in a certain number of days, 
into a state in which it was ready for expulsion from the body. It was then thrown 
off by hemorrhage, by sweat, by alvine discharges ; or deposited upon the surface 
in the form of abscess, or cutaneous eruption : and these eruptions or evacuations 
constituted the crisis of each fever. 

The doctrine thus enunciated by the father of physic is very nearly the same with 
that which Liebig is teaching in the nineteenth century. This distinguished chemist 
ascribes the phenomena which succeed the introduction of certain animal poisons into 
the blood, to a process exactly resembling fermentation. Let me try, in a few sen- 
tences, to expound to you his views on this deeply interesting subject. 

You know that the brewer excites the fermentation of his sweetwort by adding to 
it a small quantity of ?/e«.Sif. Wort is an infusion of malt, and contains sugar and 
gluten, with other vegetable matters, in solution. Yeast is putrefying gluten ; and 
its component particles are, therefore, in a state of intestine motion or transposition. 
When placed in contact with sugar in solution, it has the property of communicating 
a similar intestine motion to the elements of the sugar, whereby they arrange them- 



THEORY OF CONTAGIOUS FEVERS. 



933 



selves into new and simpler forms ; namely, into alcohol and carbonic acid. If there 
were no gluten in the wort, this would be the whole of the process ; during which 
the added yeast disappears. 

But the decomposition ox fermentation of the sugar reacts upon the gluten in the 
wort, and converts it gradually into yeast, which, mingling with the liberated car- 
bonic acid, rises and floats upon the surface of the fermenting liquid. , So that, when 
the process is completed, there has been produced thirty times as much yeast as was 
originahy added to the wort. 

Now, this is but a type of what happens in other fluids under analogous circum- 
stances ; and it may be laid down as an abstract proposition in Liebig's, or rather his 
translator's words, that " a substance in the act of decomposition, added to a mixed 
fluid in which its constituents are contained, can reproduce itself in that fluid, exactly 
in the same manner as new yeast is produced, when yeast is added to liquids con- 
taining gluten." 

Thus, the virus of small-pox (which virus is formed out of the blood) causes such 
a change in the blood as gives rise to the reproduction of the poison from the con- 
stituents of that fluid; and whilst this process is going on, the natural working of 
the animal economy is disturbed — the person is ill. The transformation is not 
arrested until all the particles of the blood v/hich are susceptible of the decomposi- 
tion have undergone the metamorphosis. 

- Liebig shows that similar processes may take place in mixed fluids (and therefore 
in the blood), without the regeneration of the added substance ; just as the ferment- 
ation of a solution of sugar is effected by the addition of yeast, without any repro- 
duction of the yeast, if there be no gluten in the saccharine solution.- In such 
cases, the disease which accompanies or results from the transformations that occur 
in the blood, is not contagious ; the poison is not renewed. It is thus, apparently, 
that certain miasms produce disorders which are not communicable from person to 
person. 

In order that a specific animal poison should effect its own reproduction in the 
blood, and excite that commotion in the system which results from the formation and 
expulsion of the new virus, it is requisite that a certain ingredient (analogous to the 
gluten in the brewer's sweetwort) should be present in the blood ; and this ingre- 
dient must have a definite relation to the given poison. 

If this ingredient be indispensably necessary to life, the poison which transforms 
and destroys it, is inevitably a fatal poison. May not this be the modus operandi 
of the poison of hydrophobia ? 

Again, if this ingredient be wanting, no reproduction of the poison takes place; 
nor, of course, any of those symptoms which are consequent upon such reproduc- 
tion. The poisonous qualities of the animal substance are not developed. It ceases 
to be a poison. 

And this ingredient, if naturally present, is exhausted and destroyed, for a while 
at least, by the operation of the poison. Hence, for a while at least, the same dis- 
ease cannot be again produced by the agency of that poison. 

Supposing the ingredient to be one which is not essential to the composition of the 
blood, and to have been thus destroyed or exhausted, it may never be replaced. Or 
it may be replaced only after a long interval. In some persons it may never exist 
at all, or it may exist at certain periods only of their lives. It may even be acquired 
by unnatural or peculiar modes of living. 

All this is not only very possible, but probable. A certain number of peculiar 
substances do certainly exist in the blood of some men which are absent from the 
blood of others. In childhood and in youth, the blood of the same individual con- 
tains variable quantities of substances which are not to be found in it at other periods 
of life. 

This theory of Liebig's offers, then, a reasonable explanation, the only explanation, 
indeed, that 1 have ever met with — of the curious facts, that certain contagious dis- 
orders furnish a protection, temporary or permanent, against their own return ; that 
they have a tolerably definite period of incubation, and run, for the most part, a de- 
terminate course ; that some persons are less susceptible than others of the influence 



934 



THEORY OF CONTAGIOUS FEVERS. 



of these animal poisons, or not susceptible at all; and that the same individual may- 
be capable of taking a contagious disease at one time, and not at another. 

Moreover, the light supplied by this theory gives distinctness to our conceptions 
respecting certain deviations from the regular course and type of these diseases ; 
which deviations are not uncommon. 

Thus the symptoms which precede and usher in the eruption are sometimes slow, 
halting, and irregular in their progress; appear, and then recede, and reappear, so 
that we are in doubt what is about to happen, until at length the disease declares 
itself in its decided and authentic form. 

We may suppose this to depend upon some tardiness or interruption of the pro- 
cess, whereby the virus is (to use the ancient term) concocted. 

Again, the series or combination of symptoms that marks the specific disease is 
sometimes, as I stated before, incomplete. We have the eruption of measles without 
the catarrhal symptoms ; the sore throat without the rash of scarlet fever. And expe- 
rience has found that, where the malady is thus imperfectly developed, the protection 
it confers against its own recurrence is also incomplete. To explain this double 
failure we may reasonably infer a corresponding defect in the series of changes which 
the poison tends to produce in the mass of the blood. 

Glandular enlargements and chronic abscesses are frequent sequelm of these ex- 
anthematous disorders. They may be considered to represent the dregs of the repro- 
duced virus, which has been imperfectly ehrninated from the system by the usual 
channels. 

Such is a brief exposition of Liebig's ingenious theory. Do you ask whether I 
adopt it, with implicit credence in its truth ? I answer, " By no means." Respect- 
ing points so curious, it is scarcely possible to refrain from speculation altogether. 
These views come recommended by the authority of a consummate chemist. They 
furnish a plausible explanation of the main facts of the case : namely, that the disease 
is produced by an animal poison ; that the specific virus increases prodigiously in 
quantity within the body during the progress of the disease ; and that the suscepti 
bility of its influence in that individual, is thereby somehow exhausted. I entertaiii 
the theory, therefore, until a better one is propounded. It has this incidental merit, 
that it involves no risk of practicaJ error. 

The subtle contaminating effluvia which proceed from the bodies of the sick enter 
the blood of those who catch the disorder, chiefly, I imagine, by being inhaled into 
their lungs in breathing. The poison may, perhaps, be capable of being spontane- 
ously absorbed through the skin : and upon this supposition oil has been smeared 
over the surface with the view of shutting out the contagion of the plague. The 
virus may gain direct entrance into the blood ; we know that it sometimes does so, 
for we ourselves insert it, in inoculation of the small-pox. Dr. Francis Home im- 
parted measles by engrafting some blood of a person ill of that complaint; and sub- 
sequent attempts to excite the disease in that way have been equally successful. 
Some rash and unfortunate trials have proved that the plague is communicable by 
inoculation with matter from the buboes. 

Endeavours have been made to estimate the distance to which the influence of 
different contagious emanations extends. The effluvia in small-pox, measles, and 
scarlet fever, are the most active ; operate, I mean, at the greatest distance. In 
continued fever they have a less range ; and in the plague the diameter of the infec- 
tious circle is probably very small. Some have even supposed that the plague is 
communicable only by actual contact; but the opposite opinion seems the more 
likely, namely, that you may touch plague patients with impunity (as Bonaparte is 
known to have done on a memorable occasion) if you avoid inhaling their breath, or 
the effluvia proceeding from their bodies. 

The most important practical result of the experiments made by Dr. Haygarth and 
others, for determining the absolute distances to which the power of the contagion 
extends in different disorders, was, that where, ventilation is complete, in other words, 
where the gaseous poison is freely diluted with atmospheric air, the sphere of its 
operation is very limited. 



CONTINUED FEVER. 



935 



It is an interesting subject of inquiry, worth glancing at for a moment, how far the 
power of different contagions is modified by differences of temperature. Small-pox 
is readily propagated either in hot or in cold regions ; in Mexico near the equator, in 
Greenland towards the pole. The plague does not spread when the temperature is 
below 60° or above 90° Fahrenheit. The vaccine matter loses its property of pro- 
ducing the cow-pox if it be exposed for a certain time to extreme cold, or to a heat 
of 95°. Typhus fever, measles, and scarlet fever, are said to be of extremely rare 
occurrence in the intertropical regions. Dr. Henry has turned these facts to useful 
account by proposing to decompose and destroy certain contagions lurking in fomites, 
by the operation of artificial heat. 

Having thus pointed out many circumstances of interest, which are common to 
all, or nearly all, the diseases grouped together under the title of exanthemata, I may 
now proceed to a more particular account of those diseases in succession. And I 
shall begin with continued fever ; because, although it does not afford the best- 
marked example of the collection of symptoms that compose CuUen's definition of 
the order, yet a right understanding of the practical points concerned in the manage- 
ment of this febrile disease will assist us materially towards a just conception of the 
modifications of treatment that may be required by the rest. 

We hear continually, both in and out of the profession, different species of fever 
spoken of. By the pubhc, typhus fever, brain fever, bilious, putrid, low, nervous. 
And systematic writers are to the full as particular: mucous fever, ataxic, adynamic, 
gastro-enteric, and so forth. Now, admitting that fever shows itself under various 
forms, I am persuaded that the effect upon the mind of all this subdivision is bad 
and hurtful. It encourages a disposition, already too prevalent, to prescribe for a 
disease according to its name. There is no line of genuine distinction between 
continued fevers that can be rehed on. They run insensibly into each other, even 
the most dissimilar of them ; and are traceable often to the same contagion. I 
shall in the first place, therefore, attempt to describe this disease of continued fever 
as it occurs in its most ordinary and simple form ; and then point out its principal 
varieties. 

Continued fever does not always commence in the same way. It often happens, 
that for several days before the disease assumes its distinct and proper aspect, and 
before the patient is rendered unable to pursue his usual occupations, he is affected 
with certain morbid symptoms, which may be considered premonitory of the fever ; 
so that it is sometimes difficult to mark the precise beginning of the disease. These 
prehminary symptoms result apparendy from an altered condition of the nervous 
system. The poison in the blood disturbs the functions of animal life before it 
causes any palpable derangement in the mechanism of the circulation. The expres- 
sion of the patient's countenance alters ; he becomes pale, languid, and abstracted. 
Those about him observe that he is looking very ill. He is feeble, and easily tired; 
reluctant to make any exertion of mind or body ; listless, and apprehensive often of 
some impending evil. He loses his appetite ; his tongue becomes white and inclined 
to tremble; the bowels are irregular, often confined, sometimes affected with diar- 
rhea; his senses lose their natural delicacy. He has uneasiness or wandering pains 
in various parts of the body ; and occasionally there is some giddiness: drowsiness, 
perhaps, during the day, and unsound and unrefreshing sleep at night. To collect 
all this into one expressive word, the patient evidently droops. 

In other cases these prehminary movements are altogether wanting. Chomel 
gives the following comparative account, deduced from the exact observation of 112 
patients in this particular. In 73 of these cases the invasion of the disease was sud- 
den, without any warning, in the midst of apparent good health. In 39 there were 
prelusive circumstances. 

The regular onset of the fever is, very frequently indeed, marked by a shivering 
fit. Another common phenomenon at the period of the invasion is severe headache; 
pain or aching across the forehead. According to Chomel, the headache is usually 
first experienced by the patient when he gets up in the morning. But this certainly 
is not a constant symptom. There is sometimes a sense of heaviness and vertigo 



936 



CONTINUED FEVER. 



rather than headache. Another symptom which sometimes, but not so often, sets in 
with the fever, is diarrhcea; and this is an important circumstance when it does 
occur. It is attended, perhaps, with pain or uneasiness in the abdomen. You will 
also perceive, even when there have been no premonitory circumstances, that symp- 
toms arise, even thus early, which belong to the nervous system, and denote some 
disturbance and alteration in the functions of sensation, thought, and voluntary mo- 
tion. They are comprised under the general phrase, febrile oppression,^^ and they 
are different from what we notice when pyrexia supervenes upon inflammation. 
You will obtain a clearer notion of what this term, febrile oppression, means, by 
watching at the bedside of one patient in this disease, than by any description I can 
give you. There is great inaptitude for exertion of the power of thought, or of mo- 
tion. The expression of the face is dull and heavy, absent, puzzled. The patient 
presents very much the appearance of a person made stupid by drink ; and he stag- 
gers a httle if he attempts to walk. The muscular power is sensibly enfeebled : 
sometimes the patient will struggle against this ; but in a few hours, or in a day or 
two at furthest, he takes to his bed. 

These are the symptoms which mark the outset of the disease we are about to 
consider. They occur sometimes in other disorders of the class in which I have 
placed continued fever. In the plague, for example. The patients appear hke people 
who are drunk. Now these symptoms result, no doubt, from changes which are 
going on in the blood, and which make an early and a strong impression upon the 
nervous system. And there is another circumstance which, when it is observable, 
denotes a depressed state of the nervous power. Practitioners sometimes are in 
doubt whether the case may not be one of some visceral inflammation : or, perhaps, 
knowing it to be continued fever, they still think it expedient to bleed the patient. 
Now faintness or actual syncope is much more easily produced by the abstraction 
of blood, in continued fever, than it is in inflammation: and this fact may occasion- 
ally be the means of distinguishing between incipient continued fever, attended, for 
instance, with catarrhal symptoms, and pure incipient pneumonia. 

In order the more clearly to describe the course of continued fever, I shall divide 
it, as others have done, into periods ; v/eekly periods. Not that there is any such 
period of seven days allotted to particular symptoms ; but that in the simplest forms 
of the disease, when it runs its course most evenly and favourably, and therefore, we 
may suppose, the most regidarJy also, there is a succession of different sets of symp- 
toms, which occupy each about that space of time ; nearly enough to allow of my 
taking it, I say, as a help to the better describing the disease. 

iVJany of the symptoms which occur during the first stage of the disorder— during 
the first week, we will say — are such as belong to the sanguiferous system. The 
pulse becomes more frequent than in health, there is increased heat of skin, and 
thirst; headache, and throbbing of the temples. The pulse varies considerably in 
different cases. Generally, I say, its frequency augments ; but sometimes it is even 
slower than natural. The acceleration of the pulse is greatest [ceteris paribus) in 
those constitutions which are the most irritable. In young persons, in females, and 
in weak or dehcate males, it will often rise, soon, to 120: while in stronger adults, 
it does not so early attain its maximum of frequency, and perhaps does not exceed 
100 throughout the whole course of the disease. Should the pulse in any instance 
reach 130 or 140, the disease is severe : and the majority of such patients die. The 
absolute frequency of the pulse is not, however, of so much importance in this dis- 
order, as its steadiness. If it shifts from one number to another, that afibrds a worse 
prognostic even than its being very frequent; provided it keeps at the same standard. 
The skin, during this period, is generally hot and dry, and it feels to a bystander 
very hot and pungent. The actual heat, however, is not so great as the sensation 
given to the hand might persuade us it was. Dr. Bateman found that, in a majority 
of the cases treated by him, the heat, as ascertained by the thermometer, was about 
100° ; and he never observed it higher than 104°. The thirst is usually troublesome 
for the first few days. The tongue becomes clammy or dry ; sometimes it is clean 
and smooth ; more ofien furred ; its edges and tip will, perhaps, be red, then a white 
fur will begin, which either covers the central part of the tongucj or is divided bj a 



SYMPTOMS. 



937 



straight brown streak whicli occupies its middle portion. This brown streak is often 
i the first step to dryness and blackness of the tongue. 

I Daring the same period a careful examination of the abdomen will detect indica- 
i lions of diseased action there. Sometimes diarrhcea is an early symptom ; generally 
! it is postponed, I think, to the next period ; or to the latter part of the first. When 
it does occur, the stools are, for the most part, loose and frequent; and either of a 
dark colour, and fetid, or of a yellow-ochre appearance, like pea-soup somewhat. 
I If you make pressure upon the abdomen, you will find it unnaturally hard and re- 
j sisting, as though its walls were made of pasteboard ; slightly tympanitic, as you 
\ learn by making percussion. Frequently, uneasiness is manifested when pressure 
I is made on the belly, particularly over the csecal region ; and Chomel remarks that 
I another symptom, not commonly met with in other diseases, is usually noticeable in 
the first stage of this, viz., a little gurgling movement, evidently from the intermix- 
I ture of liquid and gas within the bowel, which movement becomes audible, or pal- 
pable to the hand, upon pressing the same region. This symptom is still more 
common in the more advanced stages of the disorder. 
I There is evidence, frequently, of a slight affection in the membrane fining the 
air-passages, from nearly the first : some notable quickness of respiration, and some 
diffused rhonchus and sibilus, audible through the stethoscope. 

And among all the indications of increased action in the circulating system, the 
i symptoms that relate to the nervous centres remain perceptible. The aspect of the 
I patient is peculiar : the features are fixed and inexj)ressive ; or expressive merely 
of apathy and indifTerence. If he is spoken to briskly, he responds ; and although 
his sensibility seems blunted, his answers are, as yet, rational, and to the purpose, 
i Delirium does not come on, in general, till towards the end of the first week. The 
i muscular power is greatly depressed. The patient fies on his back, motionless ; he 
sleeps but little, waking often; and the short snatches of repose which, he seems to 
' get, are disturbed, apparently, by uneasy dreams : and he fancies^ and says perhaps, 
! that he does not sleep at all. Sometimes, even during the first stage of the disorder, 
when the bowels are relaxed, the prostration of strength is so great, or the tendency 
to stupor and indifference is so marked, that the stools are passed under him as he 
lies in bed, without any apparent endeavour on the part of the patient to prevent it ; 
and without any notice of his wants being made to his nurse. The urine, during 
the same stage, is scanty, and high-coloured, and ill-smelling often. Towards the 
very end of the first weekly period, the eruption which is peculiar to continued fever 
sometimes begins to show itself : but this is commonly postponed to the next stage ; 
and I shall describe it in connection with the other symptoms that are apt to occur 
in the second week of the disorder. 

It is seldom, except in very malignant forms of continued fever, that death takes 
I place during its primary stages. Of forty -two cases treated by Chomel, one alone 
was fatal in that period. 



LECTURE LXXXIV. 

I Continued fever, continued. Phenomena of the second week ; Delirium, an Erup- 

I tion, Diarrhcea: of the third week; Recovery, or death in the ivay of Coma, 

j of Jipncea, of Asthenia. Symptoms that usher in those modes of death ; morbid 

I changes found after them-. 

In the last lecture I commenced the consideration of that important disease, which 
" is best known, in this country, under the name of continued fever. I told you my 
i opinion that there is but one species, although there are many varieties, of continued 
fever. Sometimes this disease is preceded by symptoms of a slighter disturbance 
j of the system ; and sometimes it sets in suddenly, in the midst of apparent health. 

4d 

! 



CONTINUED FEVER. 



Whatever premonitory symptoms may take place, they indicate some alteration in 
the functions of the nervous system, upon which many pathologists have supposed 
that the first and most direct impression is made, by the exciting cause of the fever. 
But the exciting cause, in most cases, probably in all, is a specific poison received 
into the blood : and all analogy is in favour of the belief that the primary change is 
wrought upon the blood itself. The whole mass of the blood is gradually vitiated ; 
and the first evidence of the circulation of this altered fluid, is depression of the 
powers and functions of animal hfe. Among the earlier symptoms of the declared 
disease, shivering, headache, and occasionally diarrhcea, take the lead. 

For the convenience of description I divided the course of the disorder into three 
weekly stages : not that it necessarily nm5 its course in three weeks, but because 
the sets of symptoms which succeed each other while the disease is in progress, 
occupy, in the cases which seem to proceed the most regularly, about the space of 
seven days each. 

Now the symptoms present during the first week are expressive of disorder both 
of the sanguiferous and of the nervous system. The patient is hot, flushed perhaps, 
and thirsty, and he has a frequent and hard pulse. Besides this he manifests in- 
difference and stupor ; his senses are blunted ; his intelligence is diminished. His 
muscular strength is reduced in a remarkable manner; so that he cannot sit up ; in 
many cases he cannot even lie on his side, or turn himself about well in b^d, but 
remains in the supine position: and if he be purged by medicine, or spontaneously, 
the stools are apt to pass from him into the bed, without his knowing it, or without 
his taking any care to prevent it. This, however, is more common, and more 
marked, in the second period or week ; the phenomena of which I next go on to 
sketch. 

In the first place, in mild cases, and in some epidemics, the patients begin to 
improve soon after the first week. Dr. Welsh, in his account of fever as it occurred 
some years since in the Q,ueensbury-House Establishment in Edinburgh, says that 
of 743 patients, 373 (that is fully one-half) had passed the worst, or had begun to 
get better, by the ninth day ; and several of the physicians who witnessed the fever 
that prevailed in Ireland in the earlier part of the present century, concur in declaring 
that, in a vast majority of cases, the disease had " taken the turn," and the patient 
began to mend, by that time. But the epidemics, in these cases, were undoubtedly 
mild. In general no change for the better takes place at the end of the first seven 
or eight days ; but what are called the typhoid symptoms develop themselves more 
distinctly. 

The changes that occur are usually the following : — The pulse becomes more 
frequent, weaker, and more compressible. The tongue grows drier and brow^ner. 
More sordes, and of a darker colour, accumulate on the teeth and lips : and it is in 
this period that delirium is most apt to ensue ; and that certain eruptions are most 
often observed. But the symptoms that relate to the nervous system are often still 
the most prominent. The patient generally loses his headache. His voluntary 
movements, however, become very much w^eakened, and are sometimes exercised 
irregularly. The posture which the patient in this stage almost always assumes is, 
I say, indicative of this weakness ; he lies on his back, and he sinks down in the 
bed, slips towards the foot of the bed. He is unable to make or bear that degree of 
voluntary exertion which would be necessary to place him upon his side. Hence 
we hail it as a good omen — because it is an indication that the patient still retains 
some strength — if we find him on his side, or even on his back with his knees drawn 
up. Other proofs of muscular debility, approaching to palsy, are apt to present 
themselves. The voice becomes feeble ; the patient can scarcely utter an audible 
sound. Perhaps he is unable to swallow. This is a very bad symptom, though it 
is one that has been recovered from. Sometimes it seems that the power of degluti- 
tion is not lofst, but the sick man is too listless to try to swallow; or the dry and 
parched state of his tongue and throat renders it difficult and painful for him to 
attempt to do so. The patient is apt to he with his mouth open : and breathing 
thus through the mouth tends to dry the tongue. Hence it is well to desire the sick 
person to swallow a mouthful or two of water, and so to moisten his tongue, before 



SYMPTOMS. 



939 



you decide upon the state of that organ, or upon his facility of deglutition. Often, 
m bad cases especially, there are little convulsive startings of the tendons, {subsultus 
tendinum is the technical name of the symptom,) and other irregular and involuntary 
I actions of the muscles : tremulous movements, especially of the tongue and of the 
hands ; and sometimes the patient is unable to put out his tongue at all. There are 
two symptoms which present themselves in the majority of instances in the second 
week of the fever, and vi^hich deserve your particular attention: I mean delirium, 
! and the eruption which belongs to the disease. 

I The delirium is peculiar. The patient wanders, at first, in the night only ; and 
\ the delirium commonly appears on his awaking from disturbed sleep. Sometimes 
ne is desirous of getting up, and talks incessantly and earnestly in a loud voice, and 
I can only be kept in bed by the imposition of some restraint. Usually, however, his 
rambhng is of a tranquil kind, and without agitation. His mind seems elsewhere : 
he is inattentive to all that passes around him ; but he lies still, muttering disjointed 
words or sentences, like a man talking in his .dreams. From this state of typhO' 
mania the patient may sometimes be roused by loud speaking addressed to him, or 
by the sight of a strange face ; so that, though incoherent and dehrious just before, 
he may become collected when his medical attendant enters the room. But he 
presently relapses. During the dehrious state there is a great deficiency of sensa- 
tion, and insensibility to impressions. The patient is deaf. This deafness you may 
hear spoken of as being a good omen, or favourable sign ; but it is so only by com- 
parison : it indicates a condition of brain less perilous than its opposite, in which the 
sense of hearing is morbidly acute. Imperfection or loss of vision is much rarer, 
and much more dangerous, than deafness ; yet the eye is generally dull — unlike the 
brilhant eye of acute phrenitis ; it corresponds with the expression of the counte- 
nance, which is perplexed rather than wild. Sometimes, however, as the disease 
advances, black spots, like flies on the wing, miiscas volltantes, appear before the 
patient's eyes : in consequence, it is presumed, of partial insensibility of the retina. 
The patient attempts to grasp or catch these in the air, or to pick them from the bed 
clothes. This is calleA/loccilafio. After these symptoms recovery is not common. 
The mouth and tongue are dry ; yet the patient no longer complains of thirst. The 
taste, the smell, the sense of touch, are all impaired ; even external inflammation may 
take place, especially about the hips and sacrum, and go on to gangrene, without any 
complaint of pain from the patient. He seems altogether careless about the issue of 
his disorder. If, at this period of the fever, you ask him how he does, he will pro- 
bably declare that he is quite well. I have already alluded to the involuntary 
passage of the feces : this may depend, in part, especially in the advanced stage of 
the disorder, upon debility or paralysis of the sphincter muscles. The urine also 
dribbles away frequently : and these are points which must always be looked after ; 
first, for the sake of keeping the patient as clean and dry as possible, the irritation of 
the urine and fecal matters tending to produce sloughing ulceration; and, secondly, 
with the view of preventing the bladder from becoming unduly distended. Reten- 
tion of urine, and all its bad consequences, may otherwise occur. It is a good general 
rule,* therefore, to examine the hypogastric region every day with the hand; and also 
to ask to see the urine, not for any purposes of prognosis, but to ascertain that it is 
regularly discharged. 

It is also, I repeat, in this stage of the disorder that the rash or eruption, which so 
often accompanies it, very frequently shows itself. Sometimes it is noticed earlier. 
I It consists of small rosy blotches, of a roundish or lenticular shape ; scarcely raised, 
if raised at all, above the general surface of the skin on which they appear. Chomel 
states that they vanish under pressure ; but it is not so. I have again and again ob- 
served that they diminish or become fainter under the pressure of the finger ; but 
they are not effaced even for an instant. They are sometimes few ; sometimes so 
numerous as to dapple the whole surface of the abdomen, or of the thorax, or of both. 
Upon the limbs they are less common, and less closely set. I believe that they often 
besprinkle the back, although they are seldom looked for there. They vary in 
intensit}^ of colour, and, therefore, in distinctness. The whiter the skin, the more 



940 



CONTINUED FEVER. 



obvious do the spots become. In brunettes they may easily escape notice. In this 
form of disease tiie entire skin is often unnaturally dusky. 

The eruption does not come out all at once : nor is its duration always the same. 
Som.etimes it disappears entirely after two or three days. Sometimes, on the other 
hand, it lasts a fortnight, or more. In the latter case it is probable that successive 
crops of the spots continue to arise. 

The rash now described stamps continued fever with one of the most strikino- 
characters of the exanthematous group of febrile diseases : but it certainly is less 
constant than the cutaneous phenomena of small-pox, measles, or scarlet fever. It 
occurs much more regularly in some epidemics than in others. Fever is very rife in 
St. Giles's, and in other crowded parts of this town, just now (1838). Our wards at 
the Middlesex are full of it; and scarcely a case presents itself without these spots. 
We speak of it familiarly as the spotted fever; or, (from the resemblance which the 
rash bears to that of measles, hereafter to be described) as the rubeoloid fever. 

You cannot well confound this mottled rash with petechia, which are httle specks, 
or dark circular spots, resulting from* a minute extravasation of blood beneath the 
cuticle. The specific rash and these petechias are, however, sometimes mingled 
together. 

It may not be superfluous to caution you against mistaking flea-bites, which are 
common to nearly all our hospital patients, for this specific eruption, which is pecu- 
har to the fever patients. The round red stain, with a dark point for its centre, 
sufficiently distinguishes the mark of the insect from the rose-coloured blotches of 
the disease. 

There is another eruption described by the French as occurring in this disease 
without heiwg pecidiar to it. In this country it is now very rare ; but it used, when 
the hot plan of treatment was in vogue, to be very common indeed here, in various 
febrile complaints ; and it was, and is, occasioned by profuse sweating. Siidamina, 
the vesicles composing the eruption are called. They are small, hemispherical, 
transparent elevations of the cuticle, containing a clear watery fluid. The vesicles 
are from a quarter of a line to half a line in diameter ; they have no red bases ; and 
they are so perfectly pellucid, that when you look upon them in a direction perpen- 
dicular to the skin on which they stand, they may readily elude observation. Viewed 
sideways, they present bright surfaces, and look like so many drops of water, and 
you may feel with your hand that they roughen that part affected with them. These 
sudamina are mostly met with on the thorax, along the sides of the neck, and about 
the axillae. By degrees, the hmpid fluid disappears, and they shrivel up ; the cuticle 
becomes wrinkled, and dries into a whitish powder. 

Diarrhop.a is another marked symptom observed in many cases of continued fever, 
though not in all, at this period of the disease. When the stools are involuntary, 
when they are passed in bed without notice on the part of the patient, they add ma- 
terially to his danger, by the irritation and the sores, which are liable to result from 
their contact with the skin. There is seldom much pain of the abdomen complained 
of by the patient ; but if you make pressure, especially about the situation of the 
cfficum, you may often remark that he winces, or that a transient expression of suf- 
fering passes across his features. The character of the evacuation remains the same, 
and is almost distinctive of the disease : thin, yellowish, ochrey, like pea-soup. 
When in fever, such stools persist day after day, and several of them every day, 
you may safely infer that there is ulceration of the bowels, although there should be 
no pain complained of, even Avhen the abdomen is pressed. 

And the same conclusion wiU become still more certain when hemorrhage from 
the bowels occurs, as it is apt to do, in this stage of the fever. It often takes place 
unexpectedly, sometimes in considerable quantities, and rapidly exhausts the patient: 
or it recurs at intervals to a smaller amount, wasting his strength as effectually, 
though more slowly. The bleeding is probably owing, in general, to the division or 
opening of some of the mesenteric veins, by the ulcerating process which I shall 
more fully describe by and by. This is not, however, a necessary consequence of 
the ulceration ; for the vessels are usually obliterated previously to their erosion. 
Sometimes blood may be thus poured into the bowel without being voided. Andral 



SYxMPTOMS. 



941 



relates a case in which a man died suddenly, and unexpectedly, at an advanced 

period of continued fever. Large clots of black blood filled the lower two-thirds of 
\ the small intestines, which were crowded with patches of ulceration. No part of 

the blood had passed the valve of the csecum. 
i Hemorrhage from the bowels occurs also in continued fever sometimes in another 

way ; in connection with other, putrid symptoms, as they are not unaptly called : 
I petechise, purple spots, bruise-like blotches, and extreme depression of the vital 
;| powers. In these cases the hemorrhage is strictly of the passive kind, and it is a 
j symptom of the v/orst omen. Like those effusions of blood from the same parts that 
I happen in scurvy and purpura, it depends upon a morbid condition of the blood. 
' This is no matter of speculation, for by this time the sensible quahties of the blood 
j are manifestly changed : its natural tendency to coagulate when withdrawn from the 
' body is diminished, the crassamentum is large and loose, and fills the cup, and some- 
,j times is rather an incoherent sediment than a clot. When these putrid symptoms 
! are strongly marked, a peculiar fetor is exhaled by the patient's body ; his tongue 

becomes dry, black, and fissured; his teeth are covered with dark sordes ; sloughs 
ij form from the mere pressure of the bed on w^hich he lies ; in extreme cases the toes 

i have mortified ; and Dr. Roupell relates one terrible instance in which both legs rot- 
ted away to the bones, which it became necessary to saw through : yet this patient 
recovered. 

ii Death may take place in this, the second period of continued fever. Of forty-two 
' patients who died under his care, Chomel counted nine in which the fatal event 
' occurred between the eighth and the fifteenth days. 

The phenomena belonging to the third period of the fever vary considerably 
according as the disease is about to terminate in death, or in recovery. Among 
Chomel's forty-two fatal cases, I have already mentioned that one death took place 
in the first week, and nine in the second ; the remaining thirty-two all occurred in 
the third period. And the tendency of the fever to terminate during this period is 
I equally well-marked in the cases which recovered. Of twenty-four such patients 
one alone began to be convalescent in the first week ; and of those whose symptoms 
were at all serious, not one showed marks of convalescence before the end of the 
second. 

When the disorder is about to end favourably, the more formidable of the symp- 
toms diminish and abate. The patient begins again to attend to questions that are 
put to him; the air of stupor which had hung over his countenance clears away; 
he once more shows an interest in what is going on around him ; the temperature 
of his skin becomes more natural, the tongue moist and cleaner at its edges, and the 
frequency of the pulse is less. The evacuations from the bowels are less numerous, 
more consistent, and more healthy ; and the patient is aware when the necessity for 
i passing them arrives, and he gives notice, or asks for assistance. Generally, at the 
j same time with these tokens of improvement, the emaciation which has taken place 
I becomes remarkably conspicuous ; perhaps it is the more observable on account of 
I the patient's resuming a more natural expression of countenance. 
1 In many instances, the amendment is so gradual that we can scarcely say when 
I it begins. In other cases the favourable crisis is preceded by an aggravation oi 
most of the former symptoms, and a marked increase of the general distress. This 
is a very curious circumstance ; and it did not escape the notice of our great dra- 
i matist. 

j Before the curing of a strong disease, 

Even in the instant of repair and health, 
I The fit is strongest. Evils that take leave, 

1 In their departure most of all show evil. 

j Certain evacuations are also sometimes observed to accompany or to be connected 
with the favourable change ; and the most common of those is the evacuation of 
j sweating. 

' On the other hand, when the disease is about to terminate in death, that event may 
take place in different ways ; in either of those modes, in short, which I took some 
pains to distinguish in the earher part of this course of lectures. I told you then that 

4d3 



942 



CONTINUED FEVER. 



I had been taught the importance of studying the tendency to this or that mode of 
dying, in reference especially to fever, by Dr. Ahson. My own experience has 
since sufficiently approved to me the wisdom of his teaching. Cullen inculcates the 
necessity of "obviating the tendency to death." To do so, we must ascertain the 
direction of that tendency. We do not so much cure these exanthematous maladies, 
as keep our patients ahve while they recover. If we would prevent their dying we 
must know in what manner they are in danger of dying. 

The most common mode of death in continued fever is certainly that of coma. 
The organic hfe survives the animal life. The muttering, hall'-conscious, dream-like 
stupor, from which the patient may be roused for a while, becomes, by degrees, 
more profound, and death begins in the head. This mode of death, occurring in the 
second or third week of the fever, is associated, frequently, with the symptoms of 
putrescency already described. But as the stupor deepens, the pulse generally 
grows weak, and the extremities become cold. So that death does not come purely 
in the way of coma ; but we have a compound of coma and asthenia, in which the 
coma takes the lead. 

Now coma may result from at least two different kinds of cause. One cause is 
pressure, which is mechanical. Another, which is probably chemical, is the circu- 
lation of some noxious or narcotic substance (such as opium) in the blood. And 
there are, doubtless, many physical conditions of the nervous mass itself which are 
capable of arresting the cerebral functions, and producing coma. To which kind of 
cause are we to ascribe the stupor that supervenes during the progress of fever? 
That is an interesting, and in reference to practice, an important, question. 

Physicians have diUgently attempted its solution, by examining the dead brain. 
I cannot tell you how often I have looked, and looked in vain, for some palpable dis- 
organization, or some effusion implying pressure. All who are familiar with the 
dead-house of a hospital are aware that this fruitless search for some physical expla- 
nation of the comatose state, after death by fever, is of very common occurrence. 

Chomel — one of the latest, and a very able and accurate French writer on fever- 
gives the following statement in respect to 38 fatal cases, in which the brain was 
carefully and minutely inspected by him. In 15 of the 38, no morbid appearance 
at all was perceptible : in 12 there was some serous fluid, from a teaspoonful to a 
tablespoonful, in the ventricles : in 7 there was what he calls cedema of the meninges, 
effiision, that is, in the meshes of the pia mater : in 6 general but slight diminution 
of consistence : in 2 some alteration of density : in 5 a speckled appearance of the 
cerebral substance. Now to what conclusion do these facts lead us ? Why, in the 
first place, to the conclusion that those pathologists are in error who maintain (as Dr. 
Clutterbuck does, for whose experience and talents I entertain a sincere respect,) 
that the essence of continued fever is inflammation of the brain. Not only do we 
fail to discover, in many instances, any traces of inflammation, upon inspecting the 
dead brain, but we find that, during the life of the patient, measures which would be 
likely to aggravate any inflammatory mischief — strong stimulants, for example, wine 
or brandy, — do actually and obviously, in cases innumerable, relieve the comatose 
symptoms, and benefit the patient. The inference seems unavoidable, that the coma, 
i*i such cases, has some other cause than that mechanical pressure which arises 
sometimes from the effusion of fluid upon the surface of the brain, or within its ven- 
tricles ; and that other cause is supplied by the poisoned blood. Here again we 
may adopt the pathology of Shakspeare : — 

The life of all his blood 
Is touched corruptibly : and his pure brain 
(Which some suppose the soul's frail dwelling-house) 
Doth by the idle comments that it makes 
Foretel the ending of mortality. 

In some malign epidemics the nervous system is overwhelmed at once, in the very 
outset, by the force of the poison. The patient becomes stupid or bewildered ; his 
surface is cold, clammy, purplish, and his pulse feeble : the coma rapidly augments, 
and death may ensue within twenty-four hours. We sometimes see this fearful 
train of symptoms in small-pox ; and still more often and more strikingly in the 



MORBID APPEARANCES. 



943 



I worst forms of scarlet fever. I believe that in these cases there is no deviation, cog- 
nizable by our senses, from the healthy texture and appearance of the parts within 
the skull. 

Nevertheless, there may be, and there often is, in these fevers, actual inflammation 
of the brain or its membranes : but this is an incidental complicaiion. We conjec- 
I ture that, in addition to the influence of the poison upon the nervous system, ther.e 
'I may be a low degree of inflammation going on within the head, when we find it 
I externally hot, when the patient has flushed cheeks, and a vascular eye, and com- 
' plains of dull headache. And there are some instances in which we recognize more 
! distinctly the outward signs of encephahtis — severe pain in the head, high and fierce 
,' delirium, intolerance of light and of sound, with much heat of skin, and a hard pulse, 
j When coma succeeds such symptoms as these, we naturally ascribe it, in part at 
:! least, to the effects of the inflammation : and rightly, for we find traces of inflamma- 
i| tion after death ; serous efliision beneath the arachnoid and in the cerebral ventri- 
I cles ; shreds of coagulable lymph ; and more rarely suppuration. T suspect that 
V genuine encephalitis, which is, of course, attended with pyrexia, is sometimes mis- 
ij taken for continued fever with intercurrent inflammation of the brain. Great atten- 
I tion, and some skill and judgment, are required for discriminating those cases of fever 
in which such inflammation occurs, and for directing the appropriate treatment. 
The death in fever by apima is certainly much rarer than that by coma : yet it 
j is not very unfrequent. It often mingles itself with the death by coma. From the 
; earUest period of the fever we may, in most cases, notice some increased quickness 
1 of respiration, which is not entirely owing to the mere fever, or to acceleration of the 
circulation ; for the ear, when applied to the parietes of the chest, discovers rhon- 
j chus, and sibilus, at least. Frequently there is considerable dyspnea for some 
hours, or for a day or two, before death : and this may be apparent only, in conse- 
quence of the stupor; or it may be real, and proceeding from a low degree of pneu- 
monia, which, by interfering with the due arterialization of the blood, may aggravate, 
I or even give rise to the coma : and such pneumonia is apt to be masked by the 
fever; declaring itself by none of the ordinary symptoms of cough, rust-coloured 
sputa, or pain in the thorax. The inflammation, thus latent, is discoverable, how- 
, ever, by the sense of hearing. 

Now what does dissection teach us with respect to the condition of the lungs after 
death from continued fever ? Why, the most common unnatural appearance met 
with in the pulmonary substance is engorgement : a state similar to that which oc- 
curs in the first stage of pneumonia. But here the engorgement is probably in a 
great measure mechanical, and takes place during the last few days of the patient's 
life. As the vital powers diminish, the laws which govern the physical world re- 
sume their empire. The fluids, and the blood especially, accumulate in the most 
: depending parts of the viscera ; and the lower and posterior portions of the lungs in 
particular become loaded. But besides this, it is not unusual to find large portions of 
the lungs in a state of hepatization, and even infiltrated with pus : and the bronchial 
tubes clogged up by viscid and frothy mucus. 

The mode of death by asthenia or syncope is not very common as existing by 
itself; but it is often combined with one or both of the two other modes. In some 
cases of fever, however, death does appear to take place from mere debility of the 
heart; there having been no pulmonary embarrassment, and the head having remained 
clear. Death, in such cases, is preceded by those symptoms of debihty which have 
I been already described. The pulse becomes small and weak, and like a thread ; the 
patient lies on his back, and sinks down in the bed ; the features sharpen ; the eyes 
I are hollow and dim, as though glazed ; the spiiincter muscles fail to contract ; the 
i extremities grow cold ; cold sweats appear on different parts of the body : and at length 
' the heart ceases to beat and the patient to exist. 

{ Death occurring in this manner does not occur early. It happens at an advanced 
I period of the disease. It is noticed sometimes in persons who have been largely 
' bled, or too actively depleted at the commencement of the fever: and in those who 
have suffered a good deal from diarrhoea. In short, as the two previous modes of 
death are connected, often, with morbid conditions of the head and chest respectively, 



i 



944 



CONTINUED FEVER. 



SO death in fever occurring purely or chiefly by asthenia, connects itself with morbid 
conditions existing within the belly. 

And we trace the vestiges of disease much oftener in the abdomen than either in 
the brain or in the thorax ; and the mischief which we there discover is more con- 
stant and definite than elsewhere. It is proper, therefore, to inquire somewhat more 
closely into the morbid appearances observed in the abdomens of those who die of 
continued fever. 

I need scarcely remind you that the intestinal canai is largely furnished, on its 
inner surface, with glands, or follicles, which consist of little more than crypts, and 
of which the precise office has not yet, I think, been accurately determined. Some 
of these glands are sprinkled (one may almost say at random) over the whole tract 
of mucous surface. These are accordingly called solitary glands. Till I was better 
instructed by Professor Todd, I used to speak of them as being the glands of Brunner ; 
whereas the glands discovered and described b}'- that anatomist are limited to the 
duodenum. Other glands or folhcles are collected into groups, and are named glan- 
dulx agminate, or often the glands of Peyer, who has given a capital description 
of them. Now the arrangement of these glands of Peyer is pecuHar : and, in refer- 
ence to the morbid anatomy of continued fever, very necessary to be known. They 
are met with in the ileum alone : they are, mostly, oblong in form : and they occupy 
that part of the bowel which is opposite its mesmeric attachment. They are largest, 
and most numerous, and consequently most thickly set, in the lower end of the ileum, 
which, in some instances, is almost entirely covered with them ; they are found also 
upon the ileo-ceecal valve ; but beyond that they do not go in that direction. Ascend- 
ing from the ceecum towards the jejunum, these groups or patches become smaller, 
shorter, more circular, and less numerous ; they are separated by longer and longer 
intervals, till at last they cease to be visible at all. Where there are valvules conni- 
ventes, there the situation of these patches is very obvious ; for the valvules conni- 
ventes are interrupted, and never run across them. This fact has sometimes led to 
curious mistakes. I have seen in the museum of the College of Surgeons a prepa- 
ration put up by Mr. John Hunter (but not labeled, I presume, by him), professing 
to be an example of the destruction of portions of the valvules conniventes by ulcera- 
tion. It is nothing more than one of these natural patches, rather more plainly de- 
veloped than usual. 

These glands, in their healthy state, are much more conspicuous in some bodies 
than in others. You. may see, if you look at them attentively, that they are made 
up of a congeries of mucous folhcles, of which the orifices are obscurely apparent. 
Now the main alterations met with in the abdomen after death, in continued fever, 
are alterations of these very glands : of the sohtary glands, to wit ; and still more con- 
stantly and remarkably of the agminate glands. 

The changes which these glands undergo are of the following kind. In the first 
place they become enlarged, -and more perceptible than they are in the natural state. 
They then present a grayish transparent surface, dotted over with black points ; 
which black points mark, I conceive, the excretory mouths of the several follicles. 
Then, as the inflammation, for such it is, advances, the patch becomes reddish per- 
haps ; and the folhcles burst or ulcerate, or slough away : not altogether, but partially 
and by piecemeal; so that an irregular ragged ulcer is generally left, having thicken- 
ed edges. Sometimes, however, the follicles disappear without there being much 
redness or thickening: the mucous membrane immediately adjacent, and even the 
remaining part of the patch of folhcles, being pale, and level. Sometimes the patch 
puffs up into a sort of fungous swelling, in which all trace of the follicular structure 
is lost. The colour of the ulcerated surface is various, as well as its form and ap- 
pearance. Sometimes it is pale and grey ; sometimes red ; oftentimes yellow, as if 
the exposed cellular and other tissues were stained by the ochrey fluid which had 
been poured from the bowels during hfe. What I have hitherto stated relates to 
Peyer's glands ; but the solitary glands participate, usually, in the change. They 
become, in the first place, large and hard, and present a whitish-coloured projection 
from the surface, which, by a mistaken analogy, has sometimes been called a pustule. 



MORBID APPEARANCES. 



945 



At length a loss of substance takes place in these also ; beginning at their summit, 
and producing a small, but sometimes a deep ulcer. 

And of these changes it is further to be observed, that they are more common, 
more nCimerous, more extensive, more advanced, in proportion as we approach the 
caecum. It is natural that we should meet with more ulcers near the ccecal valve, 
because there are more glands there; but undoubtedly the ulcers are (in general) 
further advanced there than higher up in the bowel. 

Going along with this ulceration of the mucous glands of the intestines, and above 
all of the aggregate glands of the ileum, you will frequently find inflammation (z. e., 
redness, hardness, and swelling) of the corresponding me.senfen'c glands. This would 
seem to be a consequence of the inflammation and ulceration of the mucous glands. 
The inflammation of the mesenteric gland is, I conceive, secondary ; and bears the 
same relation to the ulcers seen in the bowel, as a bubo in the groin bears to a chancre 
on the glans penis. 

These alterations are extremely interesting, because they afford a plausible ex- 
planation of many of the symptoms of continued fever. They account for the 
diarrhoea ; they account for one form of occasional hemorrhage from the bowels ; 
they account for the uneasiness of pain which is experienced when the abdomen is 
pressed, and teach' us why that uneasiness is greatest in the situation of the cascum. 
Nay, we can even understand why, although these ulcerations exist, there may be 
no pain occasioned by them. This may be partly owing to the general insensibility 
to impressions and sensations of all kinds, produced by the stupor ; but partly, also, 
it probably depends upon the depth to which the ulceration goes. The mucous 
tissues are possessed of but little sensibility even under inflammation ; but if the 
muscular and peritoneal coats become involved in the inflammatory process, then 
pain begins to be felt. I remember, a few years ago, attending a young lady ill of 
fever, with a very well-informed practitioner, but one of the old school, for he had not 
turned his attention much to the state of the intestines in that disease. One day we 
learned that our patient had had hemorrhage ; from the uterus her friends supposed; 
but when I saw the discharge, I was certain, by its appearance, and by its odour, 
though it was not mixed with any feces, that it had come from the bowels ; and I 
stated my conviction that there was ulceration in the lower portion of the ileum. But 
she had no pain in the abdomen. You might press any part of it without exciting 
the smallest uneasiness. So, distrustful of my opinion, they called in an eminent 
accoucheur, who also pressed and examined the belly : but neither could he detect 
any tenderness or undue sensibility. He next examined the uterus per vaginam ; 
but could discover nothing wrong there. Some few nights afterwards the general 
practitioner was called out of his bed to this patient. He was told that the hemor- 
rhage (or flooding as they called it, for they persisted in believing that it was uterine,) 
had returned ; and before he arrived at the house the patient was dead. We next 
day opened the body together. The uterus was perfectly natural ; there was no 
vestige of discharge or bleeding in the vagina ; but the ileum, for about a foot above 
its entrance into the caecum, was in a state of superficial but ragged ulceration, and 
universally red and smeared with blood. I mention this as a strong fact in illustra- 
tion of the possibility of there being much disorganization of the inner surface of 
the intestines, without any pain to reveal it. 

Now the alterations I have last been sketching — the thickening, redness, tumefac- 
tion, and ulceration or sloughing of the*glands of Peyer, and also of the solitary 
glands — are so common in fever, particularly in some epidemics, that many patholo- 
gists are of opinion that fever is essentially inflammation of these glands, and nothing 
else. But this, I am sure, is an error. In the first place, if this doctrine were true, 
it would almost follow of necessity that the severity of the case, and the intensity of 
the symptoms, should be in proportion to the number, depth, and extent of the 
ulcerations, f But this is far from being so. In cases in which the symptoms have 
been of the worst kind, there have been found very few ulcerations, and those small 
and apparently insignificant. On the other hand, when the complaint has run a 
moderate course, but at length has terminated fatally, it is not uncommon to discover 
a frightful amount of disorganization in the ileum. 
60 



CONTINUED FEVER. 



But what is more conclusive is, that the occurrence of this inflammatory condition 
of the mucous follicles of the intestines is not constant, in continued fever. If one 
well-marked instance of the disease should occur, without any trace of a morbid 
action having been going on in the mucous follicles, that instance 'would, of course, 
suffice to overturn the theory. But scores of such cases have occurred. I have seen 
many such myself ; and other persons have seen more. Since attention has been 
drawn to the subject, the patches of glands, and the whole tract of mucous mem- 
brane, fronri the stomach to the rectum, have been diligently explored : and the result 
seems to be that, at certain times and places (in other words, in certain epidemics) 
the ulceration of the inner surface of the intestines is far less common than at others, 
It was comparatively rare in an epidemic of which I witnessed some part in Edin- 
burgh. Then I came to London ; and for several years I never saw a body opened 
after death by continued fever, without finding ulcers in the bowels. More recently, 
however, and especially during the present epidemic (1838), I have looked for them, 
carefully, in many cases that have proved fatal in the Middlesex Hospital, and have 
discovered neither ulceration nor any other apparent change in the folhcles of the 
intestines. Still, in my own experience, such ulcers have been vastly more often 
present than absent. Chomel, during five years' investigation of this matter in the 
Hotel Dieu, never met with an exception to the general rule of their occurrence ; or 
of some degree or form of that kind of alteration in the mucous glands, of which the 
ulcer is the last stage. 

We must conclude, upon the whole, that although an inflammatory state of the 
solitary and aggregate glands, which strew the surface of the mucous membrane of 
the alimentary canal, is not the essence of fever, yet that it is a very frequent com- 
panion of continued fever. 

But when it does occur, is this state of things always, or necessarily fatal ? By 
no means. It may be fatal, in more ways than one. It may lead to death, by ex- 
hausting diarrhoea, in the way of slow asthenia ; it may kill by laying open a large 
mesenteric blood-vessel, and so producing copious hemorrhage and mortal syncope ; 
it nfay, and often does, destroy the patient, by perforation of the bowel ; the ulcer 
penetrates the mucous and muscular coats, and reaches the peritoneum : and some- 
times that membrane gives way, and sometimes it does not. The consequence of its 
rupture or perforation — the escape, I mean, of the contents of the bowel, and the 
supervention of intense and uncontrollable peritonitis — I need not again dwell upon. 
But the ulcers may, and doubtless often do, heal : and the scars which they leave 
behind them are frequently to be seen. The ulcerated surface seems to clothe itself 
afresh, by degrees, with a new mucous membrane ; which is thin, however, and 
adherent to the subjacent tissues, and does not sHde over them when pressed between 
the finger and thumb, as the healthy portions of the coats of the bowel will do upon 
each other. And in the place of the cicatrix there is usually to be seen a manifest 
puckering, and a number of little wrinkles or lines, radiating from a common centre. 

The spleen — ^I may observe, before I conclude this lecture — is more frequently 
found altered in texture after death by continued fever, than any other part except 
the glands of which I was l^st speaking. It is usually enlarged, of a dark colour, 
and of soft, and sometimes almost rotten, consistence. 

To-morrow I shall endeavour to point out some of the most important varieties 
that have been found to occur in this disease of continued fever. 



LECTURE LXXXV. 

Varieties of Continued Fever. Its Causes. Exciting and Predisposing. Pro- 
phylaxis. 

Having traced, in the last lecture, as clear an outline as T could, of the ordinary 
course and the different terminations of continued fever, I wish to touch, briefly, to- 
day, on some of its principal varieties ; and then to inquire into its causes. 



CONTINUED FEVER. 



947 



Although fever is, as I have stated, a specific disease, it assumes divers forms ; 
and so dissimilar are some of its phases that they might seem to belong to totally- 
different maladies. These variations relate not only to individual cases, but to whole 
epidemics. In some places and seasons, the inflammatory type predominates, marked 
by excitement of the sanguiferous system ; in others, depression of the nervous 
system, characteristic of the typhoid type, is the prominent feature of the disease. 
Most generally of all, the disorder commences with inflammatory fever, and ends 
with typhoid symptoms. The distinctions drawn by Cullen, now well nigh obsolete, 
were founded in nature. To the inflammatory form he gives the name of synocha^ 
which he thus defines: "Calor plurimum auctus ; pulsus frequens, validus, et durus; 
urina rubra ; sensorii functiones parum turbatae." With this he contrasts his typhus. 
"Calor parum auctus; pulsus parvus, debi lis, plerumque frequens; urina parum 
mutata; sensorii functiones plurimum turbatas ; vires multum imminutse." These 
forms I would have you bear in mind : not that you are Hkely to meet with ma%^ 
instances of pure synocha, nor of pure typhus, but because they furnish standards 
of comparison, towards which, in opposite directions, the fevers of different epide- 
mics approach. The most usual variety of continued fever is represented by the 
syrfbchus of the same author, which is a compound of the two others. "Febris ex 
synocha et typho composita: initio synocha, progressu et versus finem typhus." 
The unsoundness of many of Cullen's theories, and the conceit of later and far in- 
ferior writers, have thrown his First Lines into undeserved neglect ; but his clear, 
succinct, and faithful pictures of disease, will not easily be surpassed, and are worthy 
of your attentive study. 

The difference is very striking between the kind of fever that I witnessed in Lon- 
don for ten years before the arrival of the spasmodic cholera in this country, and the 
kind of fever that has since prevailed, and is now (1838) so rife around us. During 
the first of these periods, the antiphlogistic regimen was indispensable in the outset 
of the disease ; in most instances, bleeding-, either general or topical, was required, 
and well borne ; there was no eruption to be seen upon the skin ; the glands of 
Peyer, according to my own experience of the fatal cases, were almost invariably 
affected ; and the mortality was very moderate. This was an inflammatory phase. 
The present epidemic offers a marked contrast in all these points. A large per 
centage of those who contract the fever die ; after death we seldom detect any dis- 
ease of the agminate glands of the intestine ; the peculiar rash scarcely ever fails to 
show itself ; we are taught by experience to refrain as much as possible from blood- 
letting ; and almost from the beginning, or quite, we find it necessary to sustain our 
patients by a liberal allowance of strong animal broths. The typhoid is now the 
prevaihng type. You might, I say, almost suppose that I have been speaking of 
two distinct maladies. But, during each of the periods in question, some scattered 
cases have occurred, bearing most of the characters proper to the other period. 
Moreover, all acute diseases have assumed, w^ithin the last ten years, in this town at 
least, an unusually asthenic character. So that the differences observed in the aspect 
and phenomena of continued fever, depend more, I conceive, upon an acquired dis- 
position of the human body, produced by some obscure general influence, and there- 
fore affecting the entire London community, than upon any change in the essential 
nature of the disease, or in the virus which (as I beheve) occasions it. 

The inverse relation between the rash and the intestinal ulceration ig remarkable. 
When the one is prevalent, the other is rare. It would seem, in conformity with 
Dr. William Budd's views, that the specific poison displays its elective affinities by 
settling sometimes upon the mucous glands, sometimes upon the cutaneous tissues, 
and sometimes by sharing itself, though unequally, between the two. 

I have incidentally alluded to the duration of the fever. In this particular, also, 
there is much variety; a fact which is apparent even to the vulgar, and expressed 
in their ordinary discourse. They talk of the one-and-twenty day fever, and of the 
fourteen-day fever, according as the disorder "takes the turn" in three weeks or in 
a fortnight. It appears from the report made some years ago to the government 
upon the state of fever in Ireland, that the fever there generally began to depart on 
the fifth day ; wherefore it was called, in that part of the kingdom, the five-day fever. 



948 



CONTINUED FEVER. 



Of the fever patients whom I saw in the Edinburgh Infirmary, almost all were fairly 
convalescent, or dead, before the end of the third week. In this place, the disease 
runs out longer ; lasting three, four, or five weeks. I observed also, in Edinburgh, 
that many of those who recovered had a tedious convalescence, in consequence of 
very troublesome sloughs and ulcers which formed upon the sacrum and hips. In 
London, these bed-sores are comparatively uncommon. 

The symptoms attending the fever seem to vary also, cseteris paribus, according 
to the season of the year, and the situation of the patient: whether, I mean, he be 
surrounded with pure and cool air, or with a foul and hot atmosphere. In the colder 
months there is greater risk of inflammatory complications, and especially of pectoral 
affections : in the autumn we look more for diarrhoea, or for dysenteric complaints, 
engrafting themselves on the disorder. Where the air is close and foul, the symp- 
toms show a much greater tendency to the typhoid type, and the deaths are more 
numerous, than where it is pure. 

It is of great importance to hold correct notions as to the exciting cause of conti- 
nued fever ; respecting which there has been, and there still is, a perplexing contra- 
riety of opinion among medical men. You are aware, from what has already l^en 
stated, that I consider the disorder to originate in an animal poison, and to be conta- 
gious ; communicable, I mean, from one who is labouring under the complaint, to 
another who is not. 

,When the same disease attacks many persons in the same house or neighbour- 
hood, at about the same time, the popular suspicion soon arises that the disease is 
catching. Yet you know that disorders may be widely prevalent without being 
contagious. Agues, for example, engendered by malaria ; ordinary catarrhs and 
sore throats, produced by vicissitudes of the weather. When an epidemic malady 
affects large masses of the people suddenly and at once, it is presumably not conta- 
gious ; at any rate, it must have some otTier source besides contagion. When, on 
the contrary, it begins in a certain spot, and gradually spreads thence as from a centre, 
the presumption is in favour of its propagation from person to person. In investi- 
gating this subject, if we trace the fever among persons who have had intercourse 
with the sick, and more frequently in proportion as that intercourse has been close 
and continued ; and if we find that other persons, living in the same place, and 
under precisely the same circumstances, except that they have had no known com- 
munication with the sick, escape the fever ; we have in these facts convincing evi- 
dence that the disease has been spread by such intercourse ; in one word, that it is 
contagious. 

Have we, then, facts of this kind ? We have, in the amplest abundance. 

We find, even in hospitals, where cleanhness and ventilation are prized and en- 
forced, that fever attacks many of the persons who come most often and most inti- 
mately in contact with those already ill of that disease : chiefly the nurses, next the 
clinical assistants and the most assiduous of the students, and the medical officers ; 
rarely the other patients, even in the same ward. The separation of a few feet, if 
due regard be had to ventilation, is sufficient to render the poison inoperative, by 
diluting and diffusing it in the surrounding purer atmosphere. Three of our nurses 
in the Middlesex Hospital have fallen ill of fever during the epidemic now prevail- 
ing, and two of the three have died; I am now attending a pupil of the Charing 
Cross Hospital, who is persuaded that he caught the fever while watching some bad 
cases of it there. It is only when our wards are unusually full of fever patients 
that these disasters occur ; but they happen very often, indeed, constituting the rule 
rather than the exception, wherever many fever patients are collected together: as 
in hospitals which are exclusively appropriated to their reception, or in the fever 
wards of certain general hospitals. In such places, the effluvia which proceed from 
the bodies of the sick are, in spite of all care, the most abundant and the most con- 
centrated. 

Dr. Welch, whose book I have referred to before, has the following statement in 
point : " In this hospital (that is, Queensbury House in Edinburgh, which was opened 
for the sole use of fever patients during the prevalence of a severe epidemic in that 



EXCITING CAUSE. 



949 



city, in the years 1817, '18 and '19), since it was opened (which was the year before 
the time when Dr. Welch was writing), my friends, Messrs. Stephenson and Chris- 
tison, the matron, two apothecaries in succession, the shop-boy, washerwoman, and 
thirty-eight nurses, have been infected ; and four of the nurses have died. With the 
exception of but two or three nurses, who have been but a short time in the hospital, 
I am now the only person who has not caught the disease, either here or at the 
infirmary, within the last eight or ten months." 

I may quote a passage from Dr. Alison, in illustration of the same thing. He is 
speaking of a more recent epidemic, which occurred in Edinburgh in 1827 and 1828. 
He says: "During this epidemic, as well as that of 1817-19, many of the clerks 
and nurses employed in the Royal Infirmary have taken fever. Since November 
last, six of the clerks employed in the cHnical wards only, four of those employed 
in the ordinary wards, and twenty-five nurses or servants, have taken fever. All 
these persons had necessaril}'- frequent and close intercourse with the fever patients 
in the house, having been employed more or less constantly in the fever wards, 
excepting only four of the servants. Of these four, two had been employed in the 
laundry where the Hnen from the fever wards was washed ; one was a porter em- 
ployed at the gate, who would of course have communication with the fever patients 
at their entrance or dismissal, as well as with their relations coming to visit them ; 
and one was a nurse employed in the servants' ward, but who was in the habit of 
visiting the fever wards." Now, mark the contrast. He adds that, " in this very 
place and season, those of its inhabitants who have not had intercourse with fever 
patients have almost uniformly escaped the disease. Of the inhabitants of the 
ground-floor of the house (including patients in the lock-ward), none but those 
already mentioned as having washed the linen from the fever wards, and the barber 
who shaved the heads of the fever patients, have taken the disease. Yet in the 
case of malaria" (to which I must apprise you that many medical men of great 
authority ascribe the occurrence of continued fever,) " it is the ground-floor of the 
house that is generally found the most dangerous. No one of the nurses, whose 
duty has confined them to the medical or surgical wards where no fever patients 
were admitted, has taken fever, with the single exception of the woman in the serv- 
ants' ward above mentioned. And of the numerous patients in these ordinary 
wards, the only one who has taken the fever, within my knowledge, during the pre- 
sent year, was a patient in the men's general clinical ward, who lay in the bed next 
the door that communicates with the clinical fever ward. If there be malaria in 
this house, therefore, it would seem to restrict itself in point of space, as at Queens- 
bury House in point of time, to the immediate vicinity of fever patients." To under- 
stand this last remark, you should know that, in ordinary years, the inmates of 
Glueensbury House escaped fever. 

We have similar testimony nearer home ; in this metropolis. "Every physician 
connected with the London Fever House, with one exception (writes Dr. Tweedie), 
has been attacked with fever ; and three out of eight have died of it. Also the resi- 
dent medical officers, matrons, porters, laundresses, domestic servants not connected 
with the wards, and every female who has performed the duties of nurse, have, one 
and all, invariably been the subjects of fever. And to show that the disease is capable 
of being engendered by fomites. or clothes, the laundresses, whose duty it is to wash 
the patients' clothes, are so invariably attacked with fever, that few women will un- 
dertake the loathsome and disgusting office." 

Now, it is in vain to attempt to escape from this kind of evidence, by saying that 
the situation of the Fever Hospital is infested with some local miasm ; for the in- 
mates of the Small-pox Hospital, which is immediately adjacent to it, are not afl^ected 
in this way with continued fever, but remarkably exempt from it, as Dr. Gregory 
testifies. 

Evidence of a somewhat different kind, but leading to the same conclusion, is 
to be found in the fact, that when persons, having the fever upon them, are trans- 
ferred to some distant spot that was previously free from fever, they frequently 
form centres from which the disease begins, thenceforward, to spread. It is im- 

4e 



950 



CONTINUED FEVER. 



parted, in this way, even in the country, from family to family, and from village to 
village. 

I was summoned home from Edinburgh on account of my mother's serious illness 
with continued fever. She was living in a village where there was httle or no fever 
prevailing. While she was recovering my sister took the disease, and had it se- 
verely. It had evidently been intro^ced into the house by a man-servant, whose 
family hved in a neighbouring village. This family had the disease raging in their 
house, and he was in the habit of going thither occasionally, and always of sending 
his linen to be washed there. He first, in our house, had the disorder, then two of 
the maid-servants, and next my mother. 

The cook of Trinity College, Cambridge, living in a street called the Petty Cury, 
had a daughter in London who fell ill with continued fever, and who insisted upon 
going home. At that time there probably was no case of fever in Cambridge : 
certainly none in the Petty Cury, as Dr. Haviland (who gave me the account) satis- 
fied himself by inquiry. The girl was very ill indeed, after she reached her father's 
house ; but she ultimately recovered. Every inhabitant of that house, except an 
old, seasoned nurse, became affected with the fever ; and three or four of them died. 
But no fever existed in the other houses of the same street. When one of the sick 
persons was convalescent, it was thought her recovery might be accelerated if she 
were put into a lodging at Trumpington, a small village two or three miles from 
Cambridge, in which there certainly was then no fever. Here she and the old 
nurse were waited on by a servant belonging to the Trumpington House. That 
servant soon sickened of the fever, and was sent to Addenbrook's Hospital, where 
she died. 

Take one more instance to the same effect, related by Dr. Alison. " Some years 
ago, at a time when there was no great number of fever cases in Edinburgh, I met 
with a case in the son of a shoemaker, who was lying in a room in which his father 
and two apprentices were at work. I could not prevail upon the father to remove 
his son to the hospital, although I stated the danger of the apprentices being affected. 
Within two or three weeks after, I found that the two apprentices were lying ill of 
fever in their own houses : one of them two hundred yards, the other half a mile 
distant from the workshop, and widely distant from each other. These young men 
likewise la^ at home during the fever; and each of their cases was speedily followed 
by a succession of others in the inhabitants of the rooms w^hich they occupied, and 
of those immediately adjoining, who had never been at the workshop. In one of 
these houses seven, and in the other twelve, were thus affected. Now, on the sup- 
position of the fever being contagious, all this was to be expected, and all corresponded 
to the predictions which were hazarded on that belief. But on the supposition of 
such succession of fever cases depending on miasmata, there must have been at 
least two, more probably three, separate and accidentally concurring miasmata to 
explain the phenomena here observed ; one at the workshop, and one at each of the 
houses of the apprentices : and there must have been this extraordinary coincidence, 
that at each of these last the malaria sprung up just at a time when a patient w^as 
lying ill there of fever, which he had apparently contracted elsewhere. Further, 
the three houses in which these successions of fever cases were observed, are in 
situations very different from one another; and all of them have been, to my know- 
ledge, perfectly free from fever for years together, both before and since that time, 
notwithstanding that fever has been much more generally prevalent, and that they 
have been inhabited by successive famihes. What probability is there (continues 
Dr. Alison) that three separate miasmata should h^ve arisen in these three houses, 
just at the time when their presence was required in each to produce an effect 
which had been foretold as the consequence of another cause undeniably operating 
on all ?" 

If we contrast facts such as I have been advancing, with other cases, in which all 
the circumstances appear to have been precisely the same, except the presence of the 
alleged cause of the disease — making our observations always upon as large a scale 
us possible — we approach, as nearly as the subject will admit of, to a demonstrative 
proof that continued fever spreads by contagion. 



EXCITING CAUSE. 



951 



The reports which were made by the accredited physicians, to a committee of the 
House of Commons, respecting epidemic fever in Ireland, contain abundam and 
valuable evidence on this point also. Dr. Cheyne states that the farmers and house- 
holders in some parts of Wicklow, who would not harbour or admit into their houses 
strolling persons, nor go to wakes or funerals, remained free from the disease. In 
Ballytore a committee was formed of persons who took pains to instruct the inha- 
bitants as to the precautions to be observed against infection : such as refusing admis- 
sion to wandering beggars, absenting themselves from wakes and other assemblies ; 
and even, under certain circumstances, from places of worship. These precautjons 
were so effectual that not a case of fever occurred. Four villages in the neighbour- 
hood of Lismore are stated by Dr. Barker to have been preserved from the fever, 
chiefly by the exertions of some Roman Cathohc clergymen, who persuaded the 
inhabitants to avoid all communication with Lismore, and with another town in its 
vicinity, where the fever was rife. 

Tt was observed also that bodies of persons collected together, and fenced about by 
barriers which precluded intercourse between them and places infected with the 
fever, remained exempt from it; children in charity schools, soldiers in barracks, 
and even prisoners in the jails. In the same parhamentary report you may see a 
letter from Dr. M'Donald, who had established a fever hospital at Belfast, which 
hospital alone, at one period, contained 190 cases of typhus. Very near the hospital 
was a school, containing 700 or 800 young persons ; a poorhouse with 800 inmates ; 
and a barrack with 1000 soldiers. These places were never more free from fever 
than at that time. 

Facts to the same purpose abound in the medical reports of the army and navy. 
Those of the navy are especially valuable and instructive in this matter, because the 
whole of the circumstances in which the patients are placed come under the certain 
and immediate cognizance of the medical officers superintending them. I cannot go 
into particulars here, but must content myself with referring you to the writings of 
Dr. Lind, Sir Gilbert Blane, and Dr. Trotter. You will there find that ships which 
had, for a great length of time, been quite free from fever, have had that disease 
spread rapidly from one individual, recently imported, so as to affect almost all the 
crew. This was often the case when raw recruits were drafted from the receiving 
ships. It appears, from reports made to Dr. Trotter by different naval surgeons, 
and published in his Medidna Nautica, that the fever was conveyed to a great 
number of vessels forming the Channel Fleet, from the receiving ship called the 
Cambridge, 

It is, moreover, found, that when persons ill of fever are taken away from their 
own close crowded houses, and when means of purification are employed, the fever 
ceases to spread in those houses. This well-ascertained fact it is which gives to 
fever hospitals their greatest, nay, almost their only value. They would otherwise, 
as we have already seen, be detrimental or dangerous to all concerned with them, by 
concentrating the poison that produces the fever ; whhout equivalent benefit. As it 
is, they cause, indeed, a certain amount of disease and of death ; but by affording 
opportunities for cleaning an infected neighbourhood of the seeds of the fever, and 
by so preventing its diffusion among a large and heakhy community, they save many 
more fives than they sacrifice. 

You may be surprised that I should appear to labour this point ; and should take 
so much pains to prove what may seem to you, as I confess it seems to me, to be an 
undeniable proposition. But I do so because many have denied, and do still deny 
it ; and plausible reasons are given, by men of name and character, for discarding 
altogether the notion of continued fever being propagated by contagion. Some even, 
who have begun by expressing their belief that the disorder was contagious, have 
ended by becoming strong, ay, violent anti-contagionists. The late Dr. Armstrong 
was one of these ; and there are hving men, of high and deserved repute, both in 
this country and abroad, who hold what I cannot help thinking erroneous — and if 
erroneous, then manifestly dangerous — opinions on the subject. Chomel informs us 
that not one in a hundred of the profession in Paris believes that typhoid fever is a 
communicable disease. Upon a subject so important it is right that you should be 



952 



CONTINUED FEVER. 



furnished with data for forming a correct and settled judgment. But I scarcely ex- 
pect that the facts I have now brought forward will carry the same conviction to you 
all ; for I agree with Dr. Christison in believing that the discrepancy which exists 
upon this, as upon some other controverted questions, depends, in part, upon the dif- 
ferent constitution of men's minds, and their pecuhar habits of thought. Most of the 
anti-conlagionists whom I have known have belonged to that party in this country 
which advocates what are called hberal opinions in politics and in religion. If this 
should prove to be generally true, it must be regarded as a curious psychological 
fact. 

I have laid before you some of the positive evidence which goes to prove the con- 
tagiousness of continued fever. You may naturally ask, and it is but fair that I 
should tell you, what are the arguments on the other side of the question. 

First, then, it is asserted that continued fever cannot be contagious, because some, 
nay many persons, who liave intercourse with the sick, do not contract the disease. 

But the force of this reasoning is completely broken by the well-known fact that, 
in respect to diseases which are on all hands acknowledged to be contagious, and 
w^hich are even propagable by inoculation, small-pox for example, the same kind of 
exemption notoriously happens. Some of those who so escape may have had the 
fever before ; and have thereby become less capable of being re-infected by the 
poison. I beheve it to be uncommon for a person to have genuine continued fever 
for a second time, unless he is exposed to the contagious matter in a very concen- 
trated state, or for a long time together. Some may, by original pecuharity of con- 
stitution, be proof against its power; but probably in most cases, the immunity arises 
from the circumstance that the person has been fortunate enough, or careful enough, 
to escape imbibing an effective dose of the poison. You may breathe, for a good 
while, without much hazard, an atmosphere but faintly imbued with the contagious 
effluvia ; and you may, though with somewhat more of hazard, breathe, for a short 
time, air which is strongly tainted by them, and yet go free. 

Allowance must also be made, in some cases, for the effect of habit in fortifying 
the system against contagion. Persons who are much and often exposed to these 
effluvia, are thereby seasoned, in some degree, to the noxious atmosphere : just as 
drunkards and opium eaters become at length impassive under such a dose of their 
customary stimulus as would intoxicate or stupefy a novice. Upon this principle has 
been explained the comparative immunity from contagious diseases, (under like cir- 
cumstances of exposure,) of medical practitioners, and nurses ; of the keepers of filthy 
lodging-houses, while the new-coming inmates suffer ; and even of prisoners, who, 
Mnthout having had the disease themselves, may nevertheless carry forth and com- 
municate the infection: as is said to have happened at the celebrated "black as* 
sizes" in Oxford ; and again at the Old Bailey in the year 1750. 

This argument, that the fever cannot be contagious because many of those who 
come near the sick are not affected with it, has been happily ridiculed by comparing 
an epidemic to a battle. A man might say, " T was in the battle of Waterloo, and 
saw many men around me fall down, and die, and it was said that they were struck 
down by musket balls ; but I know better than that, for I was there all the time, and 
so were many of my friends, and we never were hit by any musket balls. Musket 
balls, therefore, could not have been the cause of the deaths we witnessed." And 
if, hke contagion, they were not palpable to the senses, such a person might go on to 
affirm that no proof existed of there being any such things as musket balls. 

It must not be forgotten that this same argument, whatever may be its vahdity, is 
equally potent against any other general cause: against local miasms; against an 
undefined something in the air. 

Again, the disorder does not spread, say they, in the houses of the rich. But Avhy 
should it not do so, if it proceeds from any cause which strict attention to cleanliness 
and ventilation does not disarm? The fact, when rightly considered, is a strong cir- 
cumstance in favour of the theory of contagion. 

But then the disorder often occurs when we can trace no contagion : and the full 
answer to this argument is to be found in the fact that the same difficulty applies to 
diseases which are not only confessedly contagious, but which are believed to have, 



ALLEGED CAUSE. 



953 



HOW, no other source than contagion ; even, as I showed you before, to small-pox. 
All that the argument can amount to, is a presumption that the distemper may 
sometimes originate independently of contagion. A person may be exposed to the 
' agency of the contagious matter quite unconsciously, by coming into contact with 
j fomites, or by approaching another person who is just convalescent from the disease. 
A nobleman died here, in the prime of life, last year, of scarlet fever. The story 
goes that he had just come to town, and was dining out, and by his side sat a young 
! lady who had just recovered from that complaint ; and that from her he unwittingly re- 
j ceived it. Tn such a place as this there are a thousand unsuspected ways in which 

I contagion may be disseminated. It may lurk in a hackney coach ; you may catch 
j the complaint from your neighbour in an omnibus, or at the theatre, or at church ; 

I I your linen may be impregnated with the subtle poison in the house of your laundress ; 
or your coat may convey it from the workshop of your tailor. So that, when con- 

i tinued fever occurs, it is very difficult indeed to be sure that it has not arisen from 
contagion ; and it becomes a very interesting question whether the disease ever pro- 
; ceeds from any other cause. It is, however, of primary importance to determine 
' whether it be, or be not, communicable. By our behef in this matter the lives of 
our neighbours and chents may be saved, or lost. Even if we doubt about the con- 
tagiousness of the disease, we are bound to act as if we had no doubt upon the sub- 
, - ject; and I would admonish you (although that is a lower and poorer motive) that 
il your own reputation and success may be endangered by mistakes in this very thing. 
! ! I have been told of one instance which may serve as a warning. A lady came from 
the country to London, to see a sister, who was ill of fever. She asked the medical 
attendant if there was any danger of infection. He happened to be a staunch non- 
i contagionist ; and he said " no danger whatever." Upon the faith of that assurance, 
j the lady resolved to sit up with, and to nurse her sister ; but she fell sick herself of 
the disease, and died. I believe this did not shake the medical man's opinion. He 
' attributed the mischance to some local miasm. But he could not persuade the lady's 
I friends of this. They maintained that her death lay at his door ; and whether 
;i they were right or wrong, the affair was so much talked of, and was so injurious to 
him, that he was obliged to leave that part of the town, and to seek for practice else- 
i where. * 

Many sporadic cases occur of febrile disorder, which do not belong to the category 
of continued fevers, and yet are liable to be confounded with them. All the phleg- 
masiss are attended with pyrexia, and the local inflammation may be slight, or very 
obscurely marked, and easily overlooked ; but the febrile symptoms are much the 
same as those which constitute the more inflammatory forms of continued fever. In 
like manner severe bodilj'' injuries, compound fractures, for example, sometimes give 
rise to constitutional symptoms precisely resembling the most prominent phenomena 
of its typhoid forms. Excluding all such spurious resemblances of the genuine dis- 
ease, I confess my own opinion to be, that continued fever, like small-pox and 
measles, originates, in all cases, from a specific poison. With respect to all these 
disorders, I conceive that, in every %rge community, there is constantly kept up a 
sufficient stock of contagious matter, to act as a sort of leaven, whenever circum- 
stances favourable to the development of the disease, as an epidemic may chance to 
arise. 

Continued fever has been ascribed, by those who deny its origin in contagion, to 
' certain other causes ; some of which demand attention, not merely on account of the 
j interest that belongs to the whole inquiry, but also because they really are important 
I agents in the extension of the disease. 

1 First, then, it was, and is, a common behef, that continued fever may be generated 
\ by the effluvia constantly proceeding from the human body, even when healthy, if 
I these effluvia be accufnulated and condensed by the crowding together of many per- 
sons in close, dirty, and ill-ventilated places. It is unquestionable that, when once 
introduced, the disease spreads, under such circumstances, with fearful rapidity ; but 
the point at issue is whether it be ever so caused de novo. I must refer you, for good 
evidence that it is not so engendered, to Dr. Bancroft's book on the yellow fever. 
He shows that typhus fever does not spring up in places where it could scarcely fail 

1 



954 



CONTINUED FEVER. 



to appear if that theory were true. He instances the natives of the arctic regions, 
who, in order to shelter themselves against the extreme cold of their chmate, Hve 
during the greater part of the year in close subterraneous dwellings, from which the 
fresh air is studiously excluded, and of which the atmosphere becomes so offensively 
foul as to be scarcely supportable by a stranger : yet continued fever is not known 
among them. A similar exemption from that disease is observed within the tropics, 
in the African slave ships, where " the poor wretches are crowded together below 
the deck, as close as they can possibly lie, in a sultry chmate, barred down with iron 
to prevent insurrection." Akfiough many of them die from suffocation, and from 
fluxes, yet Dr. Trotter, who was himself, at one time, surgeon to a slave ship, de- 
clares that "contagious fevers are not their diseases." Dr. Bancroft quotes also a 
narrative of the sufferings of 193 Europeans, who, during the time of the French 
Revolution, were "deported" to Cayenne, in the Decade frigate. They were 
crowded, and even squeezed together, in so small a space, and for so long a time, 
that the sentinels, who were placed at the hatchways to guard them, and who were 
thus exposed to the hot and fetid air which came from their hole of confinement, de^ 
manded that their period of offensive duty might be shortened. Yet none of these 
miserable persons perished, nor did fever, properly so called, arise among them. 
Neither did that distemper present itself in any of the survivors of the Black Hole at 
Calcutta ; the frightful account of which, by one of those survivors, Mr. Howell, is 
abstracted in an appendix to Dr. Bancroft's work. 

Fever used to infest our Enghsh jails ; but that it was always imported, and never 
engendered there by filth and defective ventilation, and by the accumulation of 
human effluvia, may be concluded from the fact that the benevolent Howard, when 
he visited the prisons on the continent, found, to his great surprise, that they were 
free from fever, although they were no less close, crowded, and impure than our 
own. He brings the result of his observations and inquiries concerning the cause of 
the jail-fever, to this pointed conclusion : — " If it were asked," says he, " what is the 
cause of the jail-fever, it would in general be readily replied, the want of fresh air 
and cleanliness ; but as I have found in some prisons abroad, cells and dungeons as 
offensive and dirty as any I have observed in this country, where, however, this dis- 
temper was unknown, I am obliged to look out for some additional cause for its pro- 
duction" — which additional cause can be no other than the contagious poison ema- 
nating from the bodies of those who have the fever. It is true that fever is most 
frequently met with, and most rapidly propagated, where men are crowded together 
in jails, or in close and ill-ventilated places ; but this affords no reason for supposing 
that it is ever generated there, any more (to use a homely illustration of Dr. Ban- 
croft's) than the general prevalence of lice and other parasitic vermin in such places, 
proves that these vermin are generated by filth, by pent-up human effluvia, and want 
of ventilation, instead of being merely fostered thereby. 

Again, continued fever has been attributed with great confidence, to a vitiated 
state of the air, from the putrefaction of dead animal and vegetable substances. Dr. 
Bancroft deals with and demohshes this error Hso : showing that neither the putrid 
atmosphere of dissecting-rooms (respecting which you must have some personal ex- 
perience), nor the noisome effluvia from full and fll conducted burial-grounds, nor 
those to which tallow-chandlers, soap-boilers, glue and cat-gut makers, and the 
melters of whale blubber are exposed, nor the foul air of sewers and privies, have 
ever been known to produce anything like continued fever. In some parts of Essex, 
near the coast, where the farmers are in the habit of manuring their fields with shoals 
of sprats, I have seen large tracts covered with these fish in a state of putrefaction. 
The stench they occasion is horrible ; but no disease results. Dr. Chisholm, in a 
paper to which I can only refer, but which I would recommend you to look at, in the 
sixth volume of the Edinburgh Medical and SurgicalJournal, brings forward other, 
and very satisfactory, instances, to the same purpose : from a bone manufactory, near 
Briton, in Gloucestershire ; from an estabhshment (now relinquished) on the banks of 
the Avon, for converting the flesh of dead animals into adipocire ; from manufactories 
for refining sugar, where the blood of slaughtered animals is kept for that use by 
butchers ; from the leather-dressing business ; — ah tending, I say, to the conclusion, 



ALLEGED CAUSE. 



955 



that air, contaminated by :he decomposition of animal substances, is not necessarily 
noxious to life ; still less productive of that specific disease which we are now con- 
sidering. The old belief, therefore, was unfounded, that the exhalation from the 
dead and putrefying bodies of men and horses, lying unburied on the field of battle, 
is capable of producing a pestilence. Many instances to the contrary are on record: 
on.e, of an early date, is thus stated by Biemerbroek : — "Anno 1642, in agro Julia- 
censi maxima strages facta est, et ad minimum 8000 militum occisi fuerunt, prseter 
majorem adhuc famulorum, rusticorum, aurigarum, puerorum et muherum numerum, 
atque equorum copiam innumerabilem ; corpora inhumata sub dio computruerunt, 
nulla tamen pestis insecuta est." 

It has been said that fever is produced by some unknown condition of the air, im- 
perceptible by our senses, but distinct from contagion. I believe this is a very 
popular notion ; but it is perfectly gratuitous and untenable, and inconsistent with 
observed facts. Yoa may have fever raging in certain parts of a town, and yet the 
parts in the immediate vicinity of these be quite exempt frofri it. Now this could 
hardly be, if there were some general property diffused through the atmosphere 
capable of engendering continued fever ; and, as I stated before, this notion is severely 
pressed by one of the arguments which the non-contagionists themselves are fond 
of employing. If the disease depend upon contagion, some persons in the commu- 
nity may come less near the sick, or imbibe a less dose of the contagious poison, 
than others, and so escape : but if the cause of fever were spread abroad throughout 
the whole atmosphere, all must be exposed to its influence, and few, we may sup- 
pose, could avoid suffering from its operation. 

Exposure to cold is another cause to which fever has been sometimes attributed. 
But this is an agency so widely prevalent that if it alone could excite fever, that 
complaint would be far more general than it really is, and we should be able to trace 
it oflener and more distinctly than we can, to the alleged cause. That, by its debili- 
tating effect, cold will predispose the body to be affected by the contagion of fever, 
I well believe : and the same remark is appHcable to another cause that has been 
assigned ; namely, deficiency of nourishment. Dr. Alison, in his admirable .essay 
On the Management of the Poor in Scotland, has clearly proved that the preva- 
lence of contagious fever amongst the lower orders is always in direct proportion to 
their state of physical destitution. The association of pestilence with famine is pro- 
verbial. But we do not find that continued fever is ever created by the mere want 
of nutriment. In persons who have sought to starve themselves to death — among 
sailors who have of necessity been kept upon very short allowances of food — in cases 
of insulation by snow storms, or by the accidental closure of a mine — we find, indeed, 
thai disease is produced by the privation of nourishment; but it is not continued 
fever. The condition into which the suflferers are brought is more like scurvy. So 
that although a want of sufficient aliment may be, and doubtless is, a powerful aux- 
iliary in promoting the effect of the contagious poison, there is no ground for sup- 
posing that it ever primarily or solely occasions fever. 

In fact, all the circumstances which I have now been considering act as predis- 
posing causes. They render the human body an easier prey to the real exciting 
cause, which is a specific animal poison. You will remark that they are all debili- 
tafing circumstances ; and where several of them co-exist, their joint influence in 
subduing the system, and bringing it into subjection to the contagion, is very great. 
For the same reason, depression of spirits, however produced, has a strong predis- 
posing effect ; as strong, perhaps, as any other single cause. Of this I have seen, 
if I mistake not, some remarkable examples. Upon this principle we may explain 
the fact, that continued fever is especially apt to attack those of the lower classes 
who have recently come to reside in the metropolis ; who are often Hving anxiously, 
and with persons to whom they were not*' previously known. We have had nume- 
rous opportunities, in the hospital, of noticing this curious circumstance ; and it is 
mentioned by almost all the French writers on fever. To the same principle also 
we must attribute the tendency to fall down in fever, observed in young soldiers and 
sailors. You will find statements to that effect in Dr. Trotter's works, and in those 
of Dr. Lind and of Sir Gilbert Blane. When fever appears in a ship, the raw 



956 



CONTINUED FEVER. 



sailors are alwaj^s the soonest attacked by it : and it is the same with the recruits in 
the land service. • In a defeated, dispirited, or retreating army, its ravages are often 
frightful. Here we have, combined, fatigue, a deficiency of wholesome food, and 
mental depression. 

However paradoxical the assertion may seem, a predisposing cause may even be 
apphed, and operate, after the exposure to the exciting cause — and so render the 
latter effective when it might not, otherwise, have been so. Dr. Russell observed 
the plague sometimes to " hang ambiguously" about persons for several days. In 
this state, an overheated bath, or a sudden impression of fear, especially fear of the 
disease, has roused the lurking poison into activity. It is a suggestion of Dr. Hen- 
ry's, that atmospheric variations may call into action contagious poisons already 
admitted into the system, but not yet manifested by the usual phenomena ; and, 
operating thus over a v^^ide space, and upon numbers at once, may occasion those 
sudden and violent outbursts of epidemic disease, of which numerous examples are 
on record. * 

You must, I think, perceive the importance of distinguishing between the one 
exciting cause and the many predisposing causes of fever. The latter are generally 
beyond our control. We cannot hope to remedy extensive destitution ; nor to sepa- 
rate it effectually from its concomitants of filth, and despondency of mind. But we 
may, by timely dihgence, root out the specific contagion, or confine it within narrow 
bounds. When the sick can be at once removed from their crowded homes to a 
fever hospital, and their impure apartments ventilated, cleansed, and whitewashed, 
the disease may often be kept in check, if not entirely stopped ; and the yet healthy 
persons of the infected district be preserved from its grasp. For, as I stated before, 
there is reason to beheve that the poison, unless pent up, does not remain active at 
any great distance from the person from whom it proceeds ; not even many yards, 
or feet. It is very rare, I apprehend, to meet with instances of the disease being 
communicated in the open air. It is almost always caught, if at all, in the interior 
of houses. It is extremely uncommon for it to extend from one bed to another in 
our general hospitals, where great attention is paid to cleanliness and ventilation. 
The noxious quahties of the poison are diminished, and at length destroyed, by its 
dilution with common air, just as those of other gaseous poisons are : and hence, in 
private houses, in the better ranks of society, where the rooms are spacious and airy, 
and proper precautions are taken, the disease hardly ever spreads. 

What are those proper precautions ? They are simple, and may be stated in a 
very few words. 

Where choice can be made, a large apartment should be selected for the sick per- 
son. Unless the weather be very hot, there should be a fire in the room, for it acts 
as a ventilator. The air of the chamber should be kept fresh by having a window 
or door (according to the weather) always open : or both window and door. Bed 
and window curtains, carpets, and all superfluous articles of furniture, should be 
removed. Great diligence should be used in keeping the patient clean, by the 
requisite ablutions, and by frequently changing his sheets and his body hnen ; and 
these should be immersed at once ijci water ; and all discharges from the sick per^ 
son's body should be instantly carried out of the room. 

All unnecessary intercourse with the patient, by his family and friends, should, 
for his sake as well as theirs, be forbidden. As life advances, the susceptibihty of 
the disease appears to diminish : j|r which reason the nurses and personal attendants 
of the patient should not be ve;^ young : and all who do approach the sick bed 
should take care to avoid, as much as possible, inhahng the patient's breath, or the 
emanations which proceed from his person. Friends who visit the apartment at 
intervals only, should never enter it fasting. 

And you may, if you please, employ t^e chloride of hme as a disinfecting agent, 
in aid of the simple measures I have just recommended ; but by no means instead 
of them. People hang a bag of camphor round their necks, and think themselves 
safe against infection. The mental confidence which that expedient is calculated to 
inspire, may perhaps afford some degree of protection ; but camphor has, in reahty, 
no prophylactic virtue ; and all these artificial scents are objectionable, inasmuch 



TREATMENT. 957 

as they tend to conceal offensive odours which might otherwise reveal the actual 
danger. 

I shall speak of the treatrnent of continued fever when we next meet. 



LECTURE LXXXVI. 

' Continued Fever, concluded. Treatment. S7nall-pox. Its essential symptoms. 

Distinction into discrete and confluent. Periods and modes in which it proves 
I fatal. 

(I The treatment of continued fever has been, at all times, a stumbling block to young 
I practitioners ; and a subject of dispute even among physicians who have built it upon 
j their own experience. Before I attempt to trace out any plan, or to lay down any 
ji principles for your guidance, it may be useful to inquire how it happens that the 
|l practice in this disease has been so fluctuating and unsettled. 

I In the first place, then, it is very difficult to estimate the value and efficacy of any 
; particular plan of treatment, and still more of any particular remedial substances, in 
J this disease. Continued fever, hke other disorders which run a definite course, and 
i| have no direct or necessary operation in spoiling the structure of vital organs, has a 
' strong natural tendency to terminate in health. We see this tendency when the 
■ disease is left entirely to itself, and it equally exists when remedies are employed to 
j regulate its course, or to abbreviate its duration. No one can doubt, who has had 
I much experience in fever, that this tendency is sometimes thwarted by the nimia 
J cura medici; and that patients get well in spite of the well-meant but mischievous 
l! interference of the doctor. This tendency to recovery is a constant source, therefore, 
!] of fallacy in our observations upon the behaviour of this disease under different plans 
of treatment ; and upon the effects and ulihty of remedies. It leads us, too often, 
\ into the danger of ascribing to drugs what is really due to the workings of nature : 
of confounding antecedents and sequences with causes and effects ; of counting re- 
coveries as cures. And this danger is increased by the circumstance that continued 
' fever, although it observes a certain definite course, is nevertheless liable, even when 
left altogether to itself, to sudden and remarkable changes in the symptoms, some- 
times for the worse, and sometimes for the better ; and often we cannot perceive any 
obvious reason for these fluctuations. But if this happen when no medicine is g^iven, 
j so also will it happen when the disease is submitted to treatment; and it requires 
j more than a little care and discretion to avoid attributing the changes which so occur 
I to the remedy which was last employed. For example, the abatement or cessation of 
headache, after a few days have elapsed, is a natural phenomenon : whereas an 
inexperienced or a careless person might easily persuade himself tha^t it had yielded 
to his method of treatment, and that it was a favourabl^omen : neither of which 
1 conclusions would, however, be warranted by the circumstance upon which it was 
! founded. 

There is yet another source of difficulty connected with this subject. I have 
shown you that not only individual cases of fever, but different epidemics, vary 
\ much in their character; so that a plan of treatment which was well suited to 
I one epidemic, may be improper and even hurtful if indiscriminately applied in 
another. 

\ These considerations may serve in some measure to teach us how it has happened 
j that so many different, and sometimes opposite remedies and modes of treatment 
j have been recommended by different practitioners for the cure of this disorder. The 
I tendency to a termination in health was very plainly visible in the epidemic fever in 
:j Ireland, to which I have more than once referred. The mortality among the patients 
who were placed in sheds upon straw, with very little medical care, and even with- 
out any great personal attention from others, was very small indeed. No one caa 
form even an approximate judgment of this tendency, who has not seen the disease 




958 



CONTINUED FEVER. 



under several varieties of practice. Doubtless one rule which we derive from a 
clear perception of the same tendency is, that we should not interfere unnecessarily, 
Acxiiv rtfpt fa vovorifjia.'ta, 6do, (says Hippocrates) (0(|)aX£ftj/, jj' |U»7 /SxartfEcv. There are two 
things to be considered in the treatment of diseases : first, that we do the patient 
good ; secondly, that at least we do him no harm. In all these exanthemata, he 
must be reckoned the safest and the best practitioner who knows when to abstain 
from acting, as well as when to act ; in other words, who has learned when, and to 
what extent, the case may be left to the salutary processes of nature. 

However, there is an opposite error to that of mischievous activity. The tendency 
to recover which manifests itself under different modes of treatment, and even in 
spite of opposite modes, has induced, in some minds, a degree of scepticism as to the 
utihty of any remedies, that may easily be carried too far. It does not follow, be- 
cause the majority of patients under continued fever would at length emerge into 
health, although no remedial measures were employed, that the disease ought there- 
fore to be abandoned to what Cullen calls the vis medicatrix naturm. It is not quite 
correct to say, with the older pathologists, that the whole disorder is merely an effort 
of nature to throw off something noxious to the system, and therefore is not to be 
interfered with. The true view of the matter I apprehend to be that which a toxi- 
cologist might take. The disease is produced by a poison of which the injurious 
impression upon the animal economy at length ceases, or passes off, of itself ; in the 
same manner, only more slowly, as the influence of a dose of opium will spoijtane- 
ously pass away. But during the natural course of the fever, as in many other cases 
of poisoning, morbid processes are apt to be set up, which, if suffered to proceed 
unchecked, would inflict irreparable injury upon important organs, and which are 
fairly within the scope of remedial management. Our object must be, when the 
fever is once established, to conduct it to a favourable close ; to "obviate the tend- 
ency to death." Upon this point I agree most entirely with Pitcairn, who, being 
asked what he thought of a certain treatise on fevers, declared, " I do not like fever 
curers. You may guide a fever ; you cannot cure it. What would you think of a 
pilot who attempted to quell a storm ? either position is equally absurd. In the 'storm 
you steer the ship as well as you can ; and in a fever you can only employ patience 
and judicious measures to meet the difficulties of the case." 

When some immediate change ensues in the symptoms or in the feelings of the 
patient upon the administration of remedies that are generally followed by sensible 
effects, we are warranted in ascribing the change to those remedies. But even here 
comes in the fallacy already noticed, arising from the sudden and spontaneous changes 
that are apt to occur in fever : and this fallacy is to be got over only by multiplying 
our observations. 

After all, the best guide that you can have in determining upon the general 
principle of treatment in a given epidemic, or even in an individual case, is that 
which Dr. Alison has so ably enforced in his lectures and in his writings upor^ 
this subject. 1 mean the observed tendency to this or that mode of dying. The 
manner and circumstances of the deaths are of more practical importance than of 
the recoveries. 

After briefly passing in review sbme of the principal remedies that have been em- 
ployed and recommended for this disease, I propose to sketch the plan which I am 
myself in the habit of pursuing in the management of fever patients. 

It was once a favourite practice with physicians to attempt to cut short the fever 
at its outset ; and the two expedients which were chiefly relied upon for that purpose 
were emetics, and the cold affusion. They have both of them, in this country, gone 
very much out of fashion. In truth, neither reason nor experience encourages us to 
look for such a result from such measures. If fever depend (as I believe it does) 
upon a poison in the blood, it is not to be dislodged by the act of vomiting, nor washed 
out by the forcible descent of cold water upon the skin : and in the few instances 
in which the one or the other of these remedies may have seemed to arrest a fever, 
or to check its progress, that effect has always occurred at the very commencement 
of the complaint: so that we cannot be sure (and the probability lies the other way) 
that these were really cases of fever at all, or that they would not have ceased even if 



TREATMENT. 



959 



nothing had been done for them. Perhaps emetics may, in the present day, be too 
much neglected. I have no notion of their stopping the fever ; but when given 
early, especially if gastric disturbance is a prominent symptom, they are sometimes 
followed by a marked abatement of many morbid sensations. "It is astonishing," 
says the observant Sydenham, " how it happens, that a vomit, which does not pro- 
duce either a large or a morbid discharge from the stomach, should so materially re- 
lieve the nausea, restlessness, anxiety, and furred tongue of the patient." 

The cold affusion is not more effectual in cutting fever short than the treatment by 
emetics ; and it has these great disadvantages, that it fatigues and alarms the patient : 
and when the vital powers are naturally feeble, or are much depressed by the disease, 
the very shock of the affusion may be attended with injurious consequences. 

A modification of this expedient is, however, often of great use- in abating the 
morbid heat, and soothing the uneasy feehngs of the patient. I mean the practice 
of cold or tepid sponging of the surface. This is one of the remedies which, when 
the symptoms appear to indicate it, deserves to be tried ; and the propriety of con- 
tinuing or of discontinuing it may be determined by a very simple test ; namely, the 
feelings and wishes of the patient himself respecting it. It is most adapted to the 
more inflammatory, and least adapted to the more typhoid types of the malady. 

Great controversies have been maintained in regard to the effect of blood-letting 
in fever. They who hold that the fever consists in a general disturbance of the sys- 
tem, growing out of some local inflammation, and they especially who beheve that 
continued fever is nothing else than inflammation of the brain and its membranes, 
would naturally seek to cure it by the remedies of inflammation. But although local 
inflammation, and even inflammation of the brain, is very apt to spring up in the 
course of continued fever, there is no reason for thinking that inflammation anywhere 
is essential to the fever ; but very much reason for the opposite opinion. The active 
use of blood-letting has been in favour and out of favour, with the medical world, 
again and again : and this very circumstance would of itself make us doubt the pro- 
priety of its indiscriminate adoption. 

The late Dr. Armstrong gave a strong and unfortunate impulse to the practice of 
free blood-letting in continued fever, by the publication of his well-known and inge- 
nious treatise on the disease. I have no doubt that great mischief was done by that 
work. I may say so without scruple, since Dr. Armstrong is gone, and neither his 
feelings, nor his success, can be hurt by the expression of such an opinion : and I 
do so the rather, because it is well known here that Dr. Armstrong saw reason, as 
his experience increased, to qualify those views respecting the nature and manage- 
ment of fever, which his earlier observation of it in the country had led him to form. 
This change in his sentiments was probably justified and produced by a change in 
the character of the fevers that he witnessed; but it does not appear in his book. 
You have heard me state already that whereas the fevers which occurred in London 
for some time previously to the year 1831 or 1832, not only bore, but required the 
abstraction of blood, in some way or another, — since that period, and especially since 
the epidemic cholera visited us, it has been necessary to abstain, whenever we could 
with safety, from taking blood at all ; and still more necessary, even if we take away 
blood with one hand, to uphold the patient with the other : while, in the former pe- 
riod, Avine and stimulants of all kinds seemed generally superfluous, if not pernicious. 

Dr. Williams, of St. Thomas's Hospital, has shown very clearly, I think, in his 
recent publication on " Morbid Poisons," that the evidence against the efficacy and 
the safety of bleeding in continued fever — of bleeding largely, I mean, from the arm — 
far outweighs that in its favour : and I venture to advise you, as the result of aU that 
I have seen of the disease in London and elsewhere, not to draw blood from a vein, 
even early, mere/?/ because the disease is or appears to he fever ; not to order vene- 
section unless there be some other manifest reason for it — i. e., unless the febrile 
symptoms run unusually high, or unless some local inflammation is unequivocally 
present : and, when you do bleed, do not take a drop of blood more than seems ab- 
solutely necessary to answer the desired end. Bleed your patient, therefore, if at all, 
m the upright posture. 

Purgatives. — What are we to say in general with respect to them ? ThiSf I 



960 



CONTINUED FEVER. 



believe — that the intestines should be cleared by an active aperient in the outset ; 
and that laxatives should be continued if the bowels do not act every day without 
them. When the typhoid type is strongly marked, and when the symptoms indicate 
ulceration of the intestinal glands, purgatives are not to be pressed. 

Much contrariety of opinion has prevailed also among practitioners, and does pre- 
vail, about the administration of mercury in this disorder. Without attempting to 
strike the balance between these conflicting judgments, it is my business and duty 
to state my own behef, to tell you what is the result of my own observation, upon 
this and other disputed points. I must repeat, then, that my practice has altered, 
in several particulars, within the last few years. In the fevers which I treated, or 
saw others treat, in London, prior to the breaking out of the present epidemic, mer- 
cury, in one shape or another, was almost constantly prescribed : and a great num- 
ber of the patients were brought, sooner or later, under the specific operation of. that 
mineral: and in these patients (with one exception only, where the mercury appeared 
to do neither good nor harm) a decided impyvvement was almost immediately appa- 
rent upon the supervention of soreness of the mouth ; and all such patients ultimately 
recovered. I am aware, however, and I wish you to be aware, of an alleged source 
of fallacy in this matter. The gums in that variety of fever to which I am at present 
referring, did not readily take on the mercurial action ; and it might be (though such 
is not my own impression), it might be that the afTection of the mouth by mercury 
was attributable to the mildness or to the cessation of the disease, rather than the 
cessation of the disease to the effects of the mercury upon the system : that the im- 
provement was the cause, and not the consequence, of the mer-curial action. 

In the form of fever that is noz^ epidemic (1838), I do not think mercury so proper. 
Last year the spotted fever broke out in a patient of mine while he was in the hos- 
pital, and while his gums were sore. I found, upon inquiry at that time, that of 
twelve fever patients who had been recently treated in the hospital, by my colleagues 
and myself, with mercurials in greater or less quantity, four had died, in all of whom 
the gums were affected : whereas, of sixteen others, who took no mercury, three only 
died ; and of these three, one was pulseless at her admission, from uterine hemorrhage, 
and the other two were so feeble and exhausted that they were scarcely able to swal- 
low. I should give mercury very cautiously, therefore, if at all, in this typhoid 
variety of the fever. 

Besides a strict enforcement of the antiphlogistic regimen, my own mode of treat- 
ing continued fever is somewhat of this kind. I am always desirous that the patient's 
hair should be cut off. The mere removal of it is often attended with benefit : the 
headache and confusion of thought are relieved, and the patient is calmed. We can 
then also, with much greater convenience and effect, apply cold washes to the head. 
Patients sometimes demiir to this shaving of their heads : but they generally coftsent 
if you explain to them that their hair will at length fall off, in consequence of the 
fever ; and that the head, if on that account only, had better be shaved at once. 
The head and shoulders should be somewhat raised, and thin strips of hnen, kept 
constantly wet with some cold lotion, should be continually applied upon the forehead 
and scalp. It should be the business of one person to attend to this. You would be 
surprised at the rapidity with which the cloths sometimes dry. 

Now, with regard to this remedial measure, you need not have any difficulty. It 
will do good, and should be steadily employed, so long as it is grateful to the feel- 
ings of the patient ; and it will, generally, be pleasant and agreeable to him, so 
long as the head remains morbidly hot. If the temperature of the scalp be not 
above the natural standard, and especially if the cold application make him shivery 
or uneasy, and give him annoyance instead of comfort, then it must be at once 
discontinued. 

If the patient suffered intense headache, and his face were flushed, and the heat 
of the surface great, and he were wildly delirious, and his pulse were full and hard, 
I might perhaps deem it right to take blood from his arm, while he sat up. But, 
even under these circumstances, I should generally think it better to apply leeches 
to his temples, or behind his ears, or to remove a few ounces of blood from his neck 
by means of cupping-glasses, and, at the same time, to ply assiduously the cold lotion. 



TREATMENT. 



961 



If the bowels have not been already purged by nature or art, it is right to give 
three or four grains of calomel at once, and to foJlowr this up by a black dose. After 
that, I was formerly in the habit of prescribing, in the early periods of the fever, 
unless the bowels were irritable, a piJl composed of two grains of calomel with two 
grains of James's powder, every six hours ; washing it down with a common saline 
draught. In hospital practice, I frequently omitted the saline draught ; allowing the 
patient to drink toast and water, or barley water, as often as he wished. If there 
was diarrhosa, or early prostration, I gave, instead of the combination just mentioned, 
five grains of the hydrargyrum aim cretd. At the same time, I carefully investi- 
gated the state of the abdomen ; and if I found tenderness at the epigastrium, or in 
the caecal region, in both of which situations tenderness was common, I applied, over 
the tender spot, from six to ten leeches, and covered the leech-bites with a light poul- 
tice. If the diarrhoea ran on profusely, I added to the hydrargyrum cum creta a 
certain quantity of Dover's powder, or of the extract of poppy. 

In those forms of fever (whereof the prevailing epidemic affords you a well- 
defined specimen) in which there is a strong and early tendency to typhoid symp- 
toms, a signal loss of strength, a confused and dusky countenance, a mottled state 
of the skin, simulating the eruption of measles, a dark dry brown tongue, a feeble 
pulse — in these forms I begin very early to give the patient a full allowance of beef 
tea; and if the typhoid and nervous symptoms become more pronounced, I 
add ammonia, Hoffman's asther, and, what is better still, wine ; and I omit the 
mercury. 

Under this kind of management the patients will often go on, in a doubtful state, 
for some days, and at length begin to recover. Many of them, especially in the 
more typhoid varieties, sleep heavily, as the disorder passes slowly off. 

There is one point in the treatment of fever, of exceeding importance, and of 
some nicety: I mean the use of opiates. If they are given inopportunely, they are 
apt to puzzle and perplex the case. You do not know how much of the disposition 
to coma is owing to the disease, and how much is the consequence of the remedy. 
Again, you may easily augment the natural tendency to coma, and lull your patient 
into a fatal stupor. But, when judiciously administered, opium will often save a 
patient who would inevitably sink without it. 

It is in that form of fever which the French call the Jievre afaxique, — when the 
patient is affected with delirium, restlessness, wakefulness, and spasm, and the dis- 
turbance of the nervous system outruns the disturbance of the sanguiferous system, 
— that opium is so beneficial. The condition of the patient resembles that of a person 
in delirium tremens. It is said that these symptoms occur most commonly among 
patients in those ranks of life that are above the lowest rank ; and it probably is so: 
but they are apt to take place in any patients, high or low, rich or poor, who have 
had the mind over-wrought, and the nervous system unstrung, whether by dissipa- 
tion and intemperance, or by anxiety of any kind. Sydenham was quite aware of 
the existence of this particular set of symptoms, and of the remedy for them. Of 
all these symptoms, sleeplessness is the most urgent. Dr. Grattan and Dr. Latham 
have both written in praise of the same opiate treatment, under such circumstances, 
as was recommended by Sydenham. Dr. Grattan observes, with great truth, that 
two or three nights, spent in restless delirium, are followed by the worst conse- 
quences ; and that patients who pass three nights in succession in that way, almost 
invariably die. If the symptoms be well marked, the best mode of proceeding is to 
give a tolerably full dose of opium in the evening; one-third of a grain of acetate 
of morphia is a common prescription with me. The amendment of the patient, on 
the following day, is often very striking. Unless the same symptoms recur, it is 
better, I think, not to repeat the anodyne. But, as Dr. Latham cautions us, "there 
are cases, where the indications for the employment of opium are doubtful. Wild 
delirium, and long wakefulness, and a circulation weak and fluttering, seem to call for 
a considerable dose of opium. Yet, withal, there is a certain jerk in the pulse, so 
that we cannot help suspecting that the blood-vessels have something to do with the 
sensorial excitement. Under such circumstances, I have certainly seen (says he) 
twenty minims of laudanum produce tranquil sleep, from which the patient has 
61 4f 



962 



CONTINUED FEVER. 



awoke quite a new man. But I have also seen the same quantity produce a fatal 
coma, from which he has never been roused. Now, (continues Dr. Latham,) since 
it is a fearful thing to strike a heavy blow in the dark, where the alternative is of 
such magnitude, it is the safest and the best method to administer a small dose, at 
intervals of an houf or two : so as to stop short of actual mischief at the first glimpse 
of its approach, or to be led, by a plain earnest of benefit, to push the remedy to its 
full and consummate effect. Many doses may be required for this purpose ; but we 
shall see, after the first or second, whether to go on or to desist." 

When, as is sometimes the case, the stress of the disorder falls upon the thorax, 
and there is much dyspnoea, with the sounds that denote inflammation of the bron- 
chial membrane, or of the pulmonary substance, leeches or cupping-glasses may be 
applied to the chest ; and, in milder cases, a blister, or a mustard cataplasm. 

These remedies — cold to the shaven head ; the local abstraction of blood wherever 
there happens to arise evidence of local inflammation ; an active purge at first, and 
mild aperients afterwards, if the bowels are confined or sluggish; moderate astrin- 
gents, if there is much or urgent diarrhoea, a few grains of Dover's powder, for ex- 
ample, or of the extract of catechu ; opium in a more efficient dose, when the nervous 
symptoms are prominent, particularly sleepless delirium and restlessness ; in certain 
cases small and repeated doses of some preparation of mercury ; and in certain cases, 
early support by animal broths, and even by wine — these remedies, adapted to the 
partic ular circumstances of individual patients, form the staple of the treatment of 
continued fever, according to the best of my judgment and experience. 

After what has been said, I need scarcely again admonish you to study carefully, 
not merely the symptoms of any particular case to which you may be called, but the 
general character of the fevers that are at the same time prevalent, and the manner 
of dying in the fatal cases. If you find that they who die, die chiefly in the way 
of asthenia, that will be a strong reason for caution in respect to the removal of blood, 
and for the early employment of beef-tea, and other means of support. In the form 
of fever which has of late years been common in the most crowded and unhealthy 
parts of London, I am sure that the risk of beginning this sustaining treatment a little 
too early is much less than the risk of commencing it a httle too late. If plenty of 
beef-tea does not suffice, you must give the patient wine, and that sometimes to a 
considerable amount, or even brandy ; the egg-flip of the Pharmacopoeia for instance, 
the mistura vini gallici. The object is to keep him aHve, to keep the heart in mo- 
tion, until the depressing influence of the exciting cause of the disease shall have 
passed by. If the wine should flush or excite him, or render the pulse hard, it must 
be diminished in quantity, given less frequently, or omitted altogether. If there be 
indications of local inflammation — pain (for example) in the csecal region, increased 
by pressure — leeches may be used, and wine given at the same time. There is 
nothing inconsistent in such mixed practice. We seek to remove the local inflam- 
mation by unloading the capillary blood-vessels of the part, while we uphold the 
general powers of the constitution which are ready to sink. The great art of getting 
a fever patient through a bad attack, is to have him judiciously and perpetually 
watched, by night and by day. The remedy that is proper one hour may do harm 
jf pushed during the next. And there is another reason, which I may mention en 
passant, why the sick person should never be left alone, even for a moment, I have 
heard of more than one or two instances, of patients, in the dehrium which attends 
the disease, getting out of bed, and out at the window, during the temporary absence 
of their nurse, and perishing from the fall. 

If the patient relishes and wishes for the beef-tea, or the wine, that is no small 
warrant of the propriety and usefulness of its administration. 

A word or two more may be proper, even in this cursory sketch, respecting cer- 
tain incidental points of practice that are apt to arise. 

Often, when there is no longer any detectible uneasiness produced by pressing 
the belly, the diarrhoea will persist, and meteorisnius will come on ; a tympanitic 
distension of the intestines with gas. When this happens, especially in the latter 
periods of the fever, a large blister, laid over the abdomen, has often very happy 
©fets, both upon the diarrhcea and the meteorismus. The diarrhoea, when very 



CONTINUED FEVER. 



963 



urgent and obstinate, may often be checked by opiate enemata. In some cases I 
have recently found catechu of great use, in these long-drawing forms of diarrhosa 
during fever. 

Again, if the patient sinks into profound coma, a bhster should be applied to the 
shaven scalp. The sick man will sometimes awake from deep stupor while the 
blister is still rising. 

It is always a matter of importance, as I stated before, to inquire carefully, every 
day, into the condition of the bladder of these fever patients. In the state of stupor 
and indifference in which they often lie, they appear not to be sensible to the want 
of passing the urine, which collects in the bladder, and distends it enormously ; not 
only increasing the present hazard of the patient, but laying the foundation, some- 
times, of future disease of the kidneys, in case he recovers from the fever. You must 
not take the assurances of the nurses upon this point. They will often tell you that 
the patient has made plenty of water, when in fact the urine has been dribbUng away 
from him, overflowing, while the bladder is stretched to the utmost. Feel, therefore, 
with your hand, and percuss the hypogastric region, as well as that of the Coecum, 
at every visit. 

It is requisite, too, that the under surface of the patient's body should not only be 
kept scrupulously dry and clean, but be looked at every day, or twice a day. If the 
projecting points, the hip bones, the sacrum, the shoulders, the elbows, should become 
red, that is a sign that they are likely to slough or ulcerate. This evil consequence 
of continued pressure upon parts of which the vital power and healthy tone are lower- 
ed, may often be prevented by washing the erythematous spots with brandy. Should 
the skin be already broken, the place may be covered with soap-plaster. An adjust- 
ment of pillows and of posture — or the water-bed — may sometimes supersede the 
necessity of these local expedients. 

When ulceration of the mucous follicles perforates the bowel, that catastrophe does 
not always so distinctly declare itself in fever, as in other cases. I have seen such 
perforation, and its resulting peritonitis, when no complaint of pain had been made 
by the patient, so great was his insensibihty. In general, however, the accident is 
denoted by symptoms which cannot be mistaken. When it does occur, there is but 
little chance of the patient's recovery ; and that httle will be best husbanded by the 
adoption of the plan of treatment which I formerly laid down : opiates, to check the 
peristaltic movements of the intestine ; and a rigid adherence, for some days, to the 
horizontal posture. 

I have seen a few instances, in which an osdematous swelling of one leg and thigh 
has occurred in the advanced stage of fever, like that which is incidental to parturient 
women, and depending upon the same cause — inflammation and obstruction of the 
great vein that returns the blood from the limb towards the heart. I believe that 
the inflammation extends itself, in such cases, from some of the smaller veins of the 
mesentery, and is excited in them by the intestinal ulceration. Fomentation of the 
affected limb comprises all the remedial treatment which this accident requires or 
admits of. 

The management of the patient during convalescence is scarcely of less import- 
ance than during the progress of the fever. The chief danger is, that his desire to 
be allowed to get up, and his wish to eat animal food, should be too soon indulged. 
The latter of these errors is more frequently the cause of a relapse than any other 
circumstance ; and relapses are often more perilous and difficult to remedy than the 
original malady. You must be prepared, therefore, to withstand the solicitations of 
the patient and of his friends, who think that if strength be wanting, strong drinks, 
and plenty of meat, are the things to impart it. Until the tongue is quite clean and . 
moist, and of its natural colour, and the pulse has lost all its hardness, and the skin 
its excess of heat, the patient must be kept to broth, jellies, puddings, and prepara- 
tions of the well-known farinaceous articles of food. Then he may begin with some 
boiled white fish, and so gradually eat his way, through chicken, and a mutton-chop, 
to his ordinary diet again. 

Such, I say, is the general plan of treatment which some observation of this dis- 
order has persuaded me is the best. Summarily expressed, it consists in the exercise 



964 



BILIOUS REMITTENT FEVER. 



of incessant vigilance, and the adoption of the proper remedy at the proper moment. 
It lies between a timid or scepticaJ abandonment of all known resources, and a med- 
dlesome rashness in applying them. The flame of hfe may be suffered to expire 
for want of timely succour, by the practitioner who folds his arms, and looks on j 
as it may be rudely extinguished by a restless or routine interference which has 
no definite or intelligible purpose. Boerhaave, in the preface to his Aphorisms, 
professes that he knows of nothing which can be fitly termed a remedy^ "quin 
solo tempestivo usu tale fiat." In fevers the wisdom of this maxim is eminently 
conspicuous. The rational objects of treatment are, to mitigate the urgency of 
symptoms that cannot be wholly subdued ; to redress (so far as art may redress) 
those dangerous complications which are incidental, but not essential, to the dis- 
ease ; and to aid the conservative efforts of nature, when these manifestly languish 
and fail. 

Dr. Williams holds that enemata of warm water and syrup of poppies will do all 
that can be done beneficially. For some time he lost only one patient out of sixty- 
three thus treated. This was a most encouraging result. But then, when the fever 
changed its type, as it did about the period of the arrival of the epidemic cholera, 
he lost one in every four or five ; a very large mortality. These facts illustrate, in a 
strong manner, the necessity, which I have so often endeavoured to inculcate, of 
taking into the account, when we would estimate the value of a particular remedy 
or plan, the difference which obtains in different epidemics, whether bad, good, or no 
treatment at all be adopted. A far surer method is to compare (if you would expe- 
riment at all) two or more different modes of practice in different cases of the same 
epidemic. Thus Dr. Latham, finding during one season that his wards were full of 
fever, while yet its type was so mild that scarcely any died, thought this a favour- 
able opportunity for trying whether mercury had any beneficial operation upon the 
disease. Accordingly he treated half his cases with small doses of the hydrargyrum 
cum cretd ; and the other half with the liquor ammonise acetatis, and so forth, and 
no mercury ; and he found that the patients in the first of these classes were, on the 
average, convalescent sooner than those in the last. Chomel fancies, from some trials, 
that the chlorate of soda is a useful remedy, in addition to the general plan of man- 
agement ; but further experience seems wanting to settle this question. 

[Although the present note may be considered somewhat out of place, considering the 
class of diseases with which Dr. Watson has associated Continued Fever, yet as circumstances 
prevented us from introducing an account of Bilious Remittent Fever, after the author's lec- 
ture on Imer^ittents, while that portion of the work was passing through the press, we know 
of no place where it can now be introduced with more propriety than the present: the dis- 
ease holding a kind " of middle rank, as to external character, between intermittent and 
continued fevers," it matters little in connection with which it is studied. 

Bilious Remittent Fever. — With the exception of the intermittent, the most common 
form of fever prevalent in the middle, southern, and south-western sections of the United 
States, is the remittent, or. as it is generally denominated, from the evidences of more or 
less derangement of the hepatic function by which it is attended, the bilious remittent, or, 
simply, bilious fever. It constitutes the summer and autumnal endemic of many of our states, 
and even in those which are exempted from its annual occurrence, it occasionally prevails, 
during seasons of unusual heat and dryness, sporadically, or as a severe and widely-spread 
epidemic. It is this form of disease to the attack of which individuals, from the cold and 
temperate sections of our union, are so peculiarly liable on removing to those localities 
where it is endemic, or on visiting them during the summer and autumn. The bilious remit- 
tent fever is not peculiar to the United States; it prevails extensively in the southern portions 
of France and Italy, and other parts of the south of Europe, in Africa, and in the East and 
West Indies : it is in fact the endemic of the paludal districts of all hot climates. A high 
degree of atmospherical temperature has a very marked influence in the production of this 
form of fever ; either by eliminating an aeriform morbific matter, or by predisposing the sys- 
tem to the action of the morbific causes by which it is constantly surrounded. Its prevalence, 
as well as violence, is almost invariably in direct proportion to the heat of the season, while, 
in many of the more northern states, where the disease is not one of ordinary occurrence, 
during a summer of extreme heat, it will prevail, often to a considerable extent — and 
-marked, occasionally, by symptoms of extreme violence ; it being limited, however, almost 
exclusively to those situations, noted in other seasons for their insalubrity, or in which the 



BILIOUS REMITTENT FEVER. 



965 



causes of disease are ready to be developed upon the occurrence of any unusual degree of 
atmospherical heat. 

Notwithstanding the bilious remittent fever can scarcely ever be mistaken by the least 
experienced practitioner, it exhibits, nevertheless, considerable diversity in many of its phe- 
nomena in different seasons and localities, and often in different individuals. While, in 
many cases, the remissions are well-marked, approaching in some to a complete intermission, 
in others the remissions are so slight that the fever has almost a continued form. There are 
always, however, certain prominent symptoms, invariably present, an attention to which 
will lead at once to an accurate diagnosis : — These are. gastric irritability, a sense of oppres- 
sion and distress at the epigastrium, pain of the head, back, and limbs, and the great pros- 
tration of strength early exhibited by the patient. 

Bilious remittent fever is closely allied in its nature, the localities in which it chiefly pre- 
vails, and in many of its phenomena, to intermittent fever, of v/hich by many it is considered 
as a mere modification. It is presumed, and with much plausibility, that "a more intense 
operation of the same morbific cause required for the production of intermittent fever engen- 
ders remittent," and that "the more violent the latter, the more remote is its character from 
that of intermittent ; or, in other words, the less perceptible the remissions." That a more 
powerful action of the morbific cause is demanded for the production of remittent fever, is 
supposed to be indicated " by the circumstance, that when periodic fevers are prevailing in 
certain countries, the permanent residents are often observed to have the disease in the form 
of ague only, and the mortality among them is small ; but strangers, unhabituated to the cli- 
mate and its diseases, suffer fiom remittents, with a proportionably greater loss of life. In 
more sickly seasons remittents will be the prevailing form among both classes of persons, 
but strangers are more violently affected, and the mortality among them is greater. Its 
affinity to intermittent is shown, too, by the tendency which it has to pass into that form, 
and, inversely, by the proclivity of ague to assume the remittent type." (Brown Cyclopaedia 
of Pract. Med.) 

There is a very striking analogy between the milder and more ordinary form of the bilious 
remittent fever, in its course and progress, and the periods of a double tertian ague. Although 
the exacerbations occur daily, yet there is almost always a very manifest aggravation of all 
the symptons on the odd or alternate days. When the disease assumes, as it does occasion- 
ally, a quotidian type, the exacerbations generally occur several hours earlier than those of 
the double tertian form — the former happening usually about nine or ten o'clock, and the 
latter not until towards noon, or an hour or two later. 

The milder and more simple form of bilious remittent fever is generally preceded, for 
some days, by listlessness, languor, a bitter taste in the mouth, nausea, aversion from food, 
an indescribable uneasiness and sense of fulness about the epigastrium, sometimes costive- 
ness, and, very generally, more or less pain and heaviness over the eyes. The attack is 
usually ushered in by a slight chill, or merely by a sense of coldness, particularly about the 
back, which, after one or more hours, and often sooner, is followed by increased heat of the 
whole surface — the skin becoming, at the same time, dry and constricted, the face flushed 
and turgid, the eyes red and suffused, the respiration hurried and uneven, the pulse quick 
and frequent, but rarely tense ; there is great prostration of strength, with considerable rest- 
lessness and watchfulness. The patients complain of pain and a sense of fullness, weight, 
and tension of the head, pain of the back and of the extremities, particularly of the calves 
of the legs; — and of a sense of weight or oppression, and often of pain at the epigastrium, 
which part generally exhibits more or less tenderness upon pressure, even when no pain is 
complained of. The stomach is more or less irritable — some cases being attended with 
distressing nausea, while in others, everything swallowed is instantly rejected. Spontaneous 
vomiting is a not unfrequent symptom — it is often present from the commencement of the 
attack, but more generally it does not commence until the second or third day, or even later; 
the matter vomited is of a bitter taste, and of a yellow, greenish, or bright-green colour. 
The tongue is usually moist, red at the sides and edges, and coated on its upper surface with 
a whitish, light-brown, or yellowish fur, which often acquires considerable thickness. There 
are usually considerable thirst, a costive state of the bowels, and a diminished amount and 
increased coloration of the urine; and, after the disease has continued for some days, the 
skin acquires a yellow tinge, which is sometimes very decided, and extends to the adnata of 
the eyes. The exacerbation lasts from eight to twelve hours, when a gradual abatement of 
all the prominent symptoms takes place, and often a slight moisture breaks out upon the sur- 
face, and the patient falls into a refreshing sleep ; more generally, however, the skin conti- 
nues dry after the heat has declined, and the patient during the remission continues restless, 
uneasy, and disinclined to sleep. The duration of the remission varies with the violence of 
the attack; gradually, however, the heat of the surface increases, and an exacerbation of the 
fever follows, marked by the same degree of intensity as the former, or even by increased 
violence. 

All the preceding symptoms, in an aggravated degree, with long-continued exacerbations, 
and less distinct remissions, mark what has been termed the highly inflammatory form of 

4f2 



966 



BILIOUS REMITTENT FEVER. 



the disease. During the exacerbation the skin is intensely hot, the eyes are suffused, of a 
muddy, yellowish hue, and often dull and languid ; there are intense pain, and a sense 
of insupportable weight and tension of the head ; aversion from light and sound is ordina- 
rily present, and occasionally delirium ; there are great thirst, and a feeling, often almost 
insupportable, of oppression at the chest; the respiration being quick and laborious, fre- 
quently irregular; the pains in the back and extremities are often of great severity; the 
pulse is quick, frequent, and more or less tense ; occasionally it exhibits some degree of irre- 
gularity ; the nausea and vomiting are generally peculiarly distressing — the matter discharged 
being a thick ropy fluid, of a yellow, darkish-brown, or green colour ; the bowels are costive, 
or if open, discharge, with tenesmus and griping, a thin watery fluid: when evacuations are 
procured by appropriate means, they are large in quantity, dark, slimy, tenacious, and offen- 
sive. There is always an intolerable sense of oppression or constriction at the epigastrium, 
accompanied by a degree of tenderness which renders the slightest amount of pressure 
insupportable — or a severe pain and burning, attended in many cases with great nausea, 
and frequent inefiectual efforts to vomit, are experienced. There is great restlessness, with 
jactitation, and continued watchfulness. In the course of the disease, the skin acquires, 
most generally, a brownish, bronzed, or more frequently, a deep yellow tinge, which is par- 
ticularly marked upon the face and breast. A symptom mentioned by Rush, as generally 
present in cases of bilious reinittent — namely, a screatus, or constant hawking and spitting 
of a sinall quantity of tough, glairy matter — we have repeatedly noticed. 

The succeeding exacerbations are marked by an increased violence of all the predominant 
syinptoms of the disease, and unless the intensity of the fever is relieved by an appropriate 
course of treatment, the powers of life gradually sink; the sitrface, at length, becomes cool, 
and covered, generally or partially, with a cold clammy sweat; the pulse becomes small and 
weak; the tongue covered with a dark, thick coating, and occasionally dry and chapped; 
the respiration short, quick, and difficult ; the abdomea sometimes swollen and tympanitic ; 
stupor or coma often ensues ; not unfrequently, repeated, and at length involuntary, dis- 
charges take place from the bowels, of a dark, offensive matter, and finally death ensues. 

In the milder forms of the disease, or when it has been from the commencement of the 
attack subjected to an appropriate treatment, instead of an increased violence in the phencn 
mena of each succeeding paroxysm, there is less decided heat of the surface, the pulse 
becomes slower and less frequent, there is less gastric distress, less pain and tenderness of 
the epigastrium; less pain of the head and back; the exacerbation is of shorter duration, 
and as it declines, the skin becomes softer and more moist, the tongue less coated, the coun- 
tenance more cheerful, and the patient obtains often several hours of quiet and refreshing 
sleep ; the remissions are more distinct, and of longer continuance, until finally a complete 
intermission occurs, followed by a state of convalescence — which is usually protracted. 

There generally takes place in the milder and uncomplicated forms of bilious remittent, a 
distinct exacerbation, followed by an evident remission, once in every twenty-four hours: 
but in the more violent and decidedly inflammatory form, the remissions, as we have already 
remarked, are so short and slight as almost to pass unnoticed, and hence the inflammatory 
bilious fever is described by many writers as a continued fever. 

The duration of the disease varies with its degree of violence and its simple or compli- 
cated character — it may terminate in a few days or run on for several weeks — but its usual 
duration is from nine to fifteen days. It is not uncommon, Dr. Dickson, of South Carolina, 
remarks, especially among the most perfectly acclimated adult natives resident in malarious 
localities, and strangers long familiarized to them, to find bilious remittent fever of very pro- 
tracted duration ; " the patient sinking, after the tenth or twelfth day, into a low fonn, resem- 
bling the less severe grades of typhus, and hence obtaining among us the designation of the 
typhoid stage of bilious fever. Here the w^ell-marked lines which separate the period of 
exacerbation and remission, are almost effaced; the characteristic periodicity almost obli- 
terated ; the fever degenerates nearly into the continued type, and the patient, in the lan- 
guage of the older practitioners, 'wades through' the attack with no definitely regular 
changes observable from time to time, until, by the success or failure of our efforts in his 
behalf, he recovers or is lost. The pulse is small and chorded, the tongue throws ofl' its fur, 
and is smooth, red, and dry, or smeared over, like the teeth and lips, with foul sordes; the 
stomach loses its irritability, and the vomitings cease ; the stools are dark or even black ; 
meteorism occasionally shows itself; there is muttering delirium or disposition to heavy stu- 
por and coma; the countenance is dull and inexpressive; muscular languor and great debi- 
lity ensue, with nervous tremors on motion, and perpetual subsultus tendinum."' Dr. Dick- 
son has known cases of this kind protracted, in three instances, to thirty, thirty-five, and fifty 
days, though the average, he observes, would scarcely reach beyond fifteen or twenty. 

A careful analysis of the phenomena of bilious remittent fever shows, very conclusively, 
that the organs chiefly affected are the liver and stomach, and the results of post-mortem 
examinations confirm the accuracy of this deduction. In many cases, it is true, the symp- 
toms during life, and the lesions detected after death, indicate more or less affection of the 
lungs or brain j but this latter is to be viewed as an accidental complication, and not essen- 



BILIOUS REMITTENT FEVER. 



967 



tial to the disease. Basing our conclusions upon the investigations of Dr. Stewardson, 
(American Journ. Med, Scien., April, 1841, and April, 1842,) which are confirmed by the sub- 
sequent observations of Dr. Swett, (ibid^ Jan., 1845,) and correspond in many particulars 
with those of Mr. Twining (Diseases of Bengal, chap, v.), a morbid condition of the liver 
would appear to be invariably present in remittent fever — to be indeed diagnostic of the 
disease; it is nevertheless very certain that few cases of bilious fever, of any intensity, occur 
without being attended also by indubitable symptoms of gastro-enteric disease — the evidences 
of which are very generally detected in those who die of the fever. In many cases the 
indications of hepatic disease predominate, while in others those of gastric atfection are 
most prominent; in general, however, both are sufficiently well marked in the same case. 
It has been proposed to distinguish the fever, according as the phenomena of hepatic or 
gastro-enteritic disorder predominates, by the terms hepatic and gastric. Hepatic remittents 
being characterized by intense febrile heat ; violent pain of the head ; fullness and tension 
of the right hypochondrium, with pain and pulsation of this part and of the epigastrium ; 
excessive irritability of the stomach ; frequent and forcible vomiting, the ejections being 
without any trace of bile; a clean state of the tongue in the early stages; a decidedly yel- 
low colour of the skin and adnata of the eye ; great torpor of the bowels, until towards the 
decline of the disease, when a copious discharge takes place from the bowels of a dark or 
pitch-like tenacious matter, which may be considered as in some degree critical. 

Gastric remittents are distinguished by a bitter taste in the mouth ; great thirst, with 
a craving for cool and acidulated drinks ; frequent vomiting of a green or dark-brown fluid ; 
total loss of appetite, and generally disgust for every kind of food ; a feeling of great weight 
and anxiety at the praecordia ; pain and tenderness, chiefly at the epigastrium ; intense pain 
of the loins and knees, and soreness of the calves of the legs ; severe and constant pain of 
the forehead ; the tongue coated in the centre with a thick layer of yellowish mucus, and 
red at the sides and tip ; the remissions distinctly marked ; bowels costive, or v/heu dis- 
charges from them take place, these are thin and watery, and often attended with griping 
and tenesmus : in the course of protracted cases the stools not unfrequently consist of a red- 
dish fluid resembling the washings of meat. In the progress of the disease, the tongue 
becomes dry, cracked, and covered with a dark-brown or blackish crust ; upon the separation 
of which the tongue presents a smooth, shining, and red surface. In the advanced stage, 
there is often retention of urine, difficulty of swallowing fluids, meteorism of the abdo- 
men, &,c. 

Although we frequently meet with cases in which the predominance of hepatic or of gas- 
tric disorder, but especially of the first, is thus strongly marked ; nevertheless, in the gene- 
ral run of cases, there is a complete blending of the two sets of phenomena. 

There is one form of bilious intermittent still to be described, with which "the experience 
of the last ten years" has made the practitioner of the southern and south-western portions 
of the United States, "unhappily, too well acquainted, under the denomination of congestive 
fever. In certain localities, indeed, remarks Dr. Dickson, the ancient inflammatory features 
of rnalarious endemics seem to have disappeared, and to have become supplanted by the 
more hideous and pestilential modification thus entitled." 

The form of the disease to which we allude is marked by a diminished temperature and 
decreased sensibility of the whole surface of the body — the skin being, at the same time, 
soft, contracted, and often clammy, or wet with a copious perspiration; when a partial reac- 
tion takes place, the heat is never considerable, and it is often confined to particular parts of 
the surface. There are considerable and universal lassitude and debility; the head is con- 
fused and affected with vertigo, and sometimes with a deep-seated pain or a sensation of 
oppressive weight or tension ; the eyes are heavy, suffused and dull ; the countenance is 
haggard, and the face pale, and of a dingy, muddy appearance ; the pulse is small, frequent, 
and indolent, or struggling, compressible and variable; the tone of the voice is often 
changed, the articulation slow and drawling, or imperfect and stammering. The respiration 
is anxious and laborious, with frequent sighing. The tongue exhibits, at first, but little 
change, but soon becomes dark-brown or black, especially in those cases in which the earlier 
stages of the disease have been marked by some degree of excitement. The stomach 
is occasionally irritable; the epigastrium and right hypochondrium are tender upon pressure, 
and more or less tumid ; the bowels are torpid, and when stools are procured, they are dark- 
"coloured and offensive, and often attended with tormina and tenesmus. The mind is gene- 
• rally dull, indifferent, or confused, from the commencement of the attack, and, in the progress 
of the disease, sinks into a state of more or less complete stupor, or of low muttering deli- 
rium. The remissions of the fever in the congestive form are not well marked, or rather, 
there is an entire absence of the febrile exacerbations and remissions, the phenomena of the 
disease presenting but little other change than a rapid or a gradual augmentation in intensity. 
In fatal cases, death, which may take place between the fifth and fifteenth days, or even 
later, is often preceded by hiccup, subsultus tendinum, involuntary stools, hemorrhage froqa 
the stomach or bowels, petechige. &c. 

The congestive form of bilious remittent fever may attack suddenly, when it is apt to 



968 BILIOUS REMITTENT FEVER. 



assume a peculiarly malignant form, and to terminate rapidly in death ; in many cases, how- 
ever, it is preceded by the same symptoms as the milder and more open forms of the dis- 
ease. In the more violent attacks of congestive fever, " the system seems," to use the words 
of Dr. Dickson, '-to sink at once prostrate before the invasion or exacerbation, which can 
scarcely, at times, be called febrile. Reaction, to use our technical phrase, does not take 
place, or very feebly, if at all. The skin is cold, and covered with a clammy sweat, as in 
the collapse of cholera; the pulse is weak and fluttering; the stomach is very irritable, with 
frequent and painful, but usually ineffectual, efforts to vomit ; the countenance is shninken 
and pale or livid; there is often low muttering delirium, with shivering and fainting. In 
some cases, no complaint is made, a lethargic insensibility seeming to oppress the patient; 
in others, the most extreme anguish is endured by the miserable sufferer, who in his agony 
often utters groans or loud cries. The vital powers are speedily and irrecoverably exhausted 
by the recurrence of a few such exacerbations, although the remissions in this class of cases 
are usually well defined, and full of transient relief and hope. The third, fourth, or fifth 
return of the train of symptoms delineated, for the most part, puts an end to the distressing 
scene." 

The phenomena of congestive fever are evidently the result of defective innervation, and 
an impeded action of the heart and lungs; the blood, imperfectly decarbonized, accumulates 
in the interior t>rgans, and thus presents the fall and regular exercise of their functions. The 
impression of the morbific causes by which the disease is produced is, in all probability, 
made primarily upon the nervous centre, and by depressing the energy of its action, gives 
rise to all the other phenomena which characterize this form of fever. 

The propriety of denominating these cases of congestive disease bilious remittent fever, 
when they frequently run their course without exhibiting the slightest indication of febrile 
reaction, has been doubted by some. They are, however, produced by the same causes as 
the bilious fever, and, when the congestion is early reduced, the case often assumes all the 
characteristics, and runs the same course as in the ordinary form of bilious fever, showing 
that the phenomena of the latter were merely masked or suspended by the congestive state 
of the principal vital organ. 

The convalescence from an attack of all the forms of bilious remittent fever is always 
protracted, and relapses, from slight irregularities of diet or too early exposure, are not unfre- 
quent. After severe attacks, the hair often falls entirely off", and is only slowly and imper- 
fectly renewed, or the patient remains permanently bald. The functions of the stomach and 
alimentary canal, generally, are imperfectly performed for a long period after recovery, and 
require the utmost circumspection on the part of the patient to insure their complete restora- 
tion. Jaundice is a very frequent consequence of bilious remittents. This, Dr. Dickson 
states, ''was noticed generally in the summer and autumn of 1824; very few patients reco- 
vering from the fever in that year without becoming icteric. Nor is it rare to meet with 
hepatic enlargement and induration, attended by a long succession of sufferings from visceral 
obstructions and mechanical impediments to the performance of the abdominal functions, 
and to the transmission of the abdominal circulation. Hence ascites and anasarca, and hence 
diarrhoea and dysenteries called hepatic, and occasionally melsena and true intestinal hemor- 
rhage. The spleen suffers from remittents of malarious origin, as from their kindred inter- 
mittents, though not by any means so uniformly, sometimes undergoing a permanent and 
inconvenient increase of size or hypertrophy." 

With the pathological anatomy of remittent fever we are but imperfectly acquainted ; very 
few facts in relation to it have been recorded, and of these few many are loosely and imper- 
fectly detailed, while those upon the accuracy of which reliance can be placed, are derived 
from too limited a series of observations to allow of any positive general conclusions being 
based upon them. That, however, the stomach and liver are the organs in which indications 
of disease are the most ^^niformly detected, all the facts in our possession very clearly prove, 
although the exact nature of the morbid lesion is not very clearly made out. "The closest 
attention to clinical observations," remarks Mr. Twining (Diseases of Bengal, chap, v.), "as well 
as the result of post-mortem examinations, convince me, that remittent fevers in Bengal are 
invariably connected with local congestions, which often run rapidly into inflammations, attended 
with much interstitial effusion. . The seat of these local affections is found principally in the 
stomach, intestines, cellular structure about the duodenum, and at the root of the mesocolon, 
more especially where it passes across the spine. The principal disease is also often found 
in the spleen, liver, brain, or lungs." Dr. Gerhard, of Philadelphia, maintains, as the result 
of his observations, that the anatomical character of the more severe forms of intermittent 
fever is to be detected in the spleen, liver, and stomach ; the bilious and remittent fevers 
being " ])robably referable to the same class as the malignant remittents." These conclusions 
are confirmed by the observations made by Dr. Stewardson, in the Pennsylvania Hospital ; 
by those of Dr. Swett, made in the New York Hospital ; and by the results of dissections in 
single cases, as reported by Dr. Howard and others. Dr. Boyd describes the indications of 
disease, after death, in the bilious fever of Minorca, as occurring in the brain, lungs, liver, 
and stomach 5 the liver, he states, was in most instances enl5kr§edj often inflamed, with its 



BILIOUS REMITTENT FEVER. 



969 



inferior margin livid ; the gall-bladder distended with viscid bile. The stomach and intes- 
tines were often inflained ; the villous coat being of a dark colour. 

The appearances in the stomach are variously described ; but in general, they are stated 
to be injection, with increased redness of the mucous membrane — sometimes thickening and 
occasionally softening of that membrane. In many instances, the same appearances are 
described as being present in the duodenum. The glands of Brunner, in this intestine, were, 
according to Dr. Stewardson, " developed in a remarkable manner," in the cases examined 
by him ; a similar development did not, however, occur in the fatal cases which fell under 
the notice of Dr. Swett. 

In all the dissections made by Drs. Stewardson and Swett, and the one reported by Dr. 
Howard, the liver was found to be flabby, of a bronze colour, the two substances composing 
the organ being blended together in such a manner as to be scarcely distinguishable. The 
spleen was much enlarged and softened. The peculiar condition of the liver, just described, 
Dr. Stewardson considers to constitute " the essential anatomical character'' of remittent 
fever : he thinks it highly probable that the same alteratTon of the liver will be found 
to exist in intermittents which prove fatal in their early stage ; these and intermittents being, 
in his opinion, essentially the same disease. 

Drs. Gerhard, Stewardson, Swett, and Howard, never detected in any case, after death from 
remittent fever, the glands of Peyer, and the other intestinal follicles, in a diseased condition ; 
and although we believe that these parts will generally be found in a perfectly healthy state, 
nevertheless, it is certain that cases do occur, particularly of the more protracted forms of 
the disease, in which the evidences of follicular inflammation of some portion of the small 
intestines, terminating occasionally in ulceration, especially of the glands of Peyer at the 
lower end of the ileum, are present after death. Such cases are referred to by Dr. Geddings, 
of Charleston, Drs. Stevens and Vache, of New York, Dr. Harrison, of Cincinnati, as quoted 
by Dr. Dunglison, (Practice of Med,., 2d ed., vol. ii., p. 450.) A diseased condition of the glands 
of Peyer is stated to have been present also, in all the cases examined by Dr. Richardson in 
the New York Hospital, in 1840, (Dr. Swett, American Journ. Med. Sciences, January, 1845 ;) and 
the same lesion was noticed by Dr. Mc William in the African remittent fever. 

The indications of congestion and of inflammation so frequently met with in the brain 
and lungs, point out, it is true, the tendency there exists in remittent fever to disease of those 
organs, but they are not invariably present, nor are they essential to the disease. 

In cases of congestive intermittents, the anatomical lesions are the same as those de- 
scribed above, excepting, that when death takes place previously to the occurrence of 
complete reaction, there is very generally extensive hypersemia of the brain, lungs, liver, and 
spleen. 

The diagnosis in bilious remittent fever will depend, in a great measure, upon the charac- 
ter which the disease presents in different localities and in different years, as well as upon 
the constitution and other circumstances connected with the individuals attacked by it. In 
the milder forms of the disease, with distinct exacerbations and remissions, and no marked 
tendency to disease of the more important organs, particularly when they occur in persons 
of temperate habits, and of constitutions neither broken down on the one hand by previous 
disease, fatigue, or the depressing passions, &c., nor on the other, marked by undue plethora, 
or a tendency to congestive or inflammatory affections of the central organs ; by a judicious 
treatment, early commenced with, a favourable result may very generally be obtained. 
Even the more strongly marked inflammatory form of the fever seldom terminates fatally 
when vigorously treated from its onset. The congestive or malignant form of the disease is 
one in which the prognosis is much more unfavourable ; in epidemics of congestive bilious 
fever the mortality is often truly appalling. Remittent fever, generally speaking, attacks 
with less severity, and is more readily controlled in those acclimatized, as it is termed, to the 
districts of country in which it occurs as an epidemic — that is, persons who, having passed 
through the disease, continue to reside in those districts. A stranger, recently arrived, par- 
ticularly if a high liver, or of intemperate habits, or whose occupation subjects him to 
exposure and fatigue, is not only more liable to be attacked than the former class of indivi- 
duals, but in such a one the disease will usually be marked by greater severity, and be more 
liable to terminate fatally. The favourable symptoms, in individual cases, are, the mildness 
and comparative shortness of the exacerbation, tUe completeness and long duration of the 
remission, particularly when this is accompanied by a free and diffused perspiration, and 
the patient falls into a quiet and refreshing sleep ; the postponement of the succeeding exa- 
cerbations beyond their anticipated periods ; the diminution or removal of the tendency to 
disease of particular organs ; the occurrence of more regular and healthy discharges from 
the bowels ; the tongue becoming cleaner and the pulse slower and less frequent, &.c. 

The bilious remittent fever, as we have already remarked, is a disease of hot climates and 
of the season of greatest heat ; thus, while it constitutes the summer endemic of the south- 
ern portion of our Union, it seldom occurs in the middle and northern states, excepting 
during those summers that are marked by an unusual elevation of temperature; and here, as 
well as in the places where it prevails endemically, it ceases as the winter approaches. 



970 



BILIOUS REMITTENT FEVER. 



Whether the fever can be produced by exposure alone to a high degree of atmospherical 
temperature, is a question that has been frequently raised 5 and while many maintain the 
affirmative, others as positively assume the negative. It is very certain, however, that the 
long-continued actio* of excessive heat upon the body, by predisposing it to the action 
of other morbific agents, will, in this manner, often bring on an attack of bilious fever, inde- 
pendently of malarious influences. Tluis, nothing is more common than for the disease to 
immediately occur in those who, after exposvire to the midday sun, or many hours of severe 
labour in intensely hot weather, allow their bodies to become chilled by sleeping on the 
ground in the open air after night ; by neglecting to change their clothing when they become 
wet by a shower of rain or other cause; or, while the perspiration is running in streams from 
every pore, by throwing off a portion of their clothing, and sitting or lying in a draught of 
air, particularly after sundown. But while many of the sporadic cases are produced in this 
manner, and the same species of imprudence is a common exciting cause of the fever, when 
it prevails as an endemic or epidemic, a large number of incontestable facts would seem to 
prove that its more common cause is a poison produced by the action of high degrees of solar 
heat upon such portions of the earth's surface as are ordinarily covered or soaked with water, 
when these are accidentally laid bare, or rendered dry by long-continued heat and drought. 
The presence of substances, whether vegetable or animal, liable to decomposition, is to be 
included among the causes capable of generating bilious fever in hot climates, and in the 
more temperate climates during summers of unusual heat. In our larger cities the disease 
always prevails most extensively, and in its more malignant forms, in the most confined and 
filthy districts, to which it is often entirely confined ; or, when it makes its appearance in 
other parts of them, it can generally be traced to the presence of some local cause of infec- 
tion. In Philadelphia, where bilious remittent fever was formerly a common disease of the 
summer and early autumnal months, it is now of rare occurrence, excepting in its mildest 
form; and this disappearance of the disease from our city is to be ascribed more to the better 
construction and cleanliness of our docks, and the greater attention which is paid to the 
paving, draining, and sewerage of our streets ; to the filling up of the numerous ponds 
which .formerly existed in and about the city, and to the preventing any mass of putrefiable 
materials from being stored in the city proper and surrounding districts, than to any very 
decided diminution in the temperature of our summers. 

In the treatment of bilious remittent fever, the first and most important question that pre- 
sents itself is, the propriety of direct depletion by the lancet. This must be determined 
solely by the character of the symptoms and condition of the patient in each case. In the 
more decidedly inflammatory cases, when the exacerbation is well-marked and prolonged — 
when it is attended by a hot skin, flushed and turgid face, severe pain of the head and back, 
great oppression about the prsecordia, and a firm or chord ed pulse — and when the intermis- 
sions are short and imperfect — more particularly in cases occurring in young, robust, and 
plethoric habits, and who have but lately arrived from a colder climate, there can be no doubt 
of the importance of blood-letting. In such cases a vein in the arm should be opened at the 
early period of the attack, and a sufficient amount of blood drawn ofi" at once to reduce the 
violence of the exacerbation: one sufficient bleeding at the onset of the disease is far more 
efficacious and better adapted to prevent local determination than the repeated detraction of 
small quantities of blood during its course. A repetition of the bleeding will seldom be de- 
manded when the first operation has been carried to a sufficient extent ; should, however, 
the succeeding exacerbation be marked by any degree of violence, we should not hesitate 
again to resort to the lancet; but the loss of a less amount of blood will be required to 
reduce the excitement than in the first instance. If direct depletion by the lancet has been 
neglected in the early stage of the disease, it will seldom be admissible subsequently — or, 
should symptoms seem to demand it, it should be employed with the utmost caution, and 
only to a moderate extent. 

That numerous cases of bilious fever occur in which venesection is altogether unneces- 
sary, is unquestionably true ; in those, however, that are marked in their early stage by a 
high degree of arterial excitement, and a tendency to local hypersemia or inflammation, the 
remedy cannot be dispensed with without danger to the patient. When timely employed, 
we have repeatedly been surprised at the very great and prompt relief produced by it — the 
violence of the exacerbations becoming reduced, the intermissions more complete, the skin 
cooler and more relaxed — the pain of the head relieved — the bowels readily acted upon; 
and a state of calmness, often of refreshing sleep, will often succeed to the previous rest- 
lessness and distress. 

Local blood-letting is a remedy more generally demanded in bilious remittent fever than 
bleeding from the arm. In all cases attended with intense pain of the head, throbbing of 
the temples or delirium — or with pain or decided tenderness of tlie epigastrium and right 
hypochondrium, or with pain, and a sense of tightness or oppression about the thoraX'^ — in 
conjunction with general bleeding, or where this has not been judged necessary, the appli- 
cation of leeches or cups in the neighbourhood of the local suflering, in numbers propor- 
tionate to its intensity and to the age and condition of the patient, will invariably be followed 



BILIOUS REMITTENT FEVER. 



971 



I by decided and, generally, permanent relief. The very great suffering which many patients 
experience from pain in the back and loins, we have, in repeated instances, known to be 
I completely relieved by cups applied along the spine. 

I In regard to the propriety of cathartics in the treatment of bilious remittent fever, there is 
■' a much greater unanimity of opinion than in relation to blood-letting. There are few, if any 
\ cases, in which their operation will not be found beneficial, by removing from the intestines 
jj the vitiated secretions with which they are often filled — procuring regular stools, and by 
assisting to reduce the congestion of the portal system, and thus restoring the healthy func- 
]| tions of the liver and digestive organs generally. 

'i It is not, however, every purgative from which good effects are to be anticipated in bi- 
'j lious fever. Under the free employment of certain cathartics the patient will often be found 
' gradually to become more and more debilitated, and finally to sink into a state of stupor, 
with suffused eyes, weak, fluttering pulse, and other symptoms of extreme exhaustion ; in 
I such cases it will be found that the discharges from the bowels consist of a thin, serous 
l! fluid ; whereas, under the employment of such purgatives as produce consistent, viscid, and 
: dark-coloured stools, the indications of improvement in the symptoms of the disease are often 
ij prompt and striking. Calomel is probably one of our best cathartics in this disease. It may 
be given either alone, in a full dose, and followed by occasional doses of castor oil — senna 
\ tea — calcined magnesia — or laxative enemata ; or the calomel may be combined with rhu- 
Ij barb, or jalap ; or, what is frequently a more effectual plan, a full dose of the calomel ad- 
I ministered at first, and then, every three or four hours, according to the effects produced, 
[ moderate doses of the blue mass and rhubarb, with the addition of a small portion of 
; ipecacuanha. By these means we shall generally succeed in freeing the bowels of the 
jj dark-coloured, viscid matter with which they are often loaded, and procuring more regular 
|i and healthy stools — after which, an occasional dose of the milder laxatives will alone be 



In all cases of bilious remittent fever attended with a hot and dry skin, the application 
of cold to the surface, either by sponging it with cold water or cold water and vinegar, or by 
I the application of cold water in the form of affusion, will have the effect, while it reduces the 
! morbidly increased temperature, of relaxing the skin, and promoting perspiration, and in this 
1 manner of shortening the exacerbations and inducing a complete intermission ; even the ex- 
posure of the body to a current of cool air — by throwingoff the clothing and opening the doors 
' and windows of the patient's chamber, will in most cases be productive of the most beneficial 
I effects. The mere immersion of the hands and arms in cold water, by carrying off a portion 
of the morbid heat and allaying thirst and restlessness, will be found grateful to the patient, 
who not unfrequently will fall immediately afterwards into a refreshing sleep: whenever, 
however, the exacerbation is attended by intense heat of the surface and other symptoms of 
violent excitement, it is from the application of cold water to the surface by affusion or spong- 
ing that the most prompt and permanent advantage is to be obtained. Dr. Dickson ranks 
it among the most efiicient of our febrifuge measures — far above the lancet, both in the 
extent of its adaptation, and in its degree of specific utility. All that we can hope or anticipate 
from blood-letting may be obtained, in the majority of cases, from the use of the cold bath, 
while the latter possesses this striking and obvious advantage, that we can repeat it as often 
as the symptoms are renewed that require its employment. The local determination which it 
controls most promptly, he very correctly remarks, is that to the brain, shown by headache, 
flushed face, red eye, delirium, &c., with a full, hard, bounding pulse. In such cases, the 
patient being seated in a convenient receptacle, a large stream of cold water should be 
poured over his head and naked body from some elevation, and continued until he becomes 
pale, or his pulse loses its fullness, or his skin becomes corrugated and he begins to shiver ; 
he should then be dried and placed in bed, with just so much covering as he feels to be 
comfortable, the chamber being, at the same time, fully and freely ventilated; or without 
removing the patient from the bed, he may be supported in a leaning posture over its edge, 
i and the cold water poured from a pitcher over the vertex. 

1 The application of cold water to the surface is proper only when the temperature of the 
I latter is considerably and permanently increased over the whole body, and at the same time 
' the surface is perfectly dry — when the skin is cool or covered with moisture, the use of the 
j cold water is inadmissible; it is also of doubtful propriety when there exists a decided tend- 
ency to hyperssmia or inflammation of the lungs, or in cases attended with diarrhoea. Its 
I repetition is forbidden when it has occasioned a protracted chill or rigor; or the patient 
j continues to feel cold or uncomfortable after its use. 

I The testimony of Dr. Dickson in relation to the curative powers of cold water applied to 
I the surface in the bilious remittent fevers of the south is strong and pointed, and is fully 
I borne out by the experience of physicians of other portions of the United States and of 
j Europe, who have extensively employed it in the disease under consideration. Equally 
I important with the external employment of cold water is its use internally; — allowing the 
patient to drink freely of cold, or even iced water or iced lemonade, is not only highly 



required. 




972 



BILIOUS REMITTENT FEVER. 



grateful to him, but it tends to diminish the morbid excitement, relax the skin, and promote 
a free and uniform diaphoresis. 

Diaphoretics, particularly a combination of tartar emetic, nitre, and calomel, have been 
recommended and highly extolled by many practitioners, in the inflammatory forms of 
bilious fever. We have occasionally employed the combination just mentioned, but have 
never seen any decidedly beneficial effects produced by it, while the emetic tartar, in how- 
ever minute doses administered, we have found, very generally, to augment the irritability 
of the stomach, and increase in this manner the distress of the patient. The neutral mixture^ 
spirits of mindererus with the sweet spirits of nitre, or a weak solution of nitre in water, we 
have occasionally employed, but we must frankly confess, that we are not aware of any 
benefit resulting in a single case from the administration of either. 

Upon the propriety of blisters in bilious remittent fever, there exists not a little dispute, 
their use being entirely condemned by some practitioners, while others rank them among 
our most valuable remedies. In the more inflammatory forms of the disease, until the 
violence of the exacerbation has been reduced by the remedies already detailed, from the 
application of blisters more injury than good will unquestionably result; but as soon as the 
exacerbations have become less intense, and the remissions more marked, in all cases where 
considerable gastric distress remains, or any considerable affection of the head or lungs, 
from blisters over the epigastrium and right hypochondrium, to the nape of the neck, along 
the spine, or to the chest, very considerable and prompt relief will always be obtained. 

In many cases of bilious fever there is so great a degree of irritability of the stomach, 
that not only is everything taken into it rejected as soon as it is swallowed, but the patient 
is tormented with almost constant vomiting or frequent ineffectual efforts to vomit. This 
distressing symptom will, very often, be completely removed by the abstraction of blood 
from the arm, whenever this is admissible, or by cups or leeches over the epigastrium, or 
by a large blister applied to the latter part. Relief will also be obtained from small portions 
of ice held in the mouth, from the effervescing draught, the artificial mineral water of the 
shops, taken perfectly cold, or from iced lemonade or toast water. Minute doses of calomel, 
say a third to half of a grain, suspended in some simple mucilage, and repeated at short inter- 
vals, will, very generally, promptly relieve the gastric irritability and suspend the vomiting. 
In cases where every other remedy has failed in relieving the irritable state of the stomach, 
we have repeatedly seen it promptly removed by a grain of the acetate of lead, given every 
hour or two, dissolved in a small quantity of water. 

By a few practitioners, a mercurial course is recommended in all the more violent forms 
of bilious remittent fever. Calomel is directed to be given first, in large doses, as a purga- 
tive, and subsequently, in small doses, continued until its specific effects are obtained ; our 
own experience is not, however, in favour of this practice. In the inflammatory form of the 
disease, a mercurial impression is calculated rather to protract than to diminish the suffering 
and danger of the patients, while the milder forms of the fever may be readily controlled 
without it. Cases, however, occasionally occur in which an alterative course of mercury 
will be found, we are convinced, highly advantageous. We have repeatedly observed, that 
after the violence of the exacerbations has been reduced, the patients will continue to be 
affected by a low form of fever, marked by a dry skin, a small irritated pulse, a dry dark- 
brown tongue, frequent watery discharges from the bowels, restless nights, and a total want 
of appetite, and have found this condition of things to be speedily removed by a cautious 
mercurial coui'se, carried to the extent of producing a slight tenderness of the gums. In 
these cases small doses of calomel, or, what is preferable, the blue mass, combined with a 
portion of opium and ipecacuanha, may be given every three hours until the desired effect 
results. A form of the disease, somewhat similar to the one just referred to, is described 
by Eberle as occurring "when, either from the imprudent employment of irritating purges, 
or from other causes, the mucous membrane of the intestinal canal is brought into a state of 
high irritation or subacute inflammation. The disease then generally loses its remittent 
form, and often assumes a low typhoid character, with almost constant delirium, a tender 
and tympanitic state of the abdomen ; a dry, dark-brown, or black crust on the tongue, with 
clean red edges ; watery and reddish stools ; great prostration ; and a very dry and hot skin. 
Cases of this kind frequently run on for several weeks, and the convalescence is always very 
gradual and tedious." The treatment directed by Dr. Eberle is leeches to the abdomen, fol- 
lowed by a large emollient poultice ; small doses of calomel and opium — one-sixth of a grain 
of the former to a quarter of a grain of the latter — every two or three hours. The bowels to 
be kept open by laxative enemata, and the patient directed to partake freely of some bland 
mucilaginous fluid — such as barley water, very thin oatmeal gruel, or a solution of gum aca- 
cia in water ; no other article of food being allowed. " In such cases," he remarks, " I have 
thought that considerable benefit was derived from epispastics on the legs just above the 
ankles; this measure is particularly useful when the extremities are cool, while the skin of 
the body is hot — a circumstance which is not uncommon in instances of this kind. An 
emulsion of balsam copaiba may also be frequently employed with unequivocal advantage. 
I have so often seen the most decided benefit derived from this article, in cases attended 



4 

BILIOUS REMITTENT FEVER. 



973 



with great irritation or subacute inflammation of the bowels, that T should consider myself 
neglecting an important curative means, were I to omit prescribing it in diseases of this cha- 
racter." "Although very considerable prostration often occurs in such cases, stimulants or 
tonics are by no means admissible." 

Throughout the entire course of bilious remittent fever, little desire for food will be 
expressed by the patient, nor should any be allowed until after the disease is fully subdued ; 
and then only barley or rice water, thin gruel or panada, in very moderate quantities. To 
allay the thirst, which is always present and frequently very urgent, the cold drinks, already 
I pointed out, will be the most suitable. Perfectly cold toast water, slightly acidulated with 
lemon or orange juice, tamarinds, or currant or plum jelly, forms generally a very palatable 
] beverage, of which the patient may partake at short intervals. Small quantities of cold 
I acidulated fluids, slowly swallowed, it is to be recollected, are far more efficacious in allay- 
j ing thirst than large draughts hastily swallowed. Frequently sponging the patient's mouth with 
j cold water, cleaning his tongue with a slice of orange, or allowing him to suck the juice of 
the latter, will aid very materially in abating his sense of thirst, and is always refreshing 
j| to him. 

j! The chamber of the patient should be kept perfectly clean and cool, and while a free ven- 
!: tilation is kept up, it should be guarded from any glare of light. His body should be slightly 
1 covered with bed-clothes, which, together with his linen, should be frequently changed. At 
!j all times the patient should be kept perfectly quiet, and the most perfect calmness and quiet- 
1 ness should be maintained within and around his apartment. 

^ In our enumeration of the symptoms of bilious fever, it was stated that great restlessness 
and wakefulness were very commonly present. So long as the period of increased excite- 
i ment lasts, or there is any tendency to disease of the brain, the only means by which the 
I restlessness of the patient is to be subdued and sleep procured, are the general remedies that 
have been already enumerated ; but after the morbid excitement, and whatever cerebral 
affection that may exist, have been reduced, a state of restlessness and an inability to sleep 
often still continue from mere nervous irritability, when the exhibition of an opiate in the 
form of Dover's powder, about bed-time, will very generally be found advantageous : by 
some practitioners, the extract of hyosciamus, combined with ipecacuanha, is preferred to 
any preparation of opium ; while others, again, recommend the tincture of opium, combined 
with a vegetable acid, as tinct. opii 33S., acid, citric, gr, v. to viij., aq. pursB gij., M. ; of 
which a tablespoonful, or half an ounce, is a dose, to be repeated, if necessary, after a short 
interval. 

We have now presented a general outline of the treatment of bilious remittent fever, in 
its mild and inflammatory forms. It is hardly necessary for us to repeat, that the extent to 
which each remedy is to be carried, and the propriety of its repetition and continuance, as 
well as the period and particular circumstances of the disease to which it is adapted, must 
be determined by the application of the general principles of pathology and therapeutics to 
each case we are called upon to treat; and although this will demand a degree of judgment 
in the practitioner, which he can only acquire by habits of close attention and nice discri- 
mination, and a somewhat extended field for observation, it is the only course from which 
success can be anticipated in the treatment of a disease, which, like the one under considera- 
tion, varies so much in its character in different seasons and localities, and even in different 
individuals attacked at the same place and during the same period. 

When the disease, notwithstanding our best directed efforts, runs on to that stage when its 
symptoms resemble those of the last stage of typhus fever, nothing is left us but to endea- 
vour to sustain the patient's strength, and to remove or relieve any urgent cause of distress or 
danger. He should be allowed such nourishing food as is easy of digestion, as beaf tea, 
sago, arrow-root, and the like, with wine-whey, wine, pure or diluted, porter, milk-punch, or 
brandy, in quantities adapted to the emergency of the symptoms and the effects produced. 
Sinapisms or blisters may at the same time be applied to the inside of the thighs or calves 
of the legs, and to the epigastrium. If diarrhoea be present, this we should attempt to abate 
or suspend by opiate and astringent injections. The singultus, which is often present to 
a very distressing degree, may be frequently allayed by the camphor julep ; and the meteor- 
ism of the abdomen may often be considerably relieved by the spirits of turpentine, thirty 
drops of which may be given every two or three hours ; this latter is said indeed to be among 
the safest and most useful remedies at this stage of the disease ; it will often be found to pro- 
duce a beneficial impression upon the diseased mucous membrane of the alimentary canal, 
to suspend the frequent griping stools, and to correct the morbid character of the discharges. 
In the sinking stage of bilious remittent fever, the effects of ammonia, with a strong decoc- 
tion of serpentaria or valerian, or combined with the aromatic confection, have been repre- 
sented as peculiarly beneficial ; but, unfortunately, when the disease has arrived at this stage, 
j every remedy will too often be.found unavailing, and our best directed efforts to save the life 
of the patient ineffectual. 

A question has been agitated both as to the propriety of and proper period for the admi- 
nistration of cinchona or quinia in remittent fever. Without attempting to detail the various 

4g 



974 



BILIOUS REMITTENT FEVER. 



and opposite opinions that have been advanced upon this subject, we shall merely remark, 
that in the simple and inflammatory forms of bilious remittent fever, it would be reasonably 
inferred from the character of the disease, that the bark or quinia is not a remedy adapted 
to control the symptoms of its earlier stages, and the correctness of this inference has been 
very fully established by the result of experience. So soon, however, as a complete inter- 
mission has been obtained, and no indications of visceral hypersemia or inflammation are 
present, a cautious administration of the cold infusion of the cinchona, combined with ser- 
pentaria or some agreeable aromatic, will be found, in general, to cut short the remaining 
symptoms of the disease and accelerate the period of convalescence. The quinine may be 
given in solution with the addition of a few drops of the elixir of vitriol, and to the extent 
of from three to five grains, repeated at such intervals as the circumstances of the case Jnay 
demand. The more violent the form of disease has been, the more important is the 
administration of the quinine, so soon as a complete remission has been obtained, and the 
larger should be the dose of the remedy. 

During the period of convalescence, the patient should be guarded from the efiects of any 
sudden transitions of temperature, and from incurring the least degree of fatigue by sitting 
up too soon or for too long a period ; and while his mind should be occupied and amused, at 
proper times of the day, by the conversation of his friends, or some light occupation, fatigue 
from this source must also be avoided. His bowels are to be kept regularly open, which 
may generally be done by allowing him to partake, in moderation, of any of the perfectly 
ripe subacid fruits of the season ; if they, however, should become closed, some mild laxa- 
tive should be occasionally administered. In regard to diet much caution is to be observed. 
The patient should be confined at first to moderate quantities of the more agreeable farina- 
ceous articles ; and if his strength has been greatly prostrated, a glass or two of sound wine 
will not be improper. As his digestive powers improve, he may be allowed plain beef or 
chicken broth, oysters slightly cooked, parboiled eggs, and finally, the lighter and more rea- 
dily digested meats, plairdy but nicely cooked. The appetite often remains, for a long time, 
weak and capricious — and frequently, some agreeable bitter infusion, as Colombo, quassia, or 
the wild cherry tree bark, will be proper, to augment the tone of the stomach. In all cases, 
the food of the patient should be presented to him in small quantities, and served with great 
neatness ; large masses of food, slovenly prepared and served, will in general disgust, and 
thus destroy what little appetite may exist. In regard to exercise and exposure to the open 
air, the convalescent should undertake them only so soon as he has acquired some degree of 
strength, when a trip to some agreeably situated watering-place will often restore him to per- 
fect health, more quickly than can be efiected during his continuance at home, where his 
mind is too early directed with anxious care to the concerns of his family and of his pro- 
fession. 

In the congestive form of bilious fever, the indications of cure are, to rouse the nervous 
energies of the system, to relieve as quickly as possible the central organs from their state 
of hyperaemia, and to restore to the capillaries of the surface their healthy action. Among 
the most important of the remedies calculated to efiect these objects, is the external appli- 
cation of heat to the surface of the body in the form of the warm or hot bath, the vapour 
bath, or in a dry form by bags of heated bran, salt or sand, bottles of hot water, &c. We 
shall often succeed in -rousing the patient by immersing the whole of his body, as early as 
possible after he is attacked, in water, of a temperature proportioned to the urgency of his 
symptoms; that is, of a greater or less degree of heat, within proper limits, according as 
the temperature of the skin, the state of the pulse, and the general strength is more or less 
depressed, and the greater or less degree of torpor of the nervous system ; at the same time 
applying brisk friction with a soft brush or a flannel cloth, to the whole surface, and particu- 
larly to the epigastric and abdominal regions. On coming out of the bath the patient is to 
be rubbed dry with heated flannels, put into a well-aired bed between blankets, and supplied 
with some mild diaphoretic drink, as the infusion of serpentaria, of tepid warmth. A 
full dose of the Dover's powder, or a combination of opium, camphor and ipecacuanha, 
one grain each, with ten of nitre, given at this period, will often be found particularly 
beneficial. 

Next in efficacy to the warm bath, we may rank external stimulants ; sinapisms should, 
therefore, be early applied to the extremities and over the epigastrium, while frictions, with 
some stimulating liniment, are made along the spine. By some practitioners internal stimu- 
lants have been strongly recommended, as a means of rousing the central organs from their 
fstate of torpor, and bringing on a general and moderate reaction : it is probable that in certain 
cases, where the state of congestion is very considerable, and it is not promptly and perma- 
nently relieved by the remedies already recited, some mild stimulant, as the ammonia, or 
turpentine, or wine-whey, may prove ad vantageous, if cautiously administered and its efiects 
carefully watched ; as a general rule, however, the free use of = stimulants, particularly of the 
more active class, is calculated to produce injury rather than good. 

An active cathartic, as the combination of calomel or blue mass with aloes and extract of 
colocynth, followed in a few hours by the compound infusion of senna, will very generally 



SMALL-POX. 



975 



cause a copious discharge from the bowels, of a dark-coloured, tenacious matter, and by thus 
assisting to unload the portal system, will often produce a marked improvement in the general 
symptoms of the disease. In the treatment of congestive bilious fever, the abstraction of 
blood from the arm, in the first period of the attack, or subsequent to the use of the warm 
bath and frictions to the surface, has been recommended by many practitioners as an imporant 
remedy — one indeed from which more prompt and certain relief is to be obtained than from 
any other that we can employ. The evidence in its favour is certainly very strong: and we 
believe that there are many cases in which prompt reaction maybe produced, and the danger 
of permanent local disease prevented by its employment. The greatest judgment and 
caution, however, are demanded in the use of the lancet in all cases of congestive disease ; 
the effect produced upon the pulse must be carefully watched, and the flow of blood instantly 
stopped if any disposition to sinking is detected. To determine beforehand the amount of 
blood that it will be proper to take away is impossible — the efiects produced — the relief 
obtained, are the only guide. Even, however, when during the flow of blood the pulse 
becomes more free and developed, but a moderate quantity should be taken away at once — ■ 
should we have to repeat the operation after a short interval. Occasionally but a drop or 
two of blood will escape from the vein when it is first opened, but, after a short time, the 
circulation becoming more free, the blood flows in a full stream, with decided relief to the 
patient. It is only, however, in the early stage of the highly congestive forms of bilious fever 
that venesection is admissible, and even in these the flow of blood should be instantly 
arrested if the pulse is found to sink, or even to remain oppressed and undeveloped after a 
small quantity has been lost. 

When prominent symptoms of hypersemia of the brain, lungs, or other important viscera 
present themselves, the application of cups to the head, chest, or in the neighbourhood of the 
affected organ, will often be found decidedly advantageous. 

As soon as reaction takes place, the use of quinia should be commenced with, in large 
doses, repeated at short intervals. Of the curative powers of the quinia in this form of fever 
we have the fullest and most unquestionable testimony. Many of the physicians of the 
southern and western portions of the United States place their chief reliance, in congestive 
remittent fever, upon the sulphate of quinia prescribed in enormous doses — twenty, thirty, 
and even fifty grains, repeated at short intervals until a solution of the disease is obtained ; 
but although we are convinced of the propriety of large and frequent doses, those alluded to 
are certainly excessive and uncalled for. 

The period of convalescence from the congestive form of bilious fever will require the 
same management as that from the more open and inflammatory forms. 

In the highly uialignant remittent, occasionally met with, in which the vital forces, crushed 
at once by the overwhelming intensity of the morbid cause, fail apparently to exhibit any 
resistance or reaction ; they must be sustained, to use the words of Dr. Dickson, (Essays on 
Pathol, and Therapeut., vol. i., p. 319,) by every means within our power, while we have 
immediate recourse to the most impressive revulsives. The hot bath, sinapisms, vesications, 
must be quickly and assiduously applied, while we stimulate, by the freest use of internal 
remedies — carefully selecting such as are best adapted to the circumstances presented. If, 
as is often the case, the patient suffers severely from pain in the chest or abdomen, large 
doses of opium or morphine must be administered, while we keep up his sinking strength 
by brandy, ammonia or ether. In the superintendence of such cases we should rather incur 
the risk of over-stimulating transiently, than fall below the requisite point of excitement in 
our use of stimulants. Dr. Dickson is fully persuaded, that he has seen more than one patient 
die from the timidity of his physician in this respect ; who, keeping at a cautious distance 
behind the disease, would not venture on the exhibition of any excitant adapted to the feeble 
excitability, until the vital energies upon which alone stimulants can act, had become worn 
out and exhausted. If the stomach will bear it, it will be proper to administer, also, some 
of the preparations of cinchona. The sulphate of quinia in full doses will be often retained 
and do good. "Alternate, combine, and recombine your stimulants, the effects of which may 
perhaps be aided by warm and nutritious fluids, wine-whey, arrow-root with wine, wine 
alone or spiced, brandy with milk or in mucilage. These energetic measures will usually 
be found effective within a very short period — improving the pulse, and arousing the general 
powers of the system. Yet you must not permit yourselves to be disheartened into inaction 
by their apparent inefficacy or slowness of impression. Persevere, not only while there is a 
reasonable hope, but even after all hope seems extinguished ; and you will feel yourselves 
amply repaid by the gratification, which will not perhaps be denied you, of saving more than 
one fellow-creature from the destruction which seems inevitably to await him." — C] 

I pass, without pausing, from the consideration of continued fever, to that of small" 
pox or variola : a disease, fortunately, less common in this country than it used to 
be, yet still sufficiently frequent and formidable to require that we should acquaint 
ourselves with the phenomena it is accustomed to present ; and very prevalent here. 



976 



SMALL-POX. 



as it happens, at present (1838). I have already mentioned, by anticipation, several 
points in its history. 

This frightful disease sets in with smart febrile symptoms : rigors, followed by 
heat and dryness of skin, a hard and frequent pulse, pain in the epigastrium, with 
nausea and vomiting, and headache. Sometimes wild dehrium, sometimes convul- 
sions, mark its outset. Then, to use the words of Cullen's definition, " tertio die 
incipit, et quinto finitur, eruptio papularum phlegmonodearum, quas spatio octo dierum, 
in suppurationem et in cruslas demum abeunt, ssepe cicatrices depressas, sive foveolas, 
in cute relinquentes." 

When small-pox is fully formed, it cannot be mistaken for any other complaint : 
but it is of some importance to recognize it at its very commencement, for the force 
of the impending disorder may sometimes be lessened by judicious measures adopted 
at that early stage. The symptoms, however, that mark the outset of all febrile 
diseases are necessarily very much the same. If the pyrexia set in when small-pox 
is prevalent in the neighbourhood, if the person in whom it occurs be an " unpro- 
tected" person {i. e., one who has neither been inoculated nor vaccinated previously), 
and especially if he be known to have been exposed, within from nine or ten days 
to a fortnight, to the contagion of variola, we may well suspect that the disease will 
turn out to be small-pox, and act upon that suspicion. 

Nevertheless there are some symptoms which, being common in the commence- 
ment of variola, and not common at the beginning of continued fever, or of the other 
exanthemata, may assist the early diagnosis. Vomiting is one of these ; pain of the 
back another. When these symptoms are violent, they usually usher in a severe 
form of the disease. The same may be inferred from a continuance of the nausea 
and vomiting, after the coming out of the eruption ; which is very unusual. 
Heberden noticed that acute pain in the loins was almost always followed by a 
severe disorder ; that pain higher up, between the shoulders, was of better augury ; 
and that it was to be reckoned in all cases a good sign, if there was no pain of the 
back at all. Early delirium, stupor, or convulsions, announce severity in the subse- 
quent course of the malady. Yet not always, especially in children. Within the 
last month I was asked to see a child which had been suddenly attacked with con- 
vulsions, followed by coma. In due time the eruption of variola appeared, and the 
disease ran a mild course, with little aid from medicine, although the child- was 
previously unprotected. 

The peculiar eruption almost always begins to show itself on the third day of the 
fever. The earlier it comes, the severer generally does the disorder prove. In 
judging of the date of the eruption, you must bear in mind that parents and servants 
are apt to state its accession to have been later than it was in reality : for the spots 
are at first so minute that they often escape observation. They also frequently begin 
to come out in the night ; and the morning of the second day of the eruption is called 
the first day. 

< The eruption comes out first on the face, then on the neck and wrists and on the 
trunk of the body, and lastly on the lower extremities. Such is the rule ; so that 
(as is specified in the definition) it does not cease to come out till the fifth day : and 
it keeps a-head, in that order, throughout the disease. There are, indeed, some 
exceptions to this rule. Occasionally the spots appear first upon the extremities, but 
this is very rare. In some instances straggling papulae continue to spring up after 
the main crop is fairly completed ; but these stragglers seldom arrive at the same 
size with the others. 

The pimples, or papulae, ripen gradually into pustules, the suppuration being 
complete by their eighth day ; and on that day the pustules generally begin to break, 
and crusts or scabs to form. In four or five days more, the scabs are falling off. 
There are some variations in all this, also. In children, the crusts are sometimes 
visible on the seventh day ; and in adults, when the disease is severe, they sometimes 
do not begin to form till the ninth day. In all cases, some of the pustules are liable 
to be prematurely broken, by accident, or by the patient's scratching; and these will 
crust over earlier than they otherwise would have done. So that, in fixing the period 



SMALL-POX. 



977 



of incrustation, you are to regard those pustules only of which the natural pro§^ress 
has not bt?en interfered with. 

All that I have hitherto been saying, applies, with more or less exactness, to the 
disease in all its varieties. But its severity differs exceedingly, as I have already 
hinted, in different cases. Its severity, in truth, is almost always in direct relation to 
the quantity of the eruption. The number of pustules indicates, in the first place, 
the quantity of the variolous poison which has been reproduced in the blood. In 
the second place, it is also a direct measure of the extent to which the skin suffers 
inflammation. Sometimes there are not more than half a dozen pustules ; some- 
times there are many thousands. If all these were collected into one, it would be 
an enormous phlegmon. For both these reasons, the system suffers commotion, dis- 
tress and peril, in proportion to the quantity of the eruption. 

When the pustules are very many, they run together ; when they are few, they 
are separate from each other. And this affords a broad line of distinction, which 
can neither be overlooked nor mistaken, between the variola cHscreta, and the variola 
confluens. In the one, the pustules are distinct, and of a regularly circumscribed 
circular form. In the other they coalesce, and their common outline becomes 
irregular. Now, the discrete form of the disease is scarcely ever dangerous ; the 
confluent form is never free from danger. The distinction, therefore, is of the great- 
est importance and interest. For its full estimation, each form must be considered 
separately. 

In the discrete variety, in which the disorder may be presumed to run its most 
natural course, the eruption is at first, according to the phraseology of Willan, papu- 
lar. The pimples gradually increase in magnitude ; but it is not till the third day 
of their appearance that they begin to contain a Httle fluid on their summits. 

For two days after this they increase in breadth only, and a depression is observ- 
able in the centre of many of them. The cuticle is bound down there somehow, 
for a time, to the cutis vera. It is the eighth day of the disease, or the fifth day of 
the eruption, before the pustules become perfectly turgid and hemispheroidal. During 
the time in which they are thus filling up, the face swells ; often to so great a degree 
that the eyelids are closed, and the natural aspect is completely changed or concealed. 
The skin between the pustules on the face assumes a damask-red colour. About the 
eighth day of the eruption, a dark spot makes its appearance on the top of each 
turgid pustule, and at that spot the cuticle breaks, a portion of the matter oozes out, 
and the pustule dries into a scab. When this crust at length falls ofl^^ it leaves be- 
hind it either a purplish red stain, which is still very characteristic of the disease, 
and which very slowly fades ; or a depressed scar, which is indelible. In the latter 
case, the patient, or more properly his skin, is said to be pitted with the small-pox, 
or pock-marked. The sweUing of the face begins gradually to diminish after the 
eruption has become thoroughly pustular. 

This is the course which the eruption pursues on the face, where the pustules, 
even in the discrete form of the disease, are usually thicker set than on any other 
part of the surface. And it pursues the same course, only two or three days later, 
upon the extremities, where it also begins later. The feet and hands swell just as 
the face swelled, but they begin to tumefy as the features begin to subside. Some 
of the pustules, especially on the extremities, do not burst at all, but shrivel up. 

In this, the distinct variety of the disorder, the fever generally ceases entirely upon 
the coming out of the eruption ; the headache, the pain of the back, the vomiting, 
the restlessness, abate and disappear; the pulse resumes its natural force and fre- 
quency, and the skin its natural temperature. About the seventh or eighth day of 
the eruption there is commonly, for a day or two, a recurrence of fever. This is 
called the fever of maturation. 

You are to observe that we judge of the eruption as it appears on the face. The 
disease is of the confluent kind, when the pustules are confluent there, whether they 
be so or not upon the trunk and extremities. Sometimes they are neither strictly 
confluent nor strictly separate, but stand just thick enough to touch each other, with- 
out absolutely coalescing; every pustule preserving its circular outline. In that 
case, the disease is said to be of the cohering form. When the pustules are conflu* 
62 4 G 2 



978 



SMALL-POX. 



ent over the whole body, their number is often prodigiously great, and their progress 
is less regular than in the discrete and milder variety of the complaint. 

In the first place, the eruptive fever itself is usually more violent and tumultuous 
in the confluent disease ; the disturbance of the sensorial functions is more common 
and more decided, the sickness more distressing, the pain of the back and loins more 
severe. The eruption comes out earlier, and more confusedly; the pimples being 
at first very minute, and crowded together in patches, and not seldom accompanied 
by a rash like that of scarlet fever, or erysipelas : whereby the diagnosis, in so far 
as it depends upon the appearance of the skin, is rendered for a while uncertain. I 
have at present in the Middlesex Hospital a patient in whom the papulee of small- 
pox were, at the outset, so intermingled with the appearances and sensations of urti- 
caria, that I doubted, for tw^enty-four hours, what the true character, of the eruption 
might be. It is sometimes hke that of measles ; but the similarity and the uncer- 
tainty are soon at an end, for the pimples soon begin to exhibit a fluid on their sum- 
mits. They do not, however, as they advance and pass into pustules, fill up so 
completely as in the distinct form; they are flatter, less plump, more irregularly 
depressed, and even of a different colour ; being at first whitish, and then of a brown 
tint, and seldom of the yellow purulent hue which is seen in the variola discreta. 
Sometimes they are even bluish, or purple. In the confluent form there is commonly 
some abatement of the febrile distress upon the coming out of the eruption ; but the 
remission is much less marked than in the discrete. About the fifth or sixth day, 
fresh rigors are apt to occur, marking the fever of maturation. Most of these points 
of distinction between the two varieties of the disease are well marked in Cu lien's 
definitions. The distinct form he defines thus : " Variola (discreta) pustulis paucis, 
discretis, circumscriptione circularibus, turgidis ; febre, eruptione facta, protinus ces- 
sante." And of the confluent kind his definition is, "Variola (confluens) pustulis 
numerosis, confluentibus, circumscriptione irregularibus, flaccidis, parum elevatis; 
febre post eruptionem perstante." 

But the most important difference between the two forms is in what is called the 
secondary fever, which sets in about the eleventh day of the disease, or the eighth 
of the eruption, just when the maturation of the pustules is complete, and they begin 
to desiccate. This secondary fever is slightly marked in the distinct small-pox, and 
very intense and perilous in most instances of the confluent. It is at this period of 
the disorder, that death, in the fatal cases, oftenest occurs. Of 168 such cases, 
recorded by Dr. Gregory, the deaths happened in twenty-seven (nearly one-sixth of 
the whole) upon the eighth day of the eruption. That, therefore, is the most perilous 
day, as the second is the most perilous week. Thirty-two died in the first week, 
ninety-nine in the second, twenty-one in the third. The early occurrence of death 
denotes- a peculiar malignancy in the disease. The nervous system appears to be 
overwhelmed by the force of the poison. During the second week the disorder 
proves fatal chiefly in the way of apnoea ; from some afl^ection of the respiratory 
passages. After that period the characters of asthenia commonly predominate. The 
patient sinks under some casual complication, or the powers of life are gradually 
worn out by so much irritation of the surface, and so large an amount of suppuration. 

So much for the ordinary course of small-pox, and of the symptoms that are essen- 
tial to that disease. There are, how^ever, other concomitant circumstances, with 
which you ought to be acquainted : and these I will endeavour to specify at our 
next assembhng. 



X 

LECTURE LXXXVII. 

Small-pox, continued. Inoculation. Vaccination. Their comparative advantages. 
Treatment of Small-pox. 

In the last lecture I brought before you, in a rapid sketch, the ordinary course, 
and the essential symptoms of small-pox; both in its distinct and in its confluent 



&MALLrPOX, 9m 

form. I have yet to mention some other circumstances that are very frequently to 
be noticed in connection with that disease. 

Both kinds are accompanied by sore throat ; the tonsils and fauces are tumid and 
red : and with this sore throat there is associated, about the period when the face 
swells, sometimes in the discrete variety, and almost always in the confluent, more 
or less salwation, which lasts for several days. At first the discharge is thin and 
plentiful ; but, towards the period of maturation, it often becomes viscid and ropy, 
and is with difficulty got rid of by the patient. This salivation is of some importance 
as a prof^nostic symptom. If ii cease abruptly, and especially if at the same time 
the swelling of the face suddenly and prematurely subside, the peril is great. Besides 
this, Sydenham regarded the ptyalism as a diagnostic circumstance ; as a mark which 
identified with true small-pox a fever called by him the variolous fever, the variolsR 
sine variolis of De Haen and others. "The resemblance (says he) which this fever 
bore, in its sympton>«, to small-pox, induced me to give it the title of variolous fever, 
which seemed indeed so much the more appropriate, as the fever raged at the same 
time with small-pox, and got well under the same treatment. The two diseases 
belonged evidently to one family, and there was no difference between them, saving 
that in small-pox the morbific matter was directed towards the skin, in the shape of 
an eruption ; while in the variolous fever this matter was expelled from the system 
by the sahvary glands." Notwithstanding this statement, it is difficuk to believe 
that any such disorder as variolae sine variolis ever proceeds from the contagion of 
small-pox. 

This affection of the sahvary glands does not so often occur in children ; but diar- 
rhoea appears sometimes to take its place. 

The soreness of the fauces often depends, in great measure, upon pustules there 
situate. You may see that the tongue, the roof of the mouth, the inside of the 
cheeks, the uvula, and the velum palati, are thickly studded with them. It is 
affirmed by some writers that the pustules of small-pox occur in various internal 
parts of the body, and especially upon the mucous membrane of the intestinal canal. 
I believe this to be a mistake. The enlarged sohtary follicles often put on very 
much the appearance of pustules. Cotunnius, who has written a good book, De 
sedibus variolarum, asserts that pustules appear only upon the skin, and upon those 
parts of the mucous membranes which are freely exposed to the air. In one soli- 
tary instance he met with them in the trachea so low as its third ring. He fancied 
that previous desiccation of the part was necessary to their formation. He says that 
none appear on the cornea, while it is kept moist. He denies that they are seen in 
the interior of the body, or upon the fostus in utero : but in this last point he is cer- 
tainly wrong : and this is a strong objection to his theory. The most striking facts 
which he alleges in support of his opinion of the necessary presence of air — besides 
the fact of the eruption being more copious on parts usually exposed to the atmo- 
sphere, as the face and hands — are, that pustules do not form on the inner surface 
of the eyelids, except in cases of edropium ; that they appear on hemorrhoidal 
tumours only when these project beyond the margin of the anus ; and that that por- 
tion alone of the glans penis is ever affected by them which is uncovered by the 
prepuce. 

Dr. Gregory, however, states that true variolous pustules do not form upon the 
conjunctival membrane: and that the bhndness of one or both eyes which is so com- 
mon a resuk of small-pox, especially in children, is produced by an intense kind of 
ophthalmia, which sets in at the period of the secondary fever, and rapidly involves 
and spoils the transparent tissues of the organ. 

During the period of maturation, a peculiar greasy, disagreeable odour, quite sui 
generis, proceeds from the body of the patient. If taken into the sick chamber blind- 
folded, one might name the disease at once by this smell. About the same time also 
many patients are tormented by itching of the surface ; so that they are provoked to 
scratch off the heads of the pustules : and by so doing they often ensure the formation 
of pits. In many cases of confluent small-pox this itching appears to constitute the 
chief part of the patient's suffering. 

Tiiere are various troublesome cpmplications to which, in severe cases of the con 



^80 



SMALL-POX. 



fluent form, the patients are liable during the secondary fever; erysipelatous inflam- 
mation involving the subcutaneous areolar tissue in various parts of the body, and 
leading to the formation of abscesses ; glandular swellings in the groins and axillae, 
going on sometimes to suppuration; sloughing sores on the hips and sacrum; 
phlebitis ; and in two or three instances I have seen the large joints, after death, full 
of matter. One of the most serious symptoms, at this period of the disease, is 
dyspnoea. The air-passages, and especially the larynx, become clogged by viscid 
mucus, the arterialization of the blood is interfered with, and the patient is in danger 
of suffocation. Occasionally hfe is suddenly extinguished by oedema of the glottis, 
supervening upon that affection of the fauces which I mentioned just now. 

In one most fearful phase of this always formidable disorder, symptoms indicative 
of what is called the putrid diathesis manifest themselves — petechise, vibices, hemor- 
rhages from various parts of the body. The pustules, instead of being plump and 
yellow, are flat, red, purple, or blue ; that is, they contain bloocf, or a sanious ichor, 
in the place of pus, constituting the variolx nigra; of Sydenham, the bloody small- 
pox of Mead. I believe that these appearances augur in all cases a fatal result. 
Hemorrhage from the uterus is not uncommon ; and in pregnant women abortion, 
and then, most commonly, death. Heberden says that he examined, in many in- 
stances, the foetuses so parted with, but never could perceive upon them any traces 
of small-pox. His experience, therefore, agreed with that of Cotunnius ; and we 
rnay conclude that infection of the foetus in utero is very rare. Yet, unquestionably, 
it sometimes happens ; and the circumstances under which it has been noticed are 
various and interesting. In one instance, related by Mr. Flinders, the disorder was 
eight or ten days later in the foetus than in the mother. A woman, near her fuU 
time, took small-pox. The pustules were mature about the 10th or 11th of June. 
On the 18th she gave birth to a full-grown boy, upon whose face and body there 
were many pustules, discrete, and nearly ripe. The child died the same night. It 
is a very curious fact that the foetus has caught the disorder, doubtless through the 
medium of the mother, although she, having had it previously, was unaffected by the 
contagion. Dr. Mead relates that " a certain woman, who had formerly had the 
small-pox, and was now near her reckoning, attended her husband in this distemper. 
She went her full time, and was dehvered of a dead child. It may be needless to 
add, that she did not catch it on this occasion ; but the dead body of the infant was a 
horrid sight, being covered all over with pustules." In the first volume of the 
Medico- Chirurgical Transactions, Dr. Jenner gives an account of an infant which, 
upon the fifth day of its age, became indisposed, and on the seventh exhibited the 
eruption of small-pox; so that the contagion must have been communicated to it 
while yet in the womb. A few days before her confinement the mother of this child 
had seen, in the street, a person covered with small-pox pustules, the smell and sight 
of whose body had sensibly affected her. I see no reason, therefore, for doubting 
that the unborn being may pass safely through the disease while in the womb, and 
derive from that attack the customary immunity for the future. My namesake. Sir 
William Watson, describes in the Philosophical Transactions, an instance in which 
the scars left by the pustules were visible upon an infant at its birth. The child was 
afterwards inoculated without taking the disease. Its mother, who had formerly had 
it, nursed, when far advanced in pregnancy, a servant ill of small-pox. Dr. Pearson 
met with a similar example. Mary Spooner was inoculated by him in her sixth 
month of utero-gestation, and had the disease severely. Her child was twice inocu- 
lated with small-pox matter, but without effect. 

Like all these contagious exanthemata, small-pox has its periods of dormancy and 
of activity. Every now and then, at irregular intervals — and, as it would seem to 
our ignorance of the cause, capriciously — it overspreads a district or country as an 
epidemic. At this moment (1838) it is more prevalent in London, and in many 
parts of England, than it has been known to be for many years past. When epi- 
demic, it is also, in general, more than ordinarily severe ; akhough different epidemics 
vary much in that respect. 

There is no contagion so strong and sure as that of small-pox : none that operates 
at so great a distance. Dr. Haygarth states, " that during his long attention to this 



SMALL-POX. 



981 



subject, not a single instance had occurred to prove that persons liable to the small- 
pox could associate in the same chamber with a patient in the distemper, without re- 
ceiving the infection." It is readily communicable in every way ; by inoculation, by 
breathing a contaminated atmosphere, by the contact or vicinity of fomites. Nay, it 
may be caught from the dead body. Mr. Cgesar Hawkins has recorded an interesting 
example of this. The body of a man who died of small-pox, was brought into his 
dissecting room in Windmill street; and four students took the disease from that 
source. Of these, one only had touched the body. 

There is one appearance which I think curious, although, perhaps, it has not any 
great practical interest ; and which I omitted to notice in the last lecture, when de- 
scribing the course of the eruption. Without going minutely into the anatomy of 
the pustules, you may distinctly see, if you closely examine them when they are 
about five or six days old — you may see, at least, in many of them — two colours, 
viz., a central whitish disc of lymph, set in, or surrounded by, a circle of yellower 
puriform matter. Fn truth, there is, in the centre, a vesicle, which is distinct from the 
pus. You may puncture the vesicle, and empty it of its contents, without letting out 
any of the pus ; or you may puncture the part containing the pus, and let that out, 
without evacuating the contents of the vesicle. The vesicles have even, by careful 
dissection, been taken out entire ; and they are said to consist of several little cells. 
> It is most probable that the lymph contained in this separate vesicle is the purest 
part of the variolous poison. 

Before I say anything of the measures to be adopted during the progress of small- 
pox, I have to bring under your notice two expedients of still greater interest and 
importance ; the one of them contemplating a mitigation of the disorder, the other its 
total prevention. You anticipate that I am about to speak of inoculated small-pox in 
the first instance, and of the vaccine disease in the second. 

I have many times stated, and all the world knows, that small-pox maybe imparted 
to a healthy person by inserting beneath his cuticle a minute quantity of the matter 
taken from a variolous pustule. This, perhaps, is not very surprising; but it is sur- 
prising that the disease, so received, should be much milder than if it had been con- 
tracted in what is called " the natural way," by breathing an atmosphere charofed 
with the contagious poison. Why it should be so it is difficult to conjecture. The 
fact is sometimes expressed by saying that the disease is milder when the virus is 
admitted through the cutaneous, than when through the mucous tissues. But I am 
not at all sure that the hypothesis involved in this proposition is true. No attempts 
have been made, that I know of, to introduce the poison artificially through a wound 
in any mucous surface. I should rather guess that the small quantity of the poison 
conveyed by inoculation into the blood may make the difference. But whatever the 
explanation, the fact is unquestionable, and obviously of the highest importance. By 
what accident it was first learned (for it evidently could not have been reasoned out) 
we do not know. The Chinese claim to have been in the habit, for many centuries, 
of sowing the disorder, by putting some of the crusts into the nostrils. But this is a 
different thing from inoculation, the surface being entire, and the effluvia from the 
crusts being drawn into the lungs by the act of inspiration. It is said that a true 
engrafting of the virus has been in use by the Brahmins in India, time out of mind. 
It certainly was practised in Turkey at the very beginning of the last century, and 
perhaps somewhat earlier. In 1713, Dr. Emanuel Timoni, an Oxford graduate, 
who had settled at Constantinople, wrote to Dr. Woodward, in London, giving him 
an account of the new process, and testifying to its success. This account was com- 
municated to the Royal Society, and published in its Transactions the following year. 
In 1715, Mr. Kennedy, an English surgeon who had travelled in Turke)^ gave 
sin^iilar information to the English public in his Essay on External Remedies. And 
in the Philosophical Transactions for 1716 you may see a notice of the same pro- 
cess, as described by M. Pylarini, the Venetian consul at Smyrna. But these state- 
ments were neglected, or had no practical result. We owe the actual introduction 
of the practice of inoculation into Great Britain to the good sense and courage of an 
English lady, whose lively epistles have taken their permanent place in our country's 
literature. Lady Mary Wortley Montagu, the wife of our ambassador at the Otto- 



SMALL-POX. 



man Court, writes thus, from Adrianople, in the year 1718: "The small-pox, sofatai 
and so general amongst us, is here entirely harmless by the invention of engrafting, 
which is the term they give it. Every year thousands undergo the operation ; and 
the French ambassador says, pleasantly, that they take the small-pox here by way of 
diversion, as they take the waters in other countries. There is no example of any 
one who has died in it ; and you may believe I am well satisfied of the safety of this 
experiment, since I intend to try it on my dear little son. I am patriot enough to 
take pains to bring this useful invention into fashion in England." In fact, she re- 
commended it by her own example. The first person inoculated with small-pox in 
England was her daughter. Then a child of a physician. Dr. Keith, who had visited 
Miss Wortley ; afterwards some condemned felons, who were pardoned on condition 
of their submitting to the experiment ; and at length some of the royal family. But 
the practice was not thoroughly established, nor properly appreciated, by the English 
public, until the middle of that century. 

Its efficacy in mitigating the severity and danger of the disease, in saving life and 
preventing deformity, was signally great. The mortality in the natural small-pox 
was estimated at one in live. But Baron Dimsdale, a great inoculator, declared that 
not one in fifteen hundred died of the engrafted disease. Two brothers, named 
Sutton, who had introduced, or rather revived, a very improved method of treating 
the disorder, professed to have inoculated 20,000 persons without fairly losing one. 
But these, doubtless, were exaggerated statements. Among 5964 individuals, inocu- 
lated at the Small-pox Hospital in 1797, 1798, and 1799, there were nine deaths; 
i. e., one in six hundred and sixty-two. We may take Dr. Gregory's estimate of 
one death in five hundred cases, as being probably within the mark. 

In the inoculated disease the period of incubation is comparatively short ; the pus- 
tules are seldom numerous, and still more seldom confluent ; and the secondary fever 
is generally slight or awanting. 

I may mention here, also, that the eruption is not unfrequently preceded by a rash, 
something like that of scarlet fever, and called by Willan the roseola variolosa. 
It fades in the course of a day or two, and then the small-pox pustules are seen 
emerging just in the same state that they would have been in, at the same period, if 
no such rash had appeared. The efflorescence happens oftener in the inoculated 
than in the casual disease. In the former it is looked upon as rather a favourable 
sign ; in the latter, especially if the rash be of a dark red colour, it is considered un- 
favourable, and as the herald of a severe confluent disorder. 

A far superior expedient has since been discovered,- in the practice of vaccination, 
which has rendered the inoculation of small-pox not merely unnecessary, but, in 
most cases, perfectly unjustifiable. Yet circumstances do sometimes arise, even now, 
in which it may be allowable and right to engraft the matter of small-pox ; as when 
an unprotected person is unavoidably exposed, or has recently been exposed, to the 
contagion of that disease, and there is no vaccine matter at hand. The advantage 
of inoculating in such a case is, that the inoculated or milder form gets the start of 
the natural and severer ; the fever commencing sooner than it would otherwise do. 
To show you the value of the practice in such cases, and the degree of protection 
which it affords to individuals whom we cannot vaccinate, I may mention a fact 
which Professor Gregory, of Edinburgh, was in the habit of relating, and which 
'vas told him by a naval surgeon. The small-pox was introduced among the crew 
of a man-of-war, in a tropical climate, where no vaccine matter was to be procured. 
The men were almost all unprotected. Sixteen of them took the disease in the 
natural way ; and of these, nine, or more than one-half, died. Of 363 who were 
inoculated, under the disadvantages of a hot chmate, and no preparation, not one 
perished. 

That a disorder communicated to the human animal from one of the brutes should 
protect the former against the contagion of small-pox, is one of the most interesting 
facts in the whole history of medicine. How glimpses of a truth so remarkable 
were first revealed to the casual observation of certain peasants, and how the result 
of this chance observation was gradually " matured into a rational and scientific form 
by a mind deeply imbued with the best principles of sound philosophy," I have not 



VACCINATION. 



m 



leisure to tell you in detail. And it is the less necessary that I should do so, as you 
may find the whole subject thoroughly narrated and discussed by Dr. Baron, in his 
interesting biography of Edward Jenner. 

Dr. Jenner found among the great dairy farms in Gloucestershire a popular belief 
that no person who had had the cow-pox (an eruptive vesicular complaint communi- 
cated from the udder of the cow to the hands of. the milkers) could "take the small- 
pox." Satisfied, by inoculating with small-pox matter several individuals who had 
had the vaccine eruption, that this was not an unfounded notion, he at length con- 
ceived the great and happy idea of propagating the cow-pox from one human being 
to another, and so preventing, in all cases, the perilous distemper of small-pox, which 
he hoped might thus be finally expelled from the earth. 

By degrees. Dr. Jenner ascertained that some persons, who had had sore hands 
from milking, were not thereby rendered proof against the contagion of small-pox; 
but this difficulty was soon cleared up by the discovery that the teats of cows were 
liable to different kinds of eruption, and he learned, by close observation, which of 
these was the peculiar eruption that produced in the human frame the protecting 
disorder. 

Dr. Jenner set himself to trace, if possible, the origin of the disease of the cow. 
First, he found that it was peculiar to certain dairies ; then, that in those dairies men 
were employed in milking. Following up this clue, he further made out that those 
men had also the charge of the farm-horses. Next, he learned that the teats of the 
cows generally began to exhibit the specific eruption at that time of the year when 
a complaint called " the grease" chiefly prevailed among the horses. Hence he 
concluded, that the malady was conveyed lo the cows by the hands of the men who 
had been dressing the heels of horses affected with the grease. Subsequent inquiries 
have, however, shown that this conclusion was not strictly correct. 

Another difficulty which lay in Dr. Jenner's way, and which his patience and 
sagacity surmounted, was this. He found that some who were casually infected from 
the true complaint in the cow were not protected. This depended, as he afterwards 
ascertained, upon the period of the disease in the cow, at which the virus was com- 
municated to the milker. The thick matter proceeding from the vesicle late in its 
progress produced indeed a severer local sore than the thinner matter of its earher 
state, but it did not confer the desired protection. The same thing is observed in 
respect to small-pox. If the matter used for inoculating be taken from a fully 
matured pustule, it does not so surely excite the disease as when taken from a more 
crude one. 

The next important step in this most interesting investigation was to determine 
whether the vaccine disease could be transmitted, by engrafting from one human 
being to another, and whether, if so transmitted, it retained its protecting power. 
The 14th of May, 1796, was the birth-day of vaccination. On that day, " matter 
was taken from the hand of Sarah Nelmes, who had been infected by her master's 
cows, and inserted by two superficial incisions into the arms of James Phipps, a 
healthy boy of about eight years old. He went through the disease apparently 
in a regular and satisfactory manner ; but the most agitating part of the trial still 
remained to be performed. It was needful to ascertain whether he was secure from 
the contagion of small-pox. This point, so full of anxiety to Dr. Jenner, was 
fairly put to issue on the 1st of the following July. Variolous matter, immediately 
taken from a pustule, was carefully inserted by several incisions — but no disease 
followed," 

It is scarcely necessary for me to notice the objections which were made to the 
■practice of vaccination. Some of them were merely foolish — as, that it was unna- 
tural and impious to engraft the diseases of a brute upon a Christian. Others were 
untrue — as, that tt introduced into the system new disorders, distinct from the cow- 
pox. It triumphed over all these cavils ; and in six years from its first promulgation 
the discovery was known in every region of the world. 

It was soon found, however, that some, who had apparently had the cow-pox by 
inoculation, were nevertheless not incapable of taking the small-pox ; and that these 
iailures were, many of them at least, attributable to the mistakes that were m^de in 



984 



VACCINATION. 



the time or manner of performing the operation. It became necessary, therefore, to 
ascertain precisely the conditions requisite for the production of the genuine disease. 
And these conditions have been successfully fnvestigated by Dr. Jenner and by sub- 
sequent surveyors. 

You will learn to recognize the true vaccine vesicle only by repeatedly examining 
it for yourselves. Yet a brief description of its characters and progressive changes 
may be useful to you. 

On the second or third day after the insertion of the vaccine matter into the arm, 
the punctures look red and inflamed, and on the fourth or fifth day the vesicle becomes 
perceptible ; a pearl-coloured elevation of the cuticle enclosing a minute quantity of 
a thin transparent hquid. It gradually increases in magnitude till the eighth day, 
when it should measure from a quarter to half an inch across. Like the pustule of 
small-pox, it is more prominent at its circumference than at its centre, and it consists 
of small cells, from ten to fourteen in number. By puncturing carefully one of these 
cells, a drop of the virus may be let out, the other cells remaining full. Up to the 
seventh, or eighth, or even to the beginning of the ninth day, the inflammation around 
the vesicle should extend to only a very small distance from it. After this, it spreads, 
and what is called the areola is formed ; a circular red border, which continues to 
increase during the ninth and tenth days, and begins to fade on the eleventh, passing 
through shades of blue as it decHnes, and leaving a degree of hardness behind for 
two or three days more. By this time, a brown or mahogany-coloured crust has 
formed over the vesicle, of a nearly circular shape ; this becomes gradually harder 
and darker, and finally detaches itself about the twentieth day. The cicatrix which 
it leaves should be somewhat less than an inch broad, circular, shghtly depressed, 
marked by radiating lines, and dotted with httle pits which seem to correspond to 
the cells of the vesicle. 

About the eighth day there is usually some slight febrile excitement manifested, 
which soon subsides. This is analogous to the secondary fever of smali-pox : and 
it appears to furnish the condition of the desired protection. 

Of course it is of much moment to determine whether the cow-pox has run its 
proper course or not ; and it is not always easy to say how far the progress of the 
vesicle may deviate from that which has just been described, without failing of its 
protecting influence. A very ingenious tent of this, free from all ambiguity, has 
been devised by Mr. Bryce. His plan is this. He vaccinates the other arm, or 
some other part of the body, four or five days after the first vaccination. If the con- 
stitution has been properly aflected by the first operation, the inflammation of the 
second vesicle will proceed so much more rapidly than usual, that it will be at its 
height, and will decline and disappear as early as that of the first : only the vesicle 
and its areola will be smaller. In fact, from the time of the formation of the areola, 
the second vesicle is an exact miniature of the first. If the system has not been duly 
influenced by the first vesicle, the second will run its own course, increasing up to 
its eighth day, and so on. Should this be the case, the second vesicle should be 
tested by a third. 

We find the germ of this criterion in the early history of vaccination. Dr. Jenner 
vaccinated the children of his friend Mr. Hicks, the first gentleman who consented 
to adopt the practice. This Mr. Hicks became afterwards an expert vaccinator him- 
self, and it was his custom, in a doubtful case, to perform a second vaccination in a 
few days after the first : and he remarked that the second vesicle made " immense 
strides to overtake the first." 

After some time it became apparent that Dr. Tenner's estimate of the protecting 
power of the vaccine disease had been set too high. He had hoped and believed, 
as others also had, that the cow-pox would in all cases prove a perfect and permanent 
protection against the small-pox ; but those hopes have been disappomted. Doubt- 
less complete protection is the rule ; but — how thoroughly and regularly soever the 
vaccine malady may have proceeded — it is most certain that very many exceptions 
to this rule have taken place, and are daily taking place around us. 

And this fact, which has become too glaring to be denied or explained away, has 
depreciated the value of the process of vaccination, in the public esteem, far more 



SMALL-POX. 



985 



than, if rightly considered, it should have done. For it is a remarkable and most 
important truth that the disease which, in some duly vaccinated persons, follows ex- 
posure to the contagion of smali-pox, is much milder and shorter even than the 
inoculated, and a fortiori, than the natural smalt-pox. The disorder thus occurring 
is, therefore, denominated the varioloid disease, or (more conveniently, in my opinion), 
the modified small-pox. 

The constitutional symptoms of this modified disease are, in general, at the outset, 
and for several days, much the same with those of the regular small-pox. The 
eruptive fever is of equal length and intensity. There are frequently much head- 
ache, and sickness, and sometimes even dehrium. The eruption begins about the 
third day ; it is often copious, and sometimes confluent ; and in the confluent cases 
the eruptive fever does not entirely subside as soon as the crop of pimples has come 
out.' 

It is in its subsequent progress that the complaint is modified : in respect both to 
the appearances presented by the skin, and to the constitutional symptoms. 
Three distinct kinds of eruption have been observed — 

1. The eruption sometimes approaches in its character and course very nearly to 
that of the ordinary small-pox. The pustules fill up, have the central depression, 
and ultimately crust over, and the face swells. But this course is performed in a 
shorter time than that of the ordinary disease, and the pustules are usually smaller. 
This is the severest and the least common form of the modified small-pox. 

2. Sometimes the papula show a little fluid on their tops only, but never fairly 
suppurate nor break ; but the vesicles dry up, and hard prominences, with livid bases 
and horny summits, remain. 

3. There are other cases in vi^hich a great part of the eruption consists of red 
pimples, which soon become livid, but contain from first to last, no fluid whatever. 

In the majority of instances of modified small-pox, all these forms of eruption co- 
exist. Some of the papulae go on to suppuration, others become crowned with a 
horny summit, and others never exhibit any fluid at all. 

Bnt the most important characteristic of the modified disease, is the total absence 
of secondary fever. The constitutional disturbance which, for the first week, may 
have been as severe as in the ordinary small-pox, generally subsides entirely when 
the eruption has reached its acme. The patient is convalescent just when, in the 
unchecked and regular form of the malady, his danger is beginning to be most 
urgent. 

These two circumstances, then — the short duration of the eruption, and especially 
the absence of secondary fever — furnish the broad distinctions between the regular 
and the modified smail-pox : and almost always, when vaccination has been tho^ 
roughly effected, and small-pox occurs afterwards, it occurs in this modified form ; 
and the modified form of small-pox is seldom fatal, though- some instances of death 
resulting from it have certainly happened. 

Several questions of the greatest practical moment and interest here present them- 
selves : but it is impossible that T should discuss them. I wifl state some of them, 
however, that you may bear them in, mind in your future opportunities of observa- 
tion ; especially as they are yet, for the most part, undecided questions ; and ques- 
tions which can be answered only after repeated and careful observation. 

The first is, whether the protecting influence of cow-pox upon the human frame 
diminishes by lapse of time, and at length wears out. There seems reason for sus- 
pecting that such may, sometimes at least, be the case. Certainly in many, but not 
in all, of those who have gone through the vaccine disease, revaccination at a distant 
period reproduces, in a greater or less degree, its primary effects. A friend of mine, 
who was vaccinated in 1799, has a son nine or ten years old, who was vaccinated at 
the age of three weeks. Both of them have lately been revaccinated. The boy 
was somewhat afTected by the renewal of the operation ; the father not at all. It yet 
remains to be determined whether all those who are susceptible of some impression 
from a second vaccination, are liable to be affected by the contagion of small-pox: 
and whether a repetition of the operation of engrafting the cow-pox renews, or adds 
to, their security against small-pox. At any rate, the practice of revaccuiation is a 



986 



SMALL-POX. 



safe and advisable precaution. Dr. Gregory says of it, " we have sufficient facts 
before us to state with confidence that it need never be recommended prior to the 
tenth year of Me ; and that the age best fitted for it is from the period of puberty to 
that of confirmed manhood." 

But, secondly, is there any ground for supposing that the wished-for protection 
ever fails to be conferred, because the operation is performed too early? It has been 
suspected that it is less likely to produce the requisite, or an enduring, effect upon 
the constitution when it is done while the child is at the breast. But most children 
are vaccinated within that period. We know that this is a time when they are but 
little susceptible of contagious disorders in general. If this suspicion be well-founded, 
Dr. Gregory's first proposition requires correction. 

A third question is, how far the frequent failure,' in late years, of complete protec- 
tion can be ascribed to the circumstance that the vaccine virus has been repeatedly 
transmitted from one human being to another, and its supply thus kept up, without 
any fresh recurrence to the cow, the original source of the disorder. Dr. Jenner was, 
himself, not without apprehension that this might prove a cause of failure. But the 
analogy of other animal poisons supplies no warrant for such a behef. For one year 
I had a seat, as the Senior Censor of the College of Physicians, at the National Vac- 
cine Board, and I then had opportunities of satisfying myself that lymph which had 
been transmitted without interruption from person to person ever since the time of 
Jenner, continued to generate as perfect a cow-pox vesicle as at first. If, as Dr. 
Heim asserts, there are no less than five kinds of spurious cow-pox, all communicable 
by inoculation from the teats of the animal to the human body, I cannot help thinking 
that recourse should not be had rashly or needlessly to lymph recently obtained from 
the cow. 

In the fourth place there are yet moot points, respecting the number of vesicles, 
and the degree of constitutional disturbance, which are requisite to ensure, and to 
prolong, the protective power of vaccination. The constitutional effect will bear 
some proportion to the number of vesicles ; and of these, it would seem, there should 
be several ; and one or two of them, at least, should be suffered to pursue their entire 
course untouched. 

With regard to a fifth question, the most important of all, we may speak very de- 
cidedly ; and it is a question concerning which it is of the utmost consequence that 
medical men should form, and disseminate among the public, correct opinions : I 
allude to the comparative merits and advantages of inoculation with small-pox and 
vaccination. 

The advantages of the practice of inoculation to the individual, supposing him 
doomed to have small-pox, were great and obvious ; to the community at large they 
were very doubtful. It gave the undoomed individual, for certain, an ugly disease, 
which was comparatively free from danger, in exchange for the chances, on the one 
hand, of contracting a very hazardous form, and on the other, of escaping altogether 
from any form, of variola. We need not inquire which is the most eligible branch 
of this alternative ; we know which was by most men actually chosen. But the 
practice of inoculation, by carrying the virus and the disease into every village 
throughout the length and breadth of the land, filled the country with contagion ; 
ensured the disease to all who were subjected to the operation ; and diminished to 
all who were not, the chances of escaping it. No doubt the distemper was produced 
artificially in many more persons than would have caught it naturally, had inoculation 
never been thought of. So that while the relative mortality, the per centage of 
deaths from small-pox, was lessened by this practice, the absolute mortality was 
fearfully increased. Such at least is the judgment expressed by most who have 
thought and written on the subject. Dr. Heberden compared the number of deaths 
ascribed in the London bills of mortality to small-pox during the first thirty years of 
the last century, and he found that they had increased from 7*4 per cent, to 9-5 per 
cent. To be sure, some allowance must be made for the increase in the whole 
population of London during that interval ; but on the other hand we must take into 
account the deaths (not noted in those bills) which followed the inoculation of small- 
pox in secluded villages, where but for that practice, the poison might seldom have 



SMALL-POX. 



been found. It is right, I say, that this matter should be steadily contemplated, in 
all its lights, and in all its shadows, in order that the inestimable blessing conferred 
upon mankind by the researches of Dr. Jenner may be fairly set forth, and adequately 
appreciated. The vaccine virus produces a slight disorder, which is attended with, 
no risk, and which (unluckily I may say) is not communicable except by direct en- 
grafting. It not only does not disseminate a dangerous and deadly poison, but if 
rightly used, it affords the means of eradicating from a well-regulated community, 
or at least of confining within narrower limits, the most loathsome pestilence which 
the world has known. Where vaccination is, the contagion of small-pox need never 
come. In Denmark, as I told you, variola had at one time disappeared before the 
defensive influence of compelled vaccination. Chance, and a careless security, en- 
gendered by the absence of the pest, have led to its re-introduction there. It is much 
to be regretted that the boasted liberty of this countr}'- renders it almost impossible to 
enforce by law a practice which would be so conducive to the pubhc weal. Some 
good might be done by enacting that no person should be eligible to even any paro- 
chial office of trust or profit who could not produce a certificate that he had been 
duly vaccinated. And the benefits w^hich this safeguard confers on the individual 
are scarcely inferior to those which it is calculated to bestow upon society. It un- 
fortunately does not give complete protection against small-pox to all, but it gives 
complete protection to many. And you must recollect that small-pox itself is not a 
universal and absolute assurance against its own return. But the cow-pox relieves 
all from the necessity, imposed by inoculation, of coming within the sphere of the 
Tariolous contagion. It renders many, I repeat, impregnable to that poison, if, they 
do chance to be within its range ; and its advantage to the comparative few who 
suffer the double misfortune of being exposed to the contagion of sraall-pox, and of 
being affected by it, is this, that it gives safety, though not exemption ; that it takes 
away the sting and peril of the variolous disease, by curtailing it of the secondary 
fever. At the very worst, it leaves the individual liable, by a twofold ill luck, to 
contract a form of small-pox less dangerous than that which he would voluntarily 
accept by submitting to the operation of inoculation.* 

It is difficult to adduce exact numerical comparisons in iUustration of'this reason- 
ing ; but I may quote two short series of facts as samples. 

During an epidemic in Scotland, Dr. John Thomson saw from June, 1818, to De- 
'cember, 1819, 556 cases. Of these 205 had previously had neither small-pox nor 
cow-pox, and 50 of them died ; nearly 1 in 4. Forty-one took the small-pox for the 
second time, and Dr. Thomson knew of 30 other such cases, making 71 in all, 
whereof 3 died ; or 1 in 23. Three hundred and ten had been previously vaccinated, 
'and among these there was but one death. 

The population of Marseilles at the time of an epidemic there, in 1828, was esti- 
mated at 40,000; that is to say, of 30,000 vaccinated, 2000 variolated, and 8000 
unprotected. Among the 30,000 vaccinated, about 2000 were attacked with small- 
pox, and 20 perished; 1, namely, in 100. Of the 8000 unprotected, 4000 were 
attacked ; and 1000, or 1 in every 4, died. And out of the 2000 variolated, 20 took 
the disease a second time, and 4 died ; or 1 in 5. 

There yet remains a highly interesting, but a less practical question. Dr. Jenner, 
as I stated before, believed that he had traced the cow-pox to its origin in the heels 
of the horse afflicted with the grease. It has since been made out that the disease 
which, in the horse, corresponds with and produces the specific malady of the cow, 
is a vesicular eruption, having no necessary connection with the grease, but extend- 
ing sometimes all over the animal's body. Now the question is, whether these two 
distempers, occurring in the cow and in the horse, are identical in their essence and 
nature with the small-pox of man. If so (as Dr. Jenner believed, and Dr. Baron 
strongly maintains), a part of the mystery attending the whole subject vanishes. 
The protection furnished by the cow-pox resolves itself into the more familiar law, 



*[The accuracy of this latter statement is contravened by statistical results, derived from 
recent epidemics of small-pox in this country. But neither the tendency, nor the force of 
the main argunient, is much aflfected by this admission.— C.] 



988 



SMALL-POX. 



that certain diseases engendered by animal poisons, happen to the same individual 
but once, and shield the body against their own recurrence. In conformity with 
this theory, Dr. Baron names the disorders respectively, variolse, variolas vaccines, 
and variolas equinas. 

The notion, you see, is this, that the vaccine disease is in truth small-pox, rendered 
mild by passing through the system of the cow. The great object of inoculating 
the small-pox is to produce a benignant form of that disease, by diminishing the 
number of pustules. The cow-pox diminishes the number to one ; and while it 
reduces the severity of the disorder to a minimum, it absolutely takes away its 
power of propagating itself, except by a direct engrafting of the visible virus. The 
disease is not sufficiently intense to taint the air with poisonous effluvia. At the 
same time it affords (but less surely and less permanently) the customary protec- 
tion. Such is the theory, which is intelligible and plausible, and supported by strong 
facts and persuasive reasoning ; for all which I must needs refer you to Dr. Baron's 
book. 

To avoid breaking the thread which connects the different parts of the main 
subject, I have postponed to the last what I have to say respecting the treatment of 
small-pox. 

This, for a long time, was conducted upon an erroneous principle, and eminently 
disastrous. The older physicians attempted to force out, through the skin, the mor- 
bid matter existing in the blood. The eruption they considered to be the natural 
and only cure: and adopting the vulgar maxim, that "it was better out than in," 
they did all they could to promote a copious eruption, by a hot regimen, by covering 
the patient with bed-clothes, by keeping the doors and windows jealously closed, and 
excluding every breath of fresh air, and sometimes by administering wine and cor- 
dials. The celebrated John of Gaddesden, the author of that curious book, the Rosa 
Anglica, improved even upon this. He surrounded the half-suffbcated patient with 
red curtains, red walls, red furniture of all kinds : everything he saw was to be red ; 
for in that colour there was, he pretended, a pecuhar virtue. This John of Gaddes- 
den, by the way, was a very sad knave, and the first Englishman, I believe, who had 
the luck to be made court physician. He had one medicine so good as to be fit for 
the rich only; and he recommended a double dose for the wealthy. "Duplum sit, 
si pro divite." He flourished in the fourteenth century. 

Sydenham was the first, in this country, to employ the opposite or cool regimen 
in small-pox ; and although his prejudiced cotemporaries refused to follow his exam- 
ple, and adopt his practice, he confidently predicted its final triumph — "obtinebit 
demum me vita functo." 

But it was subsequendy to the introduction of the method of inoculation that the 
cooling treatment was fairly established, by the Suttons — two brothers, one of whom, 
Robert, lived at Bury St. Edmunds ; the other, Daniel, at Ingateslone, in Essex. 

These men, wiser in their generation than the regular physicians, had the good 
sense to pursue the same plan of general management which had been so prosperous 
in the East, whence the practice of engrafting was originally imported. Daniel, in 
particular, became famous for his successful inoculations : and the great secret of his 
success seems to have consisted in his making one puncture only; exposing his 
patients much and often to a cool atmosphere ; supplying them freely with refrigerant 
drinks ; and restricting them to a spare diet. Under this course, Cullen, who adopted 
it from the Suttons, declares that ninety-nine times in the hundred, inoculation imparts 
a disdnct small-pox, and very generally of the mildest form. 

Now the same principle applies to the casual disease when we have reason to 
suspect that it is impending, or to have the opportunity of treating it at its commence- 
ment. The object is to prevent, if possible, a copious eruption ; upon which, as we 
have seen, the severity and peril of the disorder entirely depend. It has been thought 
that venesection, by its antiphlogistic power, and, perhaps, by letting out, with the 
blood, some portion of the regenerated virus, might lessen the number of the forth- 
coming pustules. But you cannot ensure this effect by blood-lftting : and you must 
bear in mind that, should the eruption prove confluent, suppuration, to a large amount, 



SMALL-POX. 



989 



j is inevitable, and — like that of an extensive burn — will require in order to go on 
favourably, a certain degree of constitutional vigour. 

{ You may abate the force of the eruptive fever, and keep down, it is believed, the 

j number of pustules, by saline purgatives, so exhibited as to produce two or three 
loose stools every day, and by free ventilation of the surface of the body. The skin 

j may even be sponged with tepid water, if the temperature be very high. 

! When the eruption is all come out, if the pimples on the face be very few and 
distinct, the danger is over, and there is no more to be done. At this period Cullen 

I dissuades the further use of purgatives, as being sometimes hurtful. 

! But if the pimples on the face be many, and confluent, the patient will still re- 

' quire a great deal of attention. Our business is to look out for, and to meet, unto- 
ward symptoms. 

! About the eighth or ninth day, wakefulness, and restlessness, and sometimes tre- 
j mors, are apt to come on ; and the proper remedies for this set of symptoms, in small- 
pox as well sbs in continued fever, are opiates. In variola, when given in full doses 
at bed-time, their good effects are often very conspicuous the next day. 

If the maturation of the pustules should proceed tardily, if they should not fill up 
properly, nor their contents become purulent, then strong broths may be of use, or 
even wine. But the effects of these must be carefully watched, and their amount 
adjusted to the necessities of the case. 

When the pustulfS are livid, and intermixed with petechias, and typhoid symp- 
toms occur, the disorder generally proves fatal. In such cases it is customary to pre- 
scribe bark and acids, in addition to the wine and opiates. . 

The proper plan of managing the patient during the continuance of the secondary 
fever, is to keep his bowels moderately open by gentle laxatives, or by enemata ; and 
to give opiates once or twice a day. These are the more necessary on account of 
the irritation of the skin. The cooling regimen must now be given up ; and the 
I strength must be supported by a nourishing diet. Wine and cordials are indicated 
I if tlte pulse be feeble ; but the swelling of the hands and wrists often makes it diffi- 
cult to feel the pulse. 

Various external applications have been tried, with the view of relieving the into- 
lerable itching : which often induces the patients to scratch and tear their faces, and 
to ensure the formation of scars. Cold cream is used for this purpose : or a solution 
j of common salt, applied lukewarm ; or a hniment composed of equal parts of olive 
I j oil and lime-water. This may be smeared, from time to time, over the itching sur- 
I face, by means of a soft camel's hair pencil. 

I The dyspnoea which sometimes comes on late in the disease, is a very ugly 
! symptom. I know of nothing that can be done for it beyond blistering the throat 
I and chest. 

I [The following presents a very fair exposition of the views of a large portion of the phy- 
! sicians of the Continent of Europe in relation to the protective powers of vaccination. It 
! is the substance of a report made to the Academy of Sciences of France, on the 25th of 
! February, 1845, by the Committee on Vaccination, to which were referred the various essays 
sent in by the competitors for the prize proposed by the Academy for the most satisfactory 
I solution of the following questions : — 

I 1. Is the preservative power of vaccination absohite, or merely temporary? If it is tem- 

porary only, determine, by accurate experiments and authentic facts, what is the period for 
i which the vaccine matter exerts its protective influence against small-pox? 2. Has vaccine 
' matter, taken directly from the cow, a more certain and durable protective power than vac- 
I cine matter transmitted a greater or lesser nuniber of times through the human subject? 3. 

I If the protective power of vaccine matter becomes enfeebled, should it be renewed ; and if 

I I so, how ? 4. Is it necessary to vaccinate the same individual several times, and if so, after 
ij how many years should the vaccination be repeated? The portion of the report of which 
j.| the following is an abstract, relates to the first two questions only. 

I • The protecting power of vaccination being definitely established, the question arises — 'Is 
I it possible, after forty-five years' experience, to determine the limits of that power ? The 
j answer to this question is extremely difficult, as it embraces inquiries not in France alone, 
' but throughout the whole world : in fact, a general investigation of every case in which vac- 
] cination had been formed could alone supply the fundamental elements of the problem to be 
! answered. The competitors for the prize have particularly examined how vaccinated per- 

j 4 II 2 

I 



99a 



SMALL-POX. 



sons are circumstanced during the prevalence of epidemic small-pox; in other words, what 
is the proportion of vaccinated persons in the entire number of those attacked M^ith small- 
*pox. The protective power of vaccination is, by this mode of investigation, reduced to a 
numerical question. An attentive examination of what occurred during thirty epidemics of 
small-pox in France, shows two important facts: — First, that somewhat more than one-third 
of the entire nmnber of persons attacked with the small-pox had been vaccinated; secondly, 
that the mortality among the vaccinated persons was very small. According to the author of 
one of the memoirs, more than one-third of those attacked in the epidemics which occurred at 
Montbeillard had been vaccinated, but there was no corresponding increase in the amount 
of mortality amongst the vaccinated patients; and the same result was observed in the epi- 
demic of 1828, at Marseilles. The same results follow, also, from an examination of the 
epidemics that have occurred in England, Sweden, Denmark, Italy, Malta, Geneva, &c. 

The fact, then, being established, that vaccinated persons can become affected with small- 
pox, and the proportion so attacked during epidemics being nearly determined, a most im- 
portant problem remained to be solved — viz., what was the condition of the vaccinated per- 
sons affected as regarded the mere fact of their vaccination ? The authors of all the memoirs 
agree in stating that vaccinated persons were not affected indiscriminately or by chance, as 
it were ; on the contrary, the small-pox seems to make a kind of selection from amongst 
them. With sorne exceptions, the small-pox attacks those who have been vaccinated since 
a long period, and spares those who are recently so. An examination of the tables published 
in various parts of Europe proves positively, that children are seldom attacked with small- 
pox before the ninth year after vaccination ; and also the converse fact, namely, that it 
attacks in preference persons who had been vaccinated fifteen, twenty, thirty, or even thirty- 
five years previously. A general fact, which may be anticipated from the history of erup- 
tive complaints is, that after the age of thirty-five years, the aptitude of vaccinated persons 
to contract small-pox becomes so slight that it may be considered as having vanished. 

An investigation of the facts relative to the occurrence of small-pox in vaccinated persons 
leads to the three following conclusions: — First, The protective power of vaccination is abso- 
lute and general for the first five or six years, and even to the eleventh or twelfth year, to 
judge from the experiments on re vaccination. Second, After the foregoing period, a part, bu*^ 
a part only, of those vaccinated again become liable, especially under the influence of an 
epidemic, to contract small-pox. Third. The greater number of those vaccinated proba- 
bly remain completely protected from small-pox during their entire life. 

Has the cow-pox, taken directly frorn the cow, a more certain and permanent proteftivG 
power than vaccine matter that has been transmitted more or less frequently through the 
human constitution? The experiments contained in several of the memoirs confirm the 
observations made by the Committee on Vaccination, at Paris. The greater intensity of the 
new vaccine matter, as compared with that long in use, is a fact definitely established by 
experience in England, Germany, Italy, and France. But is this greater intensity coupled 
with a greater preservative power ? or, as the report puts the question — Is there any relation 
between the lesser or greater intensity of the local phenomena and the protective power of 
the variolous matter ? The experiments made on this point show that the protective power 
of vaccine matter is not proportionate to the intensity of the local symptoms, but that vac- 
cination with matter taken from the cow is more certain than with old vaccine matter. Ad- 
mitting that the protective power of vaccine matter diminishes with time, should it be 
renewed, and if so, how ? 

As to the means of renewal, the first mode employed was the transmission of the vaccine 
matter from man to the cow — an experiment frequently performed as a matter of curiosity, 
but only recently sought to be rendered a means of restoring to the vaccine matter its lost 
energy. The authors of several of the memoirs maintain that the cqw, when thus vaccin- 
ated, restores the vaccine matter iinaltered, and therefore unregenerated ; but the commissioji 
of the Academy thinks this conclusion too absolute : in fact, it has been established by the 
experiments of the author of one of these memoirs, that vaccine matter taken from man is 
regenerated during its transmission through the cow. The same fact results from thousands 
of experiments made in Bavaria under the direction of the government. Vaccine matter 
thus regenerated failed in less than one case in a himdred, while the failures of the old vac- 
cine matter were nearly three per cent. Would it not be better to transmit the vaccine matter 
through several cows in succession than through one only? The mode, however, which 
should be preferred to all others — the only one on which we can entirely rely — is, as recom- 
mended by Jenner, to obtain vaccine matter from its original source. Several circumstances 
seem to show that the cow-pox is perhaps of less frequent occurrence than is commonly sup- 
posed, and the commission suggests, that those who happen to meet with it should not con- 
tent themselves, as has been done hitherto, with transmitting it to man, but transmit it to 
other cows, and thus regenerate the infection. 

Is it necessary to vaccinate the same person several times ? and if so, after the lapse of 
how many years should the revaccination be performed ? On this head the report first refers 
to the fact that the re vaccinations, performed for a considerable period after the discovery of 



SMALL-POX. 



991 



vaccination, did not succeed, except in some rare cases, because they were performed too 
soon after the primary vaccination. Bn't when, at a later period, experience showed that the 
protective power of vaccination diminished with time, the practice of revaccination was 
resumed, and then succeeded beyond expectation. In some parts of Gfermany, especially, 
revaccination has been practised universally in the army, and even in civil life. Physicians, 
also, who had had small-pox, in some instances revaccinated themselves with success, of 
which Dr. Heim is a remarkable example. He attended on his brother for three weeks, 
while he laboured under confluent small-pox. and three weeks after having gone through 
this decisive trial, he vaccinated himself, and had pustules almost of the ordinary size. M, 
Moreau, the celebrated accoucheur, who had small-pox in early life, revaccinated himself 
three times with success. 

A document published by the Government of Wurtemberg, which showed that of 1677 
persons affected with small-pox, between the years 1831 and 1836, 1055 had been vaccinated, 
contributed greatly to extend the practice of revaccination in Germany, and in the north of 
Europe. In France, the statistics of epidemic small-pox show that the number of vaccinated 
persons attacked with small-pox constitute more than a third of the whole number of patients 
affected. It is impossible, therefore, to doubt the propriety of practising revaccination. It is 
during epidemic small-pox, especially, that the utility of revaccination becomes obvious. Not 
only have individuals been thus protected, but the spread of the epidemic has been arrested. 
In Prussia revaccination has been practised in the army since 1833, and the small-pox has 
been almost entirely extirpated. In Wurtemberg, but one case of variola occurred in five 
years, among 14,384 revaccinated soldiers, and three only among 29,684 revaccinated civil- 
ians. Epidemic small-pox has not appeared in France since 1830, the period when revac- 
cination was commenced. The authors of the memoir agree that during epidemics it is 
prudent to revaccinate after about the eighth or ninth year. 

The answers given by the competitors for the prize to the questions proposed by the 
Academy, may be thus summed up : — 

1st. The preservative power of vaccination is absolute for the majority, and temporary for 
a small number ; and even in the latter it is absolute until adolescence. 

2d. Small-pox rarely attacks those who have been vaccinated in infancy before the age of 
ten or twelve ; from which age, however, until thirty or thirty-five, they are particularly 
liable to small -pox. 

3d, In addition to its protective power, vaccination so modifies the animal economy, that 
it attenuates the symptoms of small-pox, abridges its duration, and considerably diminishes 
its danger. 

4th. Vaccine matter taken directly from the cow causes local symptoms of greater inten- 
sity ; its effects are also more certain than those of old vaccine matter, but after being trans- 
mitted for a few weeks through the human subject, the local intensity disappears, 

5th, The preservative power of vaccine matter does not seem to be intimately connected 
with the intensity of the symptoms of vaccination ; nevertheless, it is prudent to regenerate 
vaccine matter as frequently as possible, to preserve its protective power, 

6th. The only mode of regenerating vaccine matter deserving of confidence is to procure 
it from the cow. 

7th, Revaccination is the only known method of distinguishing those vaccinated persons 
that remain protected from those that do not, 

8th, The success of revaccination is not a certain proof that the person in whom it suc- 
ceeds was liable to contract small-pox; it merely establishes a tolerably strong presumption 
that they were more or less liable to be so. 

9th. In ordinary periods, revaccination should be practised after fourteen years, but sooner, 
as already remarked, during an epidemic. 

See also, on this subject, Condie on Diseases of Children, p. 458, et seq. — C] 



LECTURE LXXXVIII. 

Chicken-Fox. Measles. Scarlet Fever. 

I MUST not omit a short notice of the disorder called chicken-pox; for although a 
very unimportant complaint, it has given rise to many disputes. Other names which 
it has borne are varicella, crystalli, variolae pusillx. 

Connected with the small-pox, and arising from the same contagion, there are 
several forms of eruptive disease. I mentioned the chief of them in the last lecture, 
as varieties of modijied small-pox. Now these mild and irregular forms of variola, 



992 



CHICKEN-POX. 



both parents and medical men, wishing, I suppose, to believe nothing in disparage- 
ment of the protecting power of vaccination, are very apt to consider, and to call, 
chicken-pox : and this error having been discovered, some persons have rushed to, 
or rather revived, the opposite opinion — equally erroneous in my judgment — that 
there is no such substantial disorder as chicken-pox ; but that all the eruptions which 
have passed under that name have really been forms of modified small-pox. Dr. 
John Thomson, of Edinburgh, is one of the stoutest maintainors of this doctrine. No 
doubt an eruption of short duration, and vesicular through the greater part of its pro- 
gress, is often caused, especialty in persons who have been vaccinated, by the conta- 
gion of small-pox : but a similar eruption proceeds also from another distinct contagion, 
that, namely, of chicken-pox. 

The best description of the true chicken-pox that I am acquainted with has been 
given by Dr. Gregory. The disorder is almost pecuhar to infants, and children of 
tender years. Willan has, however, described one unambiguous example of it, in a 
gentleman thirty years old ; and another genuine instance was seen by Dr. Gregory, 
at the Small-pox Hospital, in the person of an adult female. The eruption is pre- 
ceded by httle or no premonitory fever, commencing usually on the shoulders, neck, 
and breast, affecting almost always the scalp, but sparing very much the face — which, 
in small-pox, never escapes. 

The eruption is composed, from the very first, of perfectly transparent vesicles, 
surrounded by a very slight degree of superficial redness. They are usually numer- 
ous, but distinct. Dr. Gregory says that when the eruption is very copious, the 
body has the appearance of having been exposed to a momentary shower of boiling 
water, each drop of which had occasioned a minute blister. Crops of vesicles ap- 
pear in succession for two or three days ; and while new ones are forming, the first 
are beginning to shrivel. The vesicles that remain after the second or third day 
become slightly opaque, and like pearls. When irritated by friction, they some- 
times take on so much inflammation as to be converted into pustules. The scabs 
are small and gummy, dry quickly, and crumble off, instead of being detached in 
one r.iass. In a few instances, shallow cicatrices are left by the vesicles. During 
the short progress of this eruptive disease there is no constitutional disturbance of 
any consequence. 

It has been ascertained of this genuine chicken-pox, or varicella lymphatica, that 
it occurs once only to the same person ; that it spreads by contagion ; that never- 
theless, it is not communicable by inoculation — whereas the matter of modified small- 
pox, when engrafted, produces genuine variola ; that it occurs equally among those 
who have, and those who have not, been vaccinated ; that its course is not affected 
by antecedent vaccination ; and that the vaccine vesicle and disease proceed with 
perfect regularity after the occurrence of chicken-pox. Now this never happens 
after small-pcfe. 

It appears, from Mohl's work Be Varioloidibus et Varicellis, that from the year 
1809 to 1823, chicken-pox was annually observed at Copenhagen without concomi- 
tant small-pox ; and that both diseases have since prevailed at intervals epidemically, 
but always under circumstances which satisfied the physicians of the town that their 
sources were distinct. 

It must, therefore, I think, be admitted, that there is a separate disease, called 
chicken-pox, which springs from a specific poison ; produces a vesicular eruption ; 
runs a definite course ; has no tendency, when undisturbed, to suppuration ; occurs 
but once ; and affords no protection against small-pox ; while, on the other hand, 
small-pox affords no protection against it. 

The main point of practical importance is, however, this ; that if we meet with 
any eruption which is at all equivocal, we should use the same precautionary mea- 
sures for preventing the extension of the disease as if we were sure that it was modified 
small-pox. But this salutary rule is often, I say, neglected or infringed, to the dan- 
ger and detriment of those unprotected persons who happen to be in the vicinity of 
the sick child. 

The treatment required in chicken-pox is abundantly simple ; it is the same, in 



MEASLES. 



993 



fact, which has been already recommended for the mildest cases of the discrete 
small-pox. 

Another of these blood diseases is the measles; called, also, by nosologists, rubeola, 
and morbilli. 

Like different human faces, all the complaints belonging to this group have the 
same set of features, and therefore a mutual resemblance, while the separate linea- 
ments differ so much in their character and relative circumstances, as to give to each 
disease its distinctive aspect. There are also minor shades of difference between in- 
dividual cases of the same specific malady. 

Measles, accordingly, has its introductory fever, its period of eruption, its peculiar 
kind of eruption, its course by stages. It is communicable from person to person, 
and it generally occurs but once to the same person. On some of these points I 
spoke before. 

The introductory fever is sometimes severe, and nearer in its type to synocha 
than to typhus. Like all fevers, it begins with lassitude, and shivering, which is 
soon followed by heat of skin, acceleration of the pulse, anorexia, and thirst. But 
the peculiarity in the fever which precedes the eruption of measles is, that it is very 
constantly attended with an imflammatory condition of the mucous membranes; 
especially of those which are proper to the air-passages. The eyes become vascular 
and watery, the eyelids heavy, turgid, and red. The membrane which lines the 
nasal cavities, the fauces, the larynx, trachea, and bronchial tubes, is affected. Hence 
we have, generally, as symptoms, much sneezing, as well as lachrymation, a copious 
defluxion from the nostrils, soreness of the throat, and an obvious redness of the fauces, 
and most commonly a dry, hoarse, pecuhar cough. In short, the symptoms which 
usher in an attack of measles are the symptoms of coryza and catarrh. In some 
instances there is diarrhoea also, indicating a simultaneous affection of the mucous 
membrane of the intestines ; and not unfrequently vomiting : but the vomiting, as in 
small-pox, ceases upon the coming out of the eruption. 

The regular period for the appearance of the eruption is the fourth day of the 
disease; seldom earlier, frequently later : sometimes as late as the eighth or tenth 
day from the commencement of the catarrh. The eruption itself is a rash, consisting, 
at first, of minute papulae, which, as they multiply, coalesce into blotches that have, 
more or less, a horse-shoe or crescentic shape, and leave the intermediate portions 
of skin of their natural colour. It is two or three days in coming out, beginning on 
the face, neck, and arms, then reaching the trunk of the body, and so travelling 
down to the lower extremities. In this course it resembles the eruption of small- 
pox. It fades in the same order, standing out three days at least on the face before 
it begins to decline ; so that its whole duration comprises a space of six or seven 
days. It becomes browner as it fades. You may feel that it is slightly elevated 
above the general surface of the skin, especially upon the face, which is somewhat 
bloated and swollen. The parts which the rash has recently occupied are left covered 
with a dry, small scurf. The cuticle does not peel off in large flakes, as I shall have 
to tell you that it oftentimes does in scarlet fever, but a great part of it crumbles 
away in a fine branny powder. Occasionally, yet very seldom I beheve, the rash is 
intermixed with a few small and short-Hved vesicles. 
' I This termination of papulae is very unlike what happens in variola ; and connected 
' with the eruption there are two other important particulars in which the measles 
i differs essentially from the small-pox. In the first place, the fever does not cease, 
1 nor even abate, upon the emergence of the eruption ; but sometimes increases in 
I intensity. And, in the second place, the disorder is not more severe, nor more dan- 
I gerous, because the eruption is plentiful, or early. So far from it, indeed, that in 
I some of the worst and most perilous cases the eruption is apt to be partial, and to 
I appear late and irregularly. 

j The eruption is the distinguishing feature of measles ; but the catarrhal affectioa 
, is, in every way, the most important. Indeed, the rash may, and sometimes does, 
happen without the fever and the catarrh ; and nosologists recognise a variety of the 
disorder under the title of rubeola sine catarrho. But it is observed of this variety 
63 



994 



MEASLES. 



that it confers no protection whatever against the recurrence of the malady ; in truth, 
it is most commonly succeeded in a few days by an attack of measles in its regular 
and complete form. 

f need not stop to repeat what I told you in a former lecture about the other gene- 
ral features of this eruptive complaint. The period of incubation is from ten days 
to a fortnight. The contagion is active enough, though certainly it is less strong and 
diffusive than that of small-pox. When once introduced into a family or school, the 
disease rapidly spreads to those individuals who have not already had it. It is capa- 
ble, though with much less readiness and certainty than small-pox, of being propa- 
gated by inoculation ; but as the disorder is not rendered milder by beings so intro- 
duced into the system, this process has no utility or interest, and is never resorted to. 
Occasionally, rubeola visits the same individual twice ; but this is the exception to 
the general rule. Perhaps, in some reputed instances of its recurrence, the first 
accession may have been without fever and catarrh, and therefore an ineffectual 
safeguard for the future. I myself know, however, two large famihes in which 
most of the children have suffered a repetition of the genuine unmitigated disease. 

The measles resembles the other diseases of the group in this also, that at times it 
pervades a community as an epidemic ; at times occurs here and there only, spora- 
dically. The general character of the symptoms varies considerably in different 
epidemics. Morton and Sydenham, and after them Sir William Watson, have 
described visitations of what they call putrid measles. Sir Wilham Watson was 
physician to the Foundling Hospital, and he witnessed two epidemics of this putrid 
kind among the children in that institution. He states that the eruption appeared 
unusually early, so early as the second day of the disease; anti that, besides cough 
and dyspncea, the complaint was marked by extreme debihty, and attended with 
dysenteric diarrhoea. More seemed to die of the intestinal affection, than of the 
pectoral. He lost, in one of these epidemics, nineteen out of one hundred and 
eighty-three patients. The malignant character of the disorder was manifested by 
the frequent occurrence of gangrene, both externally and internally. In this more 
typhoid variety of measles, the rash is often irregularly and imperfectly developed, 
and of a livid colour. 

Sydenham found that measles of an unusually bad kind prevailed in London in 
the years 1670 and 1674 ; the very same years in which small-pox was also remark- 
ably malignant and fatal. This illustrates what I have stated before, viz., that the 
typhoid tendencies of these and other febrile disorders depend less upon any pecu- 
liar virulence in their exciting causes, than upon some change previously effected 
in the human body by the silent and gradual influence of certain predisposing 
causes. 

The diagnosis of measles is seldom difficult. In the outset of the fever, you may 
guess what is coming by the coryza, catarrh, and hoarse cough ; especially if the 
disease be about. On the very first day of the eruption, the small, red, and hitherto 
separate spots, are very like the incipient pimples of small-pox. Do not, therefore, 
at this period, express too confidently your opinion respecting the nature of the com- 
plaint. Parents and nurses might be uncharitable enough to attribute your mistake 
to inexperience or ignorance. The progress of the disease will soon remove all 
doubt. The eruption of small-pox presently exhibits some fluid, while that of mea- 
eles has none — unless, indeed (what is uncommon), a few miliary vesicles mix them- 
selves with it. But these make no advance in twenty-four hours. Ordinarily, the 
isolated pimples visible upon the first day soon augment in number, and collect them- 
selves into semicircular groups ; and if any question at all arises, it is whether the 
disease be measles or scarlet fever. I shall presently describe the latter disorder; 
and then I will point out the marks of distinction between the two. 

The prognosis in measles is governed chiefly by the mildness or the severity of 
the pectoral symptoms. The most common cause of death, in the fatal cases, is 
inflammation of some one or more of the textures that compose the lungs. And 
even when this immediate danger has passed by, the disease too often leaves chronic 
pulmonary mischief behind it. In scrofulous children, and young persons, it fre- 
c^uently awakens the slumbering germs of consumption. And when that specific 



MEASLES. 



995 



effect is not produced, it is apt, in adults, to inflict upon the constitution a blow which 
is never thoroughly recovered from ; the patient becoming, from that time forwards, 
delicate and valetudinary. The prognosis is always unfavourable when the eruption 
does not stand out well, is of a livid colour, and accompanied with typhoid symp- 
toms, or with a disposition to gangrene. 

We augur favourably of the case when the thoracic symptoms are not severe; 
when the fever moderates upon the coming out of the rash ; and when the rash is 
steadily persistent, and there is no excessive prostration of the strength. 

Being contagious, and occurring for the most part but once, measles is principally 
seen in children ; although no period of hfe is exempt from its attacks. In many 
children, the disorder is so shght as to require little more than judicious domestic 
attentions. The free application of cold air to the surface, which is so beneficial in 
small-pox, would in measles be unsafe, on account of the pectoral symptoms. For 
this reason, the patient should be kept in bed; with no more clothes, however, or 
warmth of the apartment, than he is accustomed to in health. The antiphlogistic 
regimen must be adopted ; and, if the bowels are not quite open naturally, gentle 
laxatives should be given. It may be well, also, to prescribe some diaphoretic medi- 
cine ; a draught, for example, containing two or three drachms of the liquor ammonix 
acetatis, with half a drachm of the spiritus mtheris nitrici, and an ounce of cam- 
phor julep, to be taken three or four times in the twenty-four hours. 

The most important part, however, of the treatment relates to the remedies to be 
employed for the pulmonary symptoms, which, in the outset, depend almost always 
upon bronchitis. But the inflammation is apt, in severe cases, to spread insidiously 
from the mucous to the other tissues — the bronchitis becomes pneumonia — and we 
find, after death, some portions of the lungs hepatized ; usually small portions. For 
the most part, however, it is extensive inflammation of the bronchial mucous mem- 
brane that we have to dread. And really I cannot give you any better or fuller 
directions in respect to the management of these inflammatory affections, than I 
endeavoured to lay down when t was speaking of bronchitis and pneumonia, as 
they occur idiopathically. You wifl judge of the extent and severity of the inflam- 
mation, partly by the common symptoms, partly by the help of your ear ; and you 
must apportion your remedies to that intensity, so judged of. You will take blood 
from the arm, or from the chest, apply a blister, and give tartar emetic. And it is 
of importance that whatever kind or amount of depletion is adopted, should be 
resorted to early. 

When the rash is about to decline, a spontaneous diarrhoea often sets in, and 
appears to have a beneficial effect in abating the febrile symptoms. If this natural 
curative process should fail to occur, it may be imitated by the exhibition of gentle 
aperients. 

In weakly children blisters are apt to cause troublesome sores ; and in some epi- 
demics of measles, the sores thus produced show a disposition to become gangrenous. 
When any such tendency is noticed, blisters had better be avoided akogether. At 
other times, the inconvenience to be apprehended from a blister may be prevented 
by one of two plans ; either by interposing a piece of silver paper between the 
blistering plaster and the skin ; or by suffering the bfister to remain upon the part 
three or four hours only, then taking it off', and applying a poultice. The cuticle 
will rise under the poultice, and the sore will not, in general, be a troublesome one. 

If the eruption disappear prematurely, it may sometimes be restored by putting 
the patient into a warm bath. And if he be at the same time in a low state, espe- 
cially if typhoid symptoms threaten or show themselves, you must treat the case 
upon that indication, just as you would in continued fever; giving wine and support, 
with great caution and watching of their eflfects. 

It is of considerable importance to protect the patient from danger after the disease 
has subsided ; by warm clothing, by preventing him from going out of doors too 
early, or being in any way exposed to cold. Pneumonic inflammation, and dysenteric 
purging, are frequent consequences of the want of prudence in this respect*. 

I proceed, in the next place, to the consideration of scarlet fever. 



096 



SCARLET FEVER. 



This also is a contagious febrile disease, attended almost always, during a part of 
its course, by a rash, and by sore throat. It seldom comes on a second time. 

There are some distinct varieties of this disorder, concerning which it is necessary 
that I should say a few words. 

The two striking and important features of the disease are the affection of the 
throat, and ihe affection of the skin. They may both be well marked ; or only one 
of them may be well-marked : and this circumstance has led nosologists to divide 
one and the same complaint into two independent maladies ; to which Cullen and 
others have assigned the respective names of cynanche maligna, and scarlatina. 
When, in an earlier part of the course, I was treating of the diseases of the throat, I 
purposely omitted the cynanche maligna ; because that is only another name for a 
particular form of scarlet fever. If you look to Cullen's definitions of these com- 
plaints, you will see how very much alike they are. They both specify inflamma- 
tion of the fauces, a cutaneous rash, and fever. But in the definition of scarlatina, 
the rash is dwelt upon and described, and the fever is called synocha ; while in that 
of cynanche maligna, the ulceration of the throat is more insisted on, and the fever 
is said to be typhoid. The truth is, that these two kinds of disorder both spring 
from the same contagious poison. The malignant sore throat may be caught from a 
patient who has mild scarlet fever ; and mild scarlet fever may, in hke manner, be 
contracted from one who is labouring under the mahgnant sore throat. The two 
forms graduate insensibly, in different cases, towards each other; and it would be 
impossible, even if it were desirable, to draw any strict hne of separation between 
them. 

For convenience, however, of description, and for the better direction of the treat- 
ment, authors generally make three varieties of scarlatina. Scarlatina simplex, in 
which there is a florid rash, and httle or no affection of the throat ; scarlatina anginosa, 
in which both the skin and the throat are decidedly implicated ; and scarlatina ma' 
ligna, in which the stress of the disease falls upon the throat. The epithet maligna 
marks truly the fearful character of this form of the malady. 

I need scarcely remind you of a sort of mystification which prevails among the 
public about this complaint, and which many practitioners, for no good reason that I 
can see, seem disposed to encourage. Mistaking the Latin and scientific name of 
the disorder for a mere diminutive, you will hear mammas say, " Oh, my children 
have not got the scarlet fever, but only the scarlatina.''^ I always disabuse them of 
this absurd error, when the opportunity of doing so occurs. It can produce nothing 
but confusion, and a disregard of requisite precautions. 

Like measles, and for the same reasons, scarlet fever, though persons of all ages 
are susceptible of it, is eminently a disease of children ; but it is much more to be 
dreaded than the measles. 

It is somewhat strange that scarlet fever w^as not recognized, in this country at 
least, as a distinct disease, till about two centuries ago. In ail probabihty it had long 
existed, and had been always confounded with measles. Morton speaks of it under 
the name of morbili conjiuentes ; and Hoffman calls it, by a similar mistake, rubeola 
rossalia. The febris scarlatina described by Sydenham must have been of a very 
mild kind ; for he does not mention any ulceration of the throat. Dr. Fothergill, in 
1748, was the first to describe, as a new and separate disorder, that perilous form of 
the complaint which Cullen designates cynanche maligna ; and it was long called 
the Fothergill sore-throat. The identity of this affection with genuine scarlet fever 
has been slowly established by subsequent observers. The characteristic differences 
between scarlet fever and measles were first fully specified by Dr. Withering. 

The disease begins, as the exanthemata in general begin, and as continued fever, 
which I have grouped with them, is apt to begin, with shivering, lassitude, and rapidly 
nugmenting debility ; headache, frequently severe, sometimes with delirium, occa- 
sionally with nausea and vomiting. Then, generally, on the second day (and Cullen 
is wrong when he says it is generally on the fourth), the eruption begins to come 
out. In some of the worst forms of the disease, it may, indeed, be deferred till the 
fourth day. 

Although scarlet fever and measles were so long confounded together, the differ- 



SCARLET FEVER. 



997 



ences between them are well pronounced, and, when once pointed out, are easily 
enough recognized. 

Rubeola is distinguishable, then, from scarlatina — 

1. By the presence, at the outset, of catarrhal symptoms — by the sneezing, the 
cough, the defluxion from the eyes and nose, which precede the rash. There is, 
doubtless, in many cases of scarlatina, a running from the eyes and nose, but not till 
late in the disease ; at any rate not prior to the eruption. 

2. By the absence of severe inflammation and ulceration of the throat ; symptoms 
which always accompany severe cases, at least, of scarlet fever. 

3. By the characters of the eruption itself. The rash in measles is more elevated 
above the surface than in scarlatina, and of a darker colour. In measles it is said to 
present somewhat the tint of a raspberry, and in scarlet fever to be that of a boiled 
lobsters. In measles the papulee are collected into semilunar clusters, leaving inter- 
stices between them of healthy skin. The redness of scarlatina commences in 
minute points, which speedily become so numerous and crowded, that the surface 
appears to be universally red. They begin on the face, neck, and breast, and extend 
to the extremities, pervading at last every part of the skin. The scarlet colour is 
deeper, in general, about the groins, and in the flexures of the joints, than elsewhere. 
Lastly, the rash of measles, m its most regular form, appears on the fourth day of 
the disease ; that of scarlet fever on the second. 

On the arms and legs the eruption of scarlatina occasionally differs somewhat 
from that which is visible on the trunk ; is more spotty, more papular, and the 
papulae are somewhat prominent, while over the body there is a general diffused 
blush. 

In some cases of scarlet fever (probably in some epidemics, for I observed the 
phenomena I am about to mention in four or five cases in succession which were 
brought into the Middlesex Hospital within the space of a month or six weeks), 
some parts of the red surface are closely studded with little transparent vesicles, con- 
taining a thin colourless liquid, and resembhng what I described to you before as 
sudamina. In all the instances in which I have seen them, these minute vesicles 
have been most thickly set on the thorax, and on the front and sides of the neck. 
The liquid is soon re-absorbed, and the cuticle under which it had been enclosed 
shrivels up, turns white, and comes off' in a thick white scurf: so that the part from 
which it separates looks at first sight as if it had been powdered. I have recently 
seen two cases of this vesicular form of scarlatina in private practice. I show you 
Rayer's delineation of the vesicles. 

The eruption, in the most regular and favourable cases, stands out for three or four 
days, and then begins to fade and decline, becoming by degrees indistinct, and disap- 
pearing altogether, in the majority of instances, before the end of the seventh day. 
About this time desquamation of the cuticle begins to take place, in smaller scurf or 
scales from the face and body, in large flakes frequently from the extremities. The 
scarf-skin of the hands and of the feet sometimes separates almost entire. A glove 
or a slipper of cuticle comes away at once. You may see such things in most 
museums. 

In that variety of the disorder which we call scarlatina maligna, the rash is apt to 
come out late, and imperfectly, and sometimes not at all; and instead of being bright 
and florid, to present a bluish or hvid tint. Sometimes it suddenly recedes ; and 
then, perhaps, appears again : and occasionally it is diversified by purple spots. 

Willan and Bateman have given the name of roseola to an eruption which is also 
attended with inflammation of the throat, and between which and scarlatina it is cer- 
tainly difficult, if not impossible, at first to discriminate. The roseola, however, is 
not contagious, and has more of a chronic character than scarlatina. It comes and 
goes, and has no settled or definite course. Dr. A. T. Thomson lays down this dis- 
tinction between them; but I do not know that we can trust to it: — "In scarlatina 
(he says) the rash first attacks the face, and then extends to the trunk of the body, 
passing off" by the extremities ; whereas in roseola the extremities are first affected." 

The appearances of the tongue in scarlet fever are also peculiar and characteristic. 
In the scarlatina simplex, and anginosa, it is often covered, at the outset, with a 

4i 



998 



SCARLET FEVER. 



thick, white, cream-like fur, through which are seen projecting the red and exagge- 
rated papillae; the edges of the tongue being likewise of a bright red colour. The 
red points gradually multipl)^ and the white fur clears away, and at length the 
whole surface of the tongue becomes preternaturally red, and clean, and raw-looking: 
and after becoming thus clean, as well as red and rough, and hke a strawberry, it 
will sometimes, when the disease goes on unpromisingly, get dry, and hard, and 
brown — as you know it is apt to be in certain forms and stages of continued fever. 

The first thing of which the feverish patient usually complains is sore throat, with 
some stiffness of the neck : and if you inspect the fauces, you will see, without in 
general so much swelling of the tonsils as occurs in common quinsy, a diffused red- 
ness, sometimes of a dark claret colour, including a large part of the palate. In a 
short time you may perceive that the tonsils and vellum are covered irregularly with 
whitish exudations, or gray aphthous crusts : or, perhaps, you see a sloughy kind of 
ulceration left by the separation of these crusts. 

The progress of the distemper, and its degree of severity and of danger, differ very 
greatly in different cases. Sometimes the deviation from the feelings and condition 
of health is so very slight as scarcely to deserve the name of a disease ; sometimes 
the disorder defies all treatment, and the deadliest forms of plague are not more fatal. 

In these mahgnant and terrible cases, the eruption, if it appear at all, is livid and 
partial, and fades early, and is attended with a feeble pulse, a cold skin, and typhoid 
depression. Sometimes the patient sinks at once, and irretrievably, under the viru- 
lence of the poison, and life is extinguished in a few hours. A gentleman called one 
day at my house, and not finding me there, followed me between twelve and one 
o'clock to the hospital. He wished me to visit his wife, four or five miles out of 
town, who had been taken ill that morning. He feared that she was about to have 
scarlet fever, but he was not much alarmed for her safety ; for when he found that I 
could not be at his house before six, he said that that hour would not suit the gene- 
ral practitioner in attendance upon her, and he begged me to fix some time for seeing 
her the next day. I did so ; but the same afternoon rapid sinking came on, and the 
patient was dead very soon after the hour at which I had first proposed to visit her. 

In other cases of scarlatina maligna, the typhoid symptoms rapidly deepen ; and 
death, in children, is apt to occur on the fifth day of the complaint ; and not uncom- 
monly as soon as the third. The pulse becomes frequent and feeble ; the tongue 
dry, brown, and tremulous; the.debihty extreme; the throat is ulcerated and gan- 
grenous ; and the respiration is impeded by viscid mucus which collects about the 
fauces. Over this variety of the disease, medicine has comparatively little control. 

The chance of recovery is much greater in the scarlatina anginosa, when the 
eruption is florid, and stands well out. But even in this form of the disorder there 
are many sources of danger, and various ways in which it may prove fatal. 

In the first place many of the patients die, apparently from inflammation or effu- 
5 sion within the head. They have violent headache, with furious delirium, which is 
y followed by coma, and death. 

And secondly, the state of the throat is full of peril. As the disease proceeds, 
although the rash may be steadily persistent, the throat becomes foul and sloughy, 
an acrid discharge from the nostrils, which are so stuffed and swollen internally that 
the patient can scarcely breathe through them, runs over and frets the upper lip ; 
the parotid and sub-maxillary glands swell, sometimes enormously; and fever is 
lighted up afresh. In this way many cases prove fatal in the second week of the 
disorder. The cervical swelling causes constriction of the fauces and stiffness of the 
neck; and sometimes, doubtless by interfering with the free return of the blood from 
the head through the jugular veins, they produce a tendency to coma. With these 
symptoms there are often also purging, and an excoriated anus. 

The acrid matters furnished by the ulcerating and gangrenous throat irritate the 
nasal membrane in the one direction, and that of the alimentary canal in the other. 
We thus account for the running from the nose, the soreness of the alee nasi and 
upper lip, and the smarting diarrhoea : and the swelling of the parotids and neigh- 
bouring glands is evidently caused by absorption of the irritating and poisonous mat- 
ter from the ulcerated throat. There is just the same relation and dependency 



SCARLET FEVER. 



999 



between these different local alterations, as between the enlarged mesenteric glands, 
and ulceration of the follicles of Peyer in continued fever; between a bubo in the 
groin, and a chancre on the glans penis. It is the condition of the throat that gives 
rise, in these cases, to the most formidable symptoms. The system is reinoculated 
from that source. Whenever I see the glands much enlarged at the angle of the 
jaw, and beneath the jaw, in a child labouring under scarlet fever, I augur ill of the 
case. Sometimes the mischief extends into the larynx, and so destroys the patient. 
But this is probably a very rare event. There is, however, still another, and a very 
common copsequence of the throat affection — I mean inflammation of the Eustachian 
tube, reaching sometimes the tympanum itself, and causing permanent deafness, 
either by closing up the tube, or by the destruction of the membrana tympani, and 
of the Kttle bones belonging to it. In one case, which was under my own care, I 
observed that, for a short time before death, every time the child swallowed, a part 
of the fluid food ran out immediately at one of its ears. I had no opportunity of 
examining the state of the part after death, but the disorganization arising from the 
sloughing ulceration of the throat must have been frightful. 

Scarlet fever sometimes befalls parturient women ; and then it almost always 
proves fatal. I have seen three instances only of recovery from this perilous com- 
plication. 

Scarlatina simplex is scarcely, I repeat, a disease. Sydenham has said of it that 
it is "fatal only through the officiousness of the doctor." 

Even when the patient has escaped from the complaint itself, he is often exposed 
to great hazard and distress from its consequences. Children who have suffered a 
severe attack of scarlet fever are liable to fall into a state of permanent bad health, 
and to become a prey to some of the many chronic forms of scrofula : boils, strumous 
ulcers, diseases of the scalp, sores behind the ears, scrofulous swelhngs of the cervical 
glands and of the upper hp, chronic inflammation of the eyes and eyehds. The same 
afflicting results are very common after small-pox also, and measles. 

I have several times, when the rash of scarlet fever was disappearing, known pain 
and swelling of the larger joints to supervene, simulating very closely the local phe- 
nomena of subacute rheumatism : and I have noticed that the painful joints were 
eased and benefited by friction ; a circumstance which may help to distinguish this 
articular affection from true rheumatism. - Another distinctive circumstance seemed 
to be that, although all these patients were children, the heart in no instance became 
implicated, in connection with the tumid joints. Upon this point, however, my own 
experience may have been fallacious. Dr. Scott Alison has recently invited atten- 
tion to the subject, in an interesting essay " On Pericarditis, a complication and 
sequela of Scarlatina." Accepting his facts, I should ascribe the articular affection, 
and the cardiac affection, whether they occurred together or separately, to one and 
the same cause ; namely, to the retention in the blood of a poisonous excrement, by 
the defauk of the principal emunctories, and especially of the kidney. 

But certainly the most common, and a very serious sequel of scarlatina, is ana- 
sarca^ serous infiltration of the subcutaneous areolar tissue, accompanied often with 
dropsy of the larger serous cavities. So common is this that Cullen has even intro- 
duced the circumstance as a part of his definition of scarlet fever. He found the 
dropsy a very manageable complaint ; but it really is, in many — nay, in most cases, 
if we look to its probable ultimate consequences — a most formidable one. This 
affection belongs to the class of febrile dropsies. It appears to have no relation, or, 
if any, an inverse relation, to the violence and danger of the preceding exanthem. 
It is much more common after a mild than after a severe disease. This, in all pro- 
bability, is owing to the circumstance that less care and caution are observed in the 
milder cases during the dangerous period of desquamation and convalescence ; a 
period more dangerous, in that variety of scarlatina, than any other. In the graver 
cases the convalescence is slower, and more doubtful ; and accidental or careless 
exposure to cold is more guarded against, or takes place later : whereas, in the 
shghter kinds of the disorder, the patients are apt to go out while the new cuticle is 
still forming. If you carefully trace the histories of dropsy succeeding to scarlet 
fever, you will almost always find that the fever had been trifling ; and that the 



1000 



SCARLET FEVER. 



patient, considering himself well or nearly so, had heedlessly encountered a cold or 
damp atmosphere so soon as he felt himself strong enough to leave the sick chamber. 
Plenciz, who has written well on this subject, and who was quite aware of its im- 
portance, remarks that those patients who have had much desquamation of the 
cuticle are the most liable to the dropsy ; that it is more frequent in winter than in 
summer ; and in such as are early exposed to the open air after having passed 
through the fever, than in those who remain longer at home. When the desquama- 
tion is over, and the new surface has become in some degree hardened, the peril is 
past. According to the observations of Dr. Wells, the dropsical symptoms com- 
monly show themselves on the twenty-second or twenty-third day after the commence- 
ment of the preceding fever. They have been known to begin as early as the 
sixteenth, and as late as the twenty-fifth day. When no dropsy took place before 
the end of the fourth week, Dr. Wells always ventured to state that it was no longer 
to be dreaded. 

This anasarca is seldom observed except in children and young persons. The age 
of the oldest patient that Dr. Wells had known to be so afl^ected was seventeen. Of 
ten instances of the disease seen by Dr. Blackall, six occurred in children not exceed- 
ing the age of ten, and two others in persons who were respectively ten and sixteen 
years old. 

We cannot infer, from this, that the susceptibility of this dropsical condition lessens 
as years increase. The great prevalence of this variety of dropsy in early life has 
no direct relation to age as a predisposing cause. The fact is explained by the 
accidental peculiarities of the antecedent disease. The contagion of scarlet fever is 
active and widely diffused. Few children escape its agency. Few are capable 
of taking the disorder a second time. It follows that scarlet fever is rare in adult 
hfe : and as dropsy succeeds that disease in a very limited number of instances only, 
dropsy arising in connection with scarlet fever must, at the aduk age, be still more 
uncommon. 

Yet it is not unknown. One of Dr. Blackall's ten patients was thirty, another 
forty-two years old. Both of these were women. 

In this, as in other species of febrile dropsy, the urine is very constantly troubled, 
bloody, albuminous ; and it is an interesting fact, that the chronic form of renai 
dropsy, manifesting itself at some distance of time, has been distinctly traced back 
to its source in the acule anasarca immediately consequent upon scarlet fever. The 
sequence has occurred, in all probabihty, much oftener than it has been noticed. 
There is scarcely room for doubling that the series of organic changes in the kidney, 
described by Dr. Bright, do frequently date their origin from an attack of febrile 
anasarca : and in proportion as facts, accurately observed, accumulate on this sub- 
ject, the chain of connection becomes more clearly visible between acute febrile 
dropsy, dropsy succeeding scarlet fever, and chronic renal dropsy. It is evident, 
indeed, that the first two of these three are, in their characters and exciting causes, 
identical, the only difference between them consisting in the remarkable predis- 
position towards the second, impressed upon the body by the preceding exanthem. 
Both of them again are, in many instances, initiative of the third. 

It is natural therefore to expect that in the variety of febrile dropsy now under 
consideration, as well as in those which I formerly described, inflammation, and 
especially inflammation of the serous membranes, should be common, and evidenced 
by its unequivocal effects. And it is so. But the dropsy, I am persuaded, has no 
essential connection with common inflammation of any part, unless the state of the 
kidney be of that kind. I have examined the body very carefully in fatal cases, and 
found the serous cavities full of clear hquid, without a trace of redness or of any of 
the unmistakeable products, or events, of inflammatory action. 

The earliest thrt^atenings of this formidable complaint demand attention. It is 
usually preceded, for a day or two or longer, by languor and peevishness ; frequently 
by nausea and vomiting, and a costive state of the bowels. The pulse, in the out- 
set, has been found slow, and beating with irregular intervals ; but it afterwards 
becomes frequent. The urine, at first, is scanty as well as altered in appearance. 
The face becomes pale, and chuffy. Sometimes, as the disease proceeds^ violent 



SCARLET FEVER. 



1001 



headache, dilatation of the pupils, convulsions, or palsy, denote effusion within the 
head. Much more frequently the pleurse are the seat of the internal dropsical accu- 
mulation, and dyspnoea is a prominent symptom. Ascites, to any considerable 
amount, is rare. • 

The contagion of scarlet fever is active, but uncertain. It is not so strong, nor so 
uniform in its operation, as that of small-pox ; but it seems to be pecuhariy subtle 
and tenacious. Fomites infected with the variolous poison soon lose their power to 
excite the disease if they are freely exposed to fresh air. But the contagion of scarlet 
fever lurks about an apartment, or chngs to furniture and clothes, for a very long time, 
even after some care has been taken to purify them. Of this I have known several 
remarkable examples. You will be asked at what period the danger of imparting 
the disease on the one hand, or of catching it on the other, is over; and I would 
recommend you to answer that you do not know. I am sure I do not : and therefore 
I always decline the responsibility of giving an oracular opinion on the matter. 

I may arrange what I have to say of the treatment of scarlet fever, according to 
the three varieties of it already mentioned, the scarlatina simplex — anginosa — and 
maligna. 

The first of these requires nothing more than confinement to the house ; and the 
observance of the antiphlogistic regimen in regard to diet ; and regulation of the 
bowels. 

With respect to the management of the severer forms of scarlet fever, great differ- 
ences of opinion have prevailed. I should recommend you to look into Dr. Williams's 
book on Morbid Poisons, for some interesting and satisfactory information on this 
head. Satisfactory to me at least it is, because the result of it goes to justify that 
kind of practice which I have always considered to be the safest and the best in this 
disorder. 

Tn the scarlatina anginosa, the treatment I employ is very much the same as that 
which I consider proper for many cases of continued fever. If the heat of the surface 
be very great and distressing, I should certainly recommend the cold affusion, but 
cold or tepid sponging will be very refreshing and beneficial. If dehrium should 
come on, I would shave the scalp, and apply cold to it, and take away some blood 
by leeches : and the leeches I would apply to the throat rather than to the temples; 
for the tonsils, in this form of the disorder, are more swelled and inflamed, and pro- 
bably a part of the head affection may arise from disturbance of the balance of the 
cerebral circulation, produced by the tumefaction around the great veins that return 
the blood from the head. By leeching the throat you relieve that part, and at the 
same time the head also. If the fever were extreme and the dehrium violent, I 
would take blood cautiously from the arm, while the patient was sitting up, and care- 
fully watch the effect. 

When none of these untoward head symptoms declare themselves, all that we 
have to do is to keep the bowels open by moderate laxatives. The patient may take 
sahne draughts, which are grateful and cooling. The citrate of ammonia thus ad- 
ministered, is what t frequently prescribe : and if the pulse be without hardness, and 
feeble, I order an excess of the carbonate of ammonia, so that four or five grains of it 
in each dose may remain unsaturated by the lemon-juice. 

With respect, then, to this form of the complaint, the principles of treatment are, 
not to interfere unnecessarily; to take blood when certain symptoms require it, but 
to take no more than seems likely to be sufficient for the purpose in view ; to bear in 
mind that the system is labouring under a morbid poison, which we cannot eliminate 
from the blood, but the dangerous effects of which we are to watch and obviate. 

In that worst form of scarlet fever, the scarlatina maligna, all our care will too often 
be in vain. There appear to me two main sources of danger. The one arises from 
the primary impression of the contagious poison upon the body, and particularly upon 
the nervous system, which is overwhelmed by its influence. The patients sink often 
at a very early period, with but little affection either of the throat or of the skin. If 
we can save such patients at all, it must be by the liberal administration of wine and 
bark, to sustain the flagging powers until the deadly agency of the poison in some 
measure passes by. But another source of danger arises from the gangrenous ulcera- 

4i2 



10G2 



SCARLET FEVER. 



tion wh^ch is apt to ensue in the fauces, when the patient is not killed by the first 
violence of the contagion. The system is re-inoculated, I believe, with the poisonous 
secretion from the throat. Now under these circumstances also, quina, or wine — and 
upon the whole T should give the preference to wine — aroiio be dihgently, though 
watchfully given. And something may be done, by way of gargles, to correct the 
state of the throat, and to prevent the distressing and perilous consequences which 
would otherwise be hkely to flow from it. A weak solution of the chloride of soda 
may be employed for this purpose ; and if the disease occur in a child that is not 
able to gargle, this solution may be injected into the nostrils, and against the fauces, 
by means of a syringe or elastic bottle. The effect of this application is sometimes 
most encouraging. A quantity of offensive sloughy matter is brought away; the 
acid discharge is rendered harmless ; the running from the nose, and diarrhoea, cease ; 
and the disease is converted into a form which approximates to the scarlatina angi- 
nosa. This is a great improvement upon the old plan of ordering capsicum gargles. 

Of late I have been in the habit of directing a solution of the chlorate of potass in 
water, (a drachm to a pint,) as a drink for patients in scarlet fever, and in the typhoid 
forms of continued fever. This practice was suggested to me by Dr. Hunt, who 
tells me he has long employed it with advantage. Under the use of a pint, or pint 
and a half, of this solution daily, I have remarked, in many instances, a speedy im- 
provement of the tongue, which, from being furred, or brown and dry, has become 
cleaner, and moist. 

From several distinct and highly respectable sources, chlorine itself has been 
strongly pressed upon my notice, as a most valuable remedy in the severest forms 
of scarlet fever. My informants have stated, that whereas they formerly dreaded 
to be summoned to cases of that disease, they now, having had experience of the 
virtues of chlorine, felt no misgivings in undertaking its treatment. Since these 
representations were made to me, I have not had opportunities enough of trying 
this drug to enable me to speak confidently of its sanative power; but I shall cer- 
tainly euiploy it in future. I presume that its disinfecting properties may, in part, 
account for the good it does. It probably deprives the foul secretions of their noxious 
quality. 

In the fourth volume of the Medical Gazette, Messrs. Taynton and Williams, of 
Bromley, write in high praise of this remedy. I will give you the formula for its 
preparation. 

Two drachms of the chlorate of potass are to be dissolved in two ounces of 
hydrochloric acid, previously diluted with two ounces of distilled water. The solu- 
tion must be put immediately into a stoppered bottle, and kept in a dark place. 

Two drachms of this solution, mixed with a pint of distilled water, constitute the 
chlorine mixture ; of which a tablespoonful, or two, according to the age of the pa- 
tient, may be given for a dose, frequently. 

We must not omit, in this, as well as in the other forms of the complaint, to 
pay attention to the state of the bowels, and by no means to allow them to remain 
costive. 

I have seldom used blisters in this disease ; but an experienced physician has 
lately told me that, when applied early to the neck and throat, they seem to render 
the affection of the fauces mild. 

When the patient is at length convalescent, he will require careful watching till 
that period has gone by at which the dropsical symptoms are apt to appear. It is 
by neglect or imprudence that these symptoms are brought on. The patient should 
be sedulously protected from all exposure to cold, and wet, and fatigue ; indeed he 
ought not to be permitted to go out of the house until the process of desquamation 
is fairly over ; and I would not willingly let a patient go out till some little time after 
this. When dropsical symptoms do occur, if they be very slight, they may be re- 
moved in general by purgatives, and by digitaHs. The bitartrate of potass is a good 
remedy too in such cases, and the use of the warm bath, which may be repeated 
every night. 

But if there be any indication of inflammatory disease within, we must adopt 
more active measures. We have not, now, to contend with the depressing influence 



SCARLET FEVER. 



1003 



of the original poison, but we have to dread the consequences of acute inflammation ; 
or of the sudden effusion of fluid, the mere presence and pressure of which may 
fatally oppress vital organs. We should have for our object to arrest the inflamma- 
tion—or to promote the removal of the effused fluid— -by blood-letting, and by the 
exhibition of purgative medicines, and of mercury. The worst case of this kind that 
I ever witnessed occurred in a boy of fifteen, the son of a tradesman in my neigh- 
bourhood. He had had scarlet fever, mildly, and had got well, or nearly well, of it, 
! as he behoved ; and he went, one evening, into his father's stable, and stayed there 
j some time in the cold, during the period of desquamation. A day or two afterwards 
he began to have headache, and in a few hours more was seized with convulsions 
of one side of the body, coma, and at length hemiplegia; and his face and extremi- 
ties became at the same time anasarcous. A large quantity of blood was taken from 
his arm, he was cupped on the temples, and took mercury, till in a short space of 
time he was profusely salivated. Under this treatment the coma and dropsy rapidly 
disappeared, and he presently recovered the use of his palsied limbs, and got quite 
well. I make no doubt that some effusion took place within the cranium, as well 
as into the subcutaneous areolar tissue. The plan of treatment followed in this 
case, modified according to particular circumstances, is that which I should again 
pursue, and therefore what I should recommend you to pursue, in similar emer- 
gencies. 

You are probably aware that belladonna is behoved by many to exert a preventive 
and protecting influence upon the body against the contagion of scarlet fever. Hah- 
nemann, the author of the Homoeopathic hypothesis (and thereby of much mischief 
to mankind), was the first to assert this. It is said that belladonna administered in 
small doses causes sometimes a rash resembling that of scarlatina. It certainly is 
apt to produce dr}'ness and redness of the fauces. I know nothing by my own expe- 
rience of the alleged conservative power of this vegetable ; but, in the small quan- 
tities recommended, there can be no harm in trying h, provided that its employment 
does not lead to a neglect of other precautions. Three grains of the extract of bel- 
ladonna are dissolved in an ounce of distilled water; and three drops of the solution 
are given twice daily to a child under twelve months old, and one drop more for 
every year above that age. It is affirmed that if this remedy does not prevent the 
disease, it will render it mild ; and that if it be taken four or five days before exposure 
to the contagion, the resulting scarlatina never proves fatal. 

[The question in relation to the prophylactic properties of the belladonna in this disease 
is a highly interesting one. The severe and fatal character of scarlet fever, particularly when 
it occurs as an epidemic, renders every means of prevention that can be depended upon 
with any degree of certainty, of vast importance. In proof of the power of the belladonna 
to guard those who have been placed under its influence from an attack of scarlatina, we 
have certainly some very strong and respectable testimony. In a paper published by 
Bayle, in 183(3, it is stated that of 2027 individuals to whom the belladotma was adminis- 
tered, 1948 were preserved from scarlet fever, and 79 were attacked. Dusterberg reports, 
that all who were placed under the influence of the belladonna for the space of two weeks, 
were preserved from the scarlet fever. In order to ascertain the real value of the article, he 
purposely omitted to administer it to one child in each family, and this one alone, according 
to his report, was seized with the disease. He adds, however, that occasionally a child 
who had only been taking the remedy during three or four days, was attacked, but the fever 
was in such cases always mild, and often only manifested its presence by the occurrence 
of desquamation. Zeuch, physician to the Miliary Hospital for Children, in Tyrol, after 84 
of the children were attacked with scarlet fever, was induced to try the prophylactic powers 
of belladonna on the remaining 61 children: with a single exception, all of these were 
preserved from the fever, although it prevailed all around them. Schenk, Bernilt, Kohler, 
Meglin, De Lens, and many other respectable practitioners, speak in equally high <-erms of 
the preservative properties of the belladonna. We have ourselves given the belladonna to 
a number of children, on several occasions when the scarlet fever was prevailing epidemi- 
cally, with a view of testing its prophylactic powers; but although redness and dryness of 
the throat, and a diffuse scarlet effervescence were produced by it, yet in the majority of 
cases, we never found it in any instance to exhibit the slightest influence in shielding those who 
took it from an attack of the disease, or in mitigating in any degree its severity. In one case, 
the efflorescence produced by the belladonna was kept up for forty-eight hours ; in a week 
afterwards the child was attacked by the fever in its most violent form, and died on tlie fourth 



1004 



ERYSIPELAS. 



day. Recently, however, Dr. Stievenart, of Valenciennes, has published the results of a 
very extensive trial of the belladonna, as a prophylactic during the prevalence of epidemic 
scarlatina : which results, if they are correctly stated, and all sources of error have been 
carefully guarded against in the performance of the experiments upon which they are 
founded, go very far to prove that the belladonna does actually possess the property of 
shielding the constitution from an attack of scarlet fever. An epidemic of the disease 
ravaged, during the winter of 1840-1, several villages in the neighbourhood of Valen- 
ciennes, when Dr. Stievenart was induced to try the prophylactic properties of belladonna. 
The fatality of the epidemic was such that 30 had already died out of 96 attacked ; conse- 
quently any means of prevention was a subject of vast importance. In a small village, 
out of 250 individuals, 200 took the belladonna, and were all preserved from the attack of 
scarlet fever. Of the fifty others, 14 were seized with the fever, and four of them died. At 
the village of Curgies, Dr. Stievenart administered the belladonna to the children at the 
public school, and allowed them to continue at their lessons, and have free communication 
with the other children of the village. All to whom the belladonna was administered 
escaped the scarlet fever, while a few who refused to take it v/ere seized with the disease. 

The belladonna was administered in two forms — in solution, or as a powder. Two grains 
of the recent alcoholic extract of belladonna were dissolved in an ounce of any aromatic 
infusion, and of this two drops were given to a child of one year old, daily, for nine or ten 
days : an additional drop being given for every additional year of age. The largest daily dose 
was, however, limited to twelve drops. When the belladonna was used in the form of 
powder, half a grain of the powdered root was mixed with a small quantity of sugar, and 
divided into ten doses. One of these was given — morning and evening — to children of 
from one to two years old ; two powders, at the same periods, to those from three to five ; 
three powders to those from six to nine ; four to those from ten to fifteen, and five to 
adults. These small doses never produced the toxocological effects of belladonna ; in fact, 
they scarcely exhibited any marked action. In five or six cases Dr. Stievenart observed a 
rash similar to that of measles ; and, in a few other cases, headachCj with dilatation of the 
pupils, dryness of the fauces, and a slight soreness of the throat, but which had no resem- 
blance to that of scarlatina anginosa. In all the other cases no sensible or apparent effect 
resulted from the administration of the remedy. Dr. Stievenart, generally, continued the 
use of the belladonna for from nine to ten days ; in some cases, it was given for fifteen days. 
He thinks this period sufficiently long to put the system under the influence of the preserva- 
tive powers of the remedy: but recommends to resume its use if the epidemic returns or 
breaks out again with renewed violence. — C] 



LECTURE LXXXIX. 

Tlie Plague. Erysipelas. Erythema Nodosum. Urticaria. Prurigo. Scabies, 

Of that group of contagious exanthemata of which I undertook to give you some 
general account, two only remain to be noticed, viz., the plague and erysipelas. 

Concerning one of these, the plague — as I have never seen, and hope never to 
see it ; and as, with Cullen, I " think it unfit for a person who has never seen the 
disease to attempt its particular history" — I shall not presume to offer you any obser- 
vations in detail. It is a very malignant kind of contagious fever; prevailing, at 
certain times and places, epidemically ; attended with a sort of eruption, namely, 
with buboes and carbuncles ; and not furnishing, apparently, any sure or permanent 
security against its future recurrence. In Dr. Forbes' Select Medical Bibliography, 
you will find a long list of works on the plague. I would second Dr. Cullen's 
recommendation, that you should consult those authors only who have themselves 
had personal experience of the disease. Among the publications that fall within 
this rule may be mentioned, Dr. Russell's History of the Plague as he saw it in 
Aleppo; Sir James M'Grigor's Medical Sketches; Sir Arthur Brooke Faulkner's 
Account of the Plague which occurred at Maka in 1813 ; Desgenettes' Histoire 
Medicale de I'Armee d'Orient ; and Assalini's description of the malady as he wit- 
nessed it when in attendance upon the French army in Egypt. 



ERYSIPELAS. 1005 

I I proceed, therefore, to erysipelas. And I wish, in the first place, to fix and define 
j that specific complaint of wiiich alone I propose at present to spealt. The term ery- 
'i sipelas has been employed by medical men in a very loose and vague manner. Any 
I diffused redness and inflammation of the skin is apt to be set down as erysipelas ; 
j and hence we have disputes as to the distinction between erysipelas and erythema. 
i| But it would tend, in my humble judgment, to the formation of more settled opinions 
I in respect to erysipelas, if the term were restricted to that disease in which the inte- 
I guments of the/ace and head become diffusely inflamed. The phrase erysipelatous 
j inflammation may properly enough be apphed to other cases, similar to this, in so 
far as the condition of the skin is concerned ; but in what I should consider true 
erysipelas, in the medical sense of the word, there are other characters belonging to 
j the disorder, quite as important as, and more distinctive than, the cutaneous affection. 

What is usually spoken of as erysipelas of the face and head, and what I would 
I call simply erysipelas, falls naturally within that group of exanthematous diseases 
which includes small-pox, measles, scarlet fever, the plague, and continued fever. 
It is an idiopathic inflammatory disorder, running a tolerably regular and definite 
course; attended by inflammation of the integuments of the body, or, in other words, 
by an eruption; ohen prevailing epidemically, and capable of being communicated, 
under circumstances favourable to its propagation, from one person to another. Its 
power to protect the constitution from its own recurrence is less certain ; but in truth, 
!i so many different affections have been lumped together under a common name, that 
the proper phenomena of true erysipelas have not been made sufficiently an object 
. of separate study to enable us to speak with any confidence on this point. I recol- 
i lect, however, a certain female who has been three or four times my patient in the 
hospital with erysipelas : and one of the night nurses there, whom 1 treated for that 
complaint some time ago, is now lying ill of the same disorder, under the care of one 
of my colleagues. 

! Erysipelas, in the sense now explained, called in Scotland the rose, and in this 
!| country St. Anthony's fire, resembles other disorders of the same group in these 
points also, that the fever precedes the local infiammation, that certain premonitory 
' symptoms frequently go before the outbreak of the disease, and that sore throat is an 
early, and almost a constant, accompaniment of the complaint. The patient feels ill- 
shivery, feeble, languid, and often drowsy. The actual attack generally sets in with 
distinct rigors ; and the pulse is often very frequent from the first, for many hours, 
perhaps, before the redness commences. Very commonly there is also manifest dis- 
turbance of the alimentary canal, marked by nausea and vomiting, and not unfre- 
quently by diarrhoea. Then some part of the face, usually one side of the nose, or 
one cheek, or the rim of one of the ears, begins to feel hot, stiff, and tingling: and upon 
examining it you find it to be of a deep continuous red colour, and to be swelled and 
hard. The redness and swelling gradually, and sometimes rapidly, extend them- 
selves : they are defined by a distinct elevated margin ; which advances, and invades 
progressively the neighbouring healthy surface, until the whole of the face, or of the 
scalp, or of both, is occupied with the inflammation. The lips swell enormously, 
the cheeks enlarge, the eyes are sealed up by their oedematous and prominent lids, 
and all traces of the natural countenance are effaced. I know of no disease, except 
perhaps the confluent small-pox, which so completely and speedily deforms and dis- 
guises the visage of the patient. A stranger seeing a young female in the height of 
the dilbrder, and revisiting her after her recovery, is astonished at the change. It 
seems as if, by some magic process, such as we read of in our nursery tales, a hide- 
ous monster has been metamorphosed into a comely damsel. 

The inflammation frequently spreads from the face and forehead, or ears, to the 
hairy scalp ; and from the head it travels backwards, in some cases, to the neck and 
the shoulders. Sometimes — and in this it exactly resembles a scald — the inflamed 
surface becomes covered with irregular bullae, or blisters ; but often there is no vesi- 
cation. This circumstance, therefore, which has been mentioned^by some as fur- 
nishing a point of distinction between erythema and erysipelas, fails of that purpose. 

In many cases the inflammation is quite superficial: in others it dips, as it were, 
through the skin, and affects the subcutaneous areolar tissue ; and then, and there, 



1006 



ERYSIPELAS. 



suppuration, and even sloughing of that tissue, are apt to take place. We find thia 
to be the case often in the loose tissue of the eyelids ; and it is more common on the 
scalp perhaps than on the face. 

After the redness has lasted three or four days, it fades, the swollen surface sub- 
sides, and desquamation ensues ; and as the inflammation creeps, perhaps, gradually 
from one part of the surface to another, you may find the face becoming pale, and 
covered with patches of dead cuticle, while the scalp, or the upper part of the neck, 
is becoming red. Sometimes those pans of the inflamed surface on which bhsters 
had formed are covered with crusts, rather than with merel}^ dead and dry cuticle. 
In almost all these cases of erysipelas of the head and face there will be found to be 
redness and soreness of the throat also ; although this is not always inquired into, 
or complained of. 

There is considerable variety in the intensity and complication of the symptoms. 
Sometimes the sufferer lies patiently still, yet apparently conscious and rational, till 
the tumefaction diminishes, and he is again able to open his eyes. Generally there 
is some wandering of the mind, especially at night ; and in bad cases there is much 
delirium, and at length complete coma, and the patient dies at the end of a few days. 
In some of these cases the inflammation has extended to the encephalon ; in others 
it is probable that the functions of the brain are disturbed through the febrile derange- 
ment of the circulation. When death takes place, and the head is examined, serous 
fluid is usually discovered beneath the arachnoid, and in the cerebral ventricles; and 
the veins of the pia mater are turgid. I have stated before that I doubt whether 
such appearances are always to be attributed to inflammation. Sometimes there are 
no morbid appearances at all within the skull. 

It is said that the erysipelas does, now and then, suddenly desert the surface; and 
that inflammation of some internal part, and particularly of the brain, is apt to follow 
such rapid subsidence of the external malady. I presume that this metastasis is 
rare. I do not recollect to have seen it. But the extension of the inflammation, the 
supervention of delirium and coma, while the external inflammation continy,es, are 
of common occurrence. 

This, then, is one way in which erysipelas is accustomed to prove fatal; by effu- 
sion within the head, and coma. 

And there is another mode in which death is not unfrequently brought about, and 
which has not been so much attended to ; I mean by the affection of the throat. 
The patient dies sometimes almost suddenly ; unexpectedly ; you cannot account for 
the unlooked-for dissolution. But if the throat be examined you may (sometimes at 
least) there discover the solution of the mystery. The sub-mucous tissue of the 
glottis and epiglottis is filled with serum, the chink of the larynx has been nearly or 
completely closed, and the patient has died of apnoea. This is just analogous to 
what takes place externally : the enormous swelling of the eyelids, and hps, and 
face, is owing, in a great degree, to serous fluid poured out into the swh-cutaneous 
areolar membrane. 

Another way in which erysipelas may kill, is by gradual asthenia. Without any 
stupor or much wandering, without any marked affection of the breath, the pulse 
becomes weaker and weaker, the surface cold, and the heart at length ceases to pul- 
sate. This mode of dying is less common in this disorder than the other two. 

The causes of erysipelas are various, and often obscure. I have stated that it is 
communicable, by contagion, from person to person : yet this contagious prof^rty is 
so feebly marked, that it is denied by many. It is more active at certain times, at 
certain seasons, at certain places, than at others ; which is the same thing as to say 
that there are predisposing causes of the disease; that there are influences which 
augment the susceptibility of the body to the agency of the poison. 

I believe that on the continent they do not allow erysipelas to be contagious at all : 
but very satisfactory evidence of the fact has been collected by several of our ow'n 
practitioners. Iti the second volume of the Transactions of a Society for the Im- 
provement of Medical and Chirurgical Knowledge, Dr. Wells has brought together 
several examples in which the complaint appeared to be unequivocally propagated 
by contagion. "I visited (says he), on the 8lh of August, 1796, in Vine street, 



ERYSIPELAS. 



1007 



Clerkenwell, an elderly man, named Skelton, who had been attacked several days 
before with erysipelas of the face. In about a week afterwards he died. On the 
19th of the following- month, I saw a Mrs. Dyke, of about seventy years of age, the 
landlady of the house in which Skelton had been a lodger, and found her labouring 
under an erj^sipelas of her face. I inquired whether any person in her house had 
been ill of the same disease since the death of Skelton, and was told that his wife had 
been seized with it a few days after his decease, and had died in about a week. 
During my attendance upon Mrs. Dyke, an old woman, her nurse, was attacked with 
the same disorder, and was sent to her parish-workhouse, where she died. Mrs. 
Dyke has since informed me that a young man, the nephew of Skelton, was taken 
with the disease of which his uncle had died, shortly after visiting him, and survived 
the attack only a few days. That she herself had been several times with Skelton 
and his wife during their sickness, and after their death had removed some furniture 
from the room they had occupied to her own apartment." Dr. Wells relates other 
histories of the same kind, all occurring when there was no particular epidemic of 
erysipelas prevailing to account for them. Professor Arnott has given some other 
examples, still more striking, of the propagation of erysipelas from one person to 
another, not only under the same roof, and in the same locality, but also when the 
parties lived at a distance from each other, and the intercourse between them had 
been casual and temporary. These cases are stated, I think, in the fifty-seventh 
volume of the London Medical and Physical Journal. The following incident has 
been told me upon good authority. A man living somewhere in Westminster fell ill 
of idiopathic erysipelas. In that state, for some reason or other, he was removed 
thence ; and his brother, who was a servant in or near Portland Place, received him 
clandestinely into his master's house, and allowed him (for two nights, I beheve) to 
share his bed. That brother was soon attacked with erysipelas; and in the course 
of his illness was visited by his master. The master also was attacked ; and it is 
worthy of remark, that in both master and servant the disease showed itself just 
seven days after they had respectively come near another who was affected with it. 
Dr. Elliotson gives an account of having suffered the disease in his own person. It 
came on in him five days after the breath from one of his patients, over whom he 
was stooping to examine the skin, and who had er5?'sipela3 badly, and died of it, had 
come upon his face. " I turned away (he says) disgusted, and said, 1 hope I have not 
caught it ; but five days afterwards, having forgotten the circumstance, I was seized 
with it." More than once I have had occasion to remark that successive tenants 
of the same bed in a hospital have been seized with erysipelas after admission. 

But allowing, as 1 think we cannot but allow, that contagion is one of the exciting 
causes of erysipelas, there are others which more frequently excite it. At least there 
are many instances of the disorder in which we can trace no exposure to contagion, 
and in which we can perceive some other probable reason for its occurrence. Some- 
times, no doubt, it comes on without any obvious cause. The application of cold 
often gives rise to it. Irregularity of diet is said to do the same. Violent mental 
emotions are also accused of being occasionally its cause : it is said to have been 
brought on both by anger, which is an exciting, and by fear, which is a depressing, 
passion. It is incidental to what I have called purulent infection of the blood. Many 
cases, not to be distinguished in their appearances and effects from idiopathic erysi- 
pelas, result from local injury. I have already told you that there is no inconsistency 
or absurdity in supposing that a disorder which originates in some common cause, 
may be capable of spreading in the way of contagion. And the testimony of Mr. 
Lawrence (who is not prone to admit of contagion on light grounds) goes to the effect 
that such is the case with the disease in question. He mentions an instance in which 
erysipelas of the head and face, which commenced after the insertion of a seton in 
the neck, appeared to him to have affected two individuals by contagion. 

I say that erysipelas further resembles the disorders of the group in which I have 
placed it, that it sometimes prevails epidemically : and on those occasions, like the 
rest of the group, its occurrence is promoted by all circumstances that tend to debili- 
tate the body : by intemperance ; by previous disease ; by low spirits and anxiety ; 
by insufficient nourishment ; and by foul air. It used to be much more common 



1008 



ERYSIPELAS. 



formerly in hospitals than it is at present ; when less attention was paid to cleanliness 
and ventilation. 

Erysipelas is another of the diseases concerning the treatment of which there has 
been, and there is, a most embarrassing difference of opinion. Some, prescribing 
according to a name, tell you that it is inflammation, and therefore that the remedies 
of inflammation, and especially blood-letting, are to be vigorously employed. Others 
declare that the safety of the patient lies in the early and hberal administration of 
wine and bark. You will not think me a trimmer, I hope, or one who is content 
with indecisive practice, when I state that neither of these plans, in my judgment, is 
universally either proper or safe ; yet that each of them is the best, under certain cir- 
cumstances. 

I think the more you see of this disease the more convinced you will be that it is 
not to be cut short by any particular mode of treatment ; that it will run a certain 
course ; and that it will generally terminate sooner or later, by resolution, whether 
remedies be employed or not. It does not follow from this that remedies are of no 
use : but it does follow that we are to exhibit them, not with the view of curing the 
disorder, but with the view of conducting it safely to its termination. 

If you look at the history of erysipelas, and of the notions which have prevailed 
respecting it, you will find that the opinions in favour of giving support, and of ab- 
staining, as much as possible from the abstraction of blood, greatly preponderate. In 
the outset of the complaint, if the pulse be hard as well as frequent, and there be 
much headache, and active delirium, you must take blood either from the arm, or 
from the neck by cupping, or by leeches from behind the ears. But (I speak of the 
disease as it occurs in London) the time for this kind of practice soon passes by : and 
when you do bleed from the arm, you must (in this town) bleed with caution, and in 
the upright posture ; that the desired effect may be produced by the abstraction of 
the smallest quantity of blood. 

In all cases it will be right to purge the patient briskly at the commencement. 
A full dose of neutral salts, or of rhubarb and magnesia, will answer better, I think, 
in these cases, than calomel and senna. If you see the patient very early, and if 
there be any nausea or oppression of the stomach, it will be proper to administer an 
emetic. 

In most instances you will soon perceive evidence of great debility : a feeble as 
well as a frequent pulse ; tremors ; a dry and brown tongue often. And these 
symptoms increase, if you then persist in drawing blood. The carbonate of am- 
monia does great good sometimes in such a condition : and this I am very much in 
the habit of giving. The bad cases of erysipelas are apt to baffle us aU. I am not 
aware that I lose more of them than my neighbours. Speaking generally, a large 
majority of my patients get well ; but I do not bleed one patient in a hundred, from 
the arm. 

I am bound, however, to set before you the kind of evidence which exists in favour 
of the bark ; or rather of the sulphate of quina, which is what I mean when I speak 
of the bark. 

Dr. Fordyce, Dr. Wefls, Dr. Heberden — all men of great sagacity and experience 
— recommend the treatme*nt by bark. Dr. Jackson, an American physician, advo- 
cates, T see, the same plan. He says that after a purge, and, if necessary, an emetic, 
the sulphate of quina should be given in as large doses as the patient will bear ; that 
from twelve to twenty-five grains in the twenty-four hours will generally suffice ; and 
that we may know when the dose is sufficient by a buzzing which comes on in the 
ears. Dr. EUiotson also — whom I here quote the more willingly because I think he 
is rather of an antiphlogistic turn than otherwise, in general — says, that he has never 
seen quina do harm, even in active tonic erysipelas; and that in doubtful cases, when 
yoa hesitate whether to bleed and put the antiphlogistic plan in force, or to stimulate 
and support, the quina is always a safe and eligible medicine. Dr. Williams, of St. 
Thomas's Hospital, thinks better still of wine, which he gives in all cases from the 
very beginning. 

I have hitherto Hmited my observations to erysipelas of the face and head as it 
occurs in London : and I have done so because I really believe that in the purer 



ERYSIPELAS. 



1009 



air of the country, and in young, strong, vigorous country persons, bleeding may be 
proper and requisite. You will find country practitioners pretty well agreed on this 
point. 

But taking the disease as I see it here, I should say that many cases do well with 
but little care or interference from medicine ; that many also, but a fewer number 
than the former, prove fatal under whatever plan of treatment may be adopted; and 
that many patients are to be saved, by judicious management, who would otherwise 
die. 

The first requisite for rescuing these perilous, yet recoverable cases, is that they 
i should be perpetually watched and tended. The indications of treatment may alter 
from one hour to another, and it is only by great vigilance on the part of the medical 
I attendant, and on the part of an inteUigent and obedient nurse, that medicine obtains 
its full chance of bringing the patient through. 

After clearing out the alimentary canal, then, I would not be active in either wa}--, 
unles^ I saw some plain indication for activity. If the pulse became weaker, and I 
did not feel sure about the propriety of stimulating, I would give five or six grains 
of the carbonate of ammonia every four hours, and beef-tea. If the disease went on 
smoothly under that treatment, well and good. If the powers still continued to sink, 
I should have recourse to wine, or to both bark and wine ; but of the two, I am more 
friendly to Avine ; and as the patients like it better, you may be more sure of their 
taking it. If, on the other hand, there were much headache, and the pulse were 
hard, and the febrile distress great, I should apply a few leeches, and prescribe the 
tartarized antimony in a saline draught. The bowels should not be allowed to be- 
come confined; but the mild aperients are better than the drastic in these cases. 

Various external medicaments have been used and recommended for the inflamed 
part. Putting leeches upon it ; puncturing it with needles, or lancets ; covering, or 
surrounding it with blister, or with the lunar caustic in substance or in strong solu- 
tion ; dusting the surface over with magnesia, or flour ; smearing it with various 
unguents, and particularly with mercurial ointment ; keeping it wet with some cold 
lotion ; or fomenting it with hot flannels. 

Now of all these local appliances, that which, according to my own observation, 
is the most useful, and which affords the greatest comfort to the patient, is the last 
that I mentioned ; fomentation by flannels wrung out of a hot decoction of poppy- 
heads. But in order to give this, also, fair play, it should be continual; not used 
for half an hour, and then intermitted ; but it should be one person's business to 
apply the fomentation assiduously, as long as it is soothing and grateful to the pa- 
' tient. In a few cases, and but a few, the warm applications have been disHked, and 
cold lotions preferred ; and when such is the case, there is no risk incurred by using 
■ them, so far as I know ; no hazard, I mean, such as you may read of, of the inflam- 
mation being repelled from the surface, and driven in upon some^ vital organ. The 
- local treatment most in favour with our apothecary at the hospital is that of covering 
the inflamed face and head with flour, by means of a dredging-box. The patients 
declare that the flour cools, soothes, and comforts them. Now this is a more conve- 
nient, and, in some respects, a more eligible, application than that of hot flannels. 
It is less Kkely to fail of its purpose through the negligence of the nurse. 

[Keeping the inflamed surface constantly covered with perfectly fresh hog's lard, has 
a very soothing effect, and tends to reduca the violence of the inflammation. We have 
occasionally employed an ointment formed of acetate of lead fifteen grains, riibbed up with 
one ounce of hog's lard, and have been pleased with its effects. — C] 

So much for erysipelas, as it usually comes under the notice and the management 
of the physician. You are aware that an affection of the skin very similar to that 
which I have been describing, and called also by the same name of erysipelas, is 
very common in other parts of the body ; on the extremities especially, and occa- 
sionally on the trunk : and it will travel sometimes from an extremity till it reaches 
the head. These varieties of cutaneous inflammation are, in most instances, the 
indirect-consequences of some local injury; of punctured wounds; of the stings of 
insects, or the bites of venomous reptiles : of mere scratches sometimes. Or the 
\ cutaneous inflammation will spread from old sores; or supervene upon dropsical 
64 4 k 



1010 



ERYSIPELAS. 



limbs. It is curious that these complaints also are much more apt to occur, and 
even to multiply by a sort of contagion, or in virtue of some epidemic atmospheric 
influence — at certain times and places than at others. You will find there are pe- 
riods when the surgeons of hospitals dread to perform any operation, lest it should 
be followed by this spreading inflammation of the skin. There are many points of 
great interest connected with these diversified forms of what is called erysipelas ; 
they are more hable to be attended with gangrene than erysipelas of the face and 
scalp : on the other hand, they are more hable also to be complicated with inflam- 
mation of the subcutaneous areolar tissue, and with suppuration ; and to require 
incisions to relieve the great tension of the inflamed parts, and to facihtate the escape 
of the pus, or of sloughy dead portions of areolar tissue ; but all these matters be- 
long rather to surgery, and have been discussed, I make no doubt, by the Professor 
of Surgery. 

[Erysipelas is of frequent occurrence in the earlier period of infancy, and is among the 
most fatal of the diseases which occur at that period. It very generally terminates in' death 
especially when it occurs during the first month. Its danger gradually diminishes as the 
child advances in age, but even when it attacks after the fourth month, the greater portion 
of the cases terminate fatally. 

The invasion of the disease is always extremely insidious. The child appears somewhat 
morose ; his sleep is slightly diminished, and he sucks rather less than before ; with these 
trifling symptoms, there is associated a small patch of redness upon the pubes, which is 
painful upon pressure. The redness gradually spreads over the abdomen and thighs, and 
is, occasionally, disseminated. When the redness extends to the hands and feet, these parts 
acquire a degree of redness and swelling far greater than that of any other part. The geni- 
tal organs, in some cases, sphacelate, in consequence of the local inflammation, and in many 
acquire an emphysematous appearance. In place of appearing first upon the pubes, the 
erysipelas has been known to extend from the areola of the vaccine vesicle, less frequently 
from any accidental laceration of the skin or from the excoriations so common in the cuta- 
neous folds of the groin and other parts. 

The disease at first appears perfectly local — it is not until several days have elapsed, that 
general uneasiness and fretfulness present themselves. The colour of the skin, and the 
expression of the couritenance, often remain for some days without exhibiting any striking 
change, when, suddenly, an ashy cadaverous paleness is observed ; the child cries inces- 
santly, there is constant jactitation, and complete loss of sleep. These symptoms are suc- 
ceeded by deep stupor and death. The pulse is at first frequent, and the heat of the skin 
sinks only during the fatal stupor whicii precedes death. Convulsions, diarrhoea, and vomit- 
ing are seldom observed. When the progress is such as we have described, peritonitis has 
occurred — which is, according to M. Trousseau, a frequent disease in children, and one 
which has not hitherto been accurately described. The duration of infantile erysipelas 
varies considerably, sometimes being extremely short, in others, on the contrary, being pro- 
longed to the end of the week. 

In post-mortem examinations, the cutaneous disease is occasionally the only morbid change 
detected ; but when peritonitis (a frequent complication) has occurred, the umbilical vein 
is often found inflamed, and filled with pus, as far as the transverse furrow of the liver, 
while inflammatory exudations are found on the peritoneal surface of the abdominal viscera. 

According to M. Trousseau, infantile erysipelas is principally observed when puerperal 
fever prevails in the wards of the lying-in hospitals of Paris. The infants appear to inherit 
from their mother a purulent diathesis, and seem to be still, within certain limits, subject to 
the same maladies as the mother, whose constitutioia has so lately been theirs. The peri- 
tonitis of the infant may be, therefore, as properly termed puerperal as that of the mother, 
because its general cause is to be sought for in the circumstances which have accompanied 
the last stage of child-bearing, and parturition. It is natural that the skin should be the seat 
of disease, from its having been so recently called upon to the performance of functions as 
new as they are important. 

In the infants predisposed to erysipelas, the umbilical cicatrix does not form readily, and 
the ulceration which results is sometimes the occasional — the local cause — of the cutaneous 
disease. 

Dr. F/"8be {Journal fur Kinderkrankheiten) describes a form of erysipelas which commences 
about the umbilicus, within a few weeks after birth, and is frequently accompanied with 
ulceration of the navel, and inflltration of lymph or pus into the subcutaneous cellular tissue, 
and deposits of a similar nature in the partially obliterated umbilical vessels. It is attended 
with great and rapidly increasing exhaustion, and occasionally convulsive symptoms of more 
or less severity. It is most generally fatal ; often within the course of forty-eight hours, and 
vritliout having extended more than tliree fingers' breadth around the navel. 

Dr. Friebe is inclined to viow this form of infantile erysipelas as a variety of partial indu- 



ERYSIPELAS. 



1011 



ration of the cellular substance, in consequence of the cachectic condition of the infants in 
whom it usually" occurs, and the peculiar character of the inflammation — while the circum- 
stance of the umbilical vessels being, in fact, converted into fibrous cords, previously to the 
commencement of the disease, leads him to believe that it cannot arise from the umbilical 
phlebitis. 

We have met very frequently with this form of infantile erysipelas among the children of 
the poor, and our observations have convinced us that, in the majority of cases at least, it is 
dependent upon phlebitis of the umbilical vessels ; the evidences of inflammation of the 
latter were unquestionably present in almost every instance in which we have made an 
examination. 

In regard to the treatment of infantile erjisipelas, although in those cases in which the 
disease occurs soon after birth there is but little chance of saving the life of the child, yet 
when the patient is a few months old, we may do much in arresting the progress of the dis- 
ease, and conducting it to a favourable termination. 

We may remark, however, that erysipelas is always to be considered a dangerous disease 
during infancy, but more particularly when it occurs in infants of a weakly and unhealthy 
habit of body. 

The bowels should be freely opened by a grain or two of calomel, followed in a few 
hours by a teaspoonful of castor oil, or a simple laxative enema, and they should be kept in 
a free condition subsequently, by the exhibition, every three hours, of divided doses of calo- 
mel, combined with minute doses of ipecacuanha and extract of hyosciamus — the addition 
of the latter is calculated to prevent or allay irritation, without interfering with the aperient 
action of the calomel. When the skin is warm or dry, the liquor acetatis amonise alone, or 
combined with antimonial wine, will often prove beneficial, as will also the occasional use 
of the warm or tepid bath. 

If symptoms of cerebral disease should occur, a leech or two should be applied to the 
temples, — cold applications to the scalp, — the bowels should be freely opened by calomel, 
followed by castor oil, or purgative enemata, and warm sinapised pediluvia should be 
resorted to. 

In a few cases where tl^e parts occupied by the disease are decidedly red and swollen, a 
few leeches applied upon the sound skin, in the neighbourhood of the inflammation, will 
often prove beneficial. Much judgment, however, is required, to discriminate the kind of 
cases which are likely to be benefited by local depletion. As a general rule, a very mode- 
rate abstraction of blood will be sufiicient. 

When a tendency to gangrene is obvious, and the disease assumes a low typhoid charac- 
ter, it will be necessary to resort at once to the use of the carbonate of ammonia, in doses 
adapted to the age of the patient, and the urgency of the symptoms ; and at the same time, 
the child should be nourished at the breast of a healthy nurse, or if weaned, its diet should 
consist of animal jellies dissolved in water, beef tea, chicken water, or sago. It is all im- 
portant in these cases that the patient be removed to a healthy situation, where he can enjoy 
the tonic influence of a pure, free atmosphere. When the symptoms of prostration are 
more considerable, we may combine the use of the ammonia with the sulphate of quinia 
and extract of hyosciamus. 

Should diarrhoea ensue, particularly after suppuration has taken place, it should be imme- 
diately checked by the cretaceous mixture, with the addition of tincture of kino and lauda- 
num. When the discharges from the bowels are of a vitiated character, or attended with 
griping or colicy pains, a few drops of turpentine, three times a day, will be found a very 
valuable remedy. The turpentine may be combined with the tincture of kino and 
laudanum. 

With respect to the local treatment — washing the inflamed parts frequently with tepid 
water, or some mucilaginous fluid, will, in many cases, be productive of very great relief to 
the patient, and occasionally will produce an abatement of the disease ; in the intervals, the 
parts may be dusted with powdered starch, or covered with carded cotton. 

When there is decided redness, swelling and tension of the skin, a lotion, composed of a 
solution of equal parts of the acetate of lead and subcarbonate of ammonia, has been highly 
recommended. Covering the parts with rags wet with the camphorated tincture, is said to 
prove often very beneficial. Others recommend a wash composed of a solution of corrosive 
sublimate, three grains to the ounce of water, or of nitrate of silver of the same strength. 
It is said that the progress of the disease has been promptly arrested by applying once or 
twice a very strong solution of the nitrate of silver, by means of a pencil, upon the sound 
skin, for about an inch around the margin of the inflammation. One of the best applications 
in cases which exhibit an early tendency to gangrene, is the chloride of lime in solution, in 
the proportion of half a drachm to a pint of water. Velpeau has employed with advantage 
a solution of half an ounce of the sulphate of iron to eight ounces of water. 

The local remedies just recited are to be employed in the early stages, previous to the rup- 
ture of the vesications, and to the occurrence of suppuration or gangrene. 

Among the local remedies which appear to be the most generally applicable to infantile 



1012 



ERYTHEMA. 



erysipelas, is a blister sufficiently large to extend over the inflamed skin, and for a short dis- 
tance beyond it; after vesication has been produced, the serum should be evacuated, and the 
vesicated surface dressed vt^ith fresh lard. When the erysipelas occurs upon the extremi- 
ties, a blister applied around the limb, beyond the inflamed surface, will frequently arrest 
the progress of the disease in that direction. When we have resorted to blisters, which are 
only proper in the early stages of the disease, we have applied them along the edges of the 
inflamed portion, partly upon it, and partly upon the sound skin, removing them at the end 
of three hours, and immediately covering the parts with a soft emollient poultice, with the 
addition of lard. The most important result which we have derived from the use of blis- 
ters is to prevent the spread of the disease. 

The mercurial ointment has been strongly recommended in the treatment of infantile ery- 
sipelas. It is to be spread on a piece of soft linen, with which the afiected parts are to be 
covered. 

In cases attended with an intolerable sensation of burning, we have often derived benefit 
from the local application of a watery solution of opium. 

In a large number of instances, however, no benefit whatever will be derived from any 
local application. M. Trousseau states that he has tried every imaginable one — ointments, 
lotions, blisters, even the actual cautery — without suspending the progress of the disease. 
Three cases only, occurring within the month, has he seen recover under the use of the 
etherial solution of camphor, and baths containing corrosive sublimate. The disease is cer- 
tainly a very unmanageable one when it occurs in very yourig infants ; we have nevertheless 
seen it in children a few months old in many instances promptly arrested by the remedies 
already detailed. 

Whenever the cellular membrane is involved in the disease, free incisions should be early 
made, as well to unload the vessels, and relieve the swelling and distension, as to give exit 
to the purulent fluid and dead portions of cellular structure.- The pus, if allowed to remain, 
will travel beneath the skin, and between the muscles and tendons, and thus increase the 
danger and extent of the disease. After the incision, the part should be covered with soft 
emollient poultices, and kept as much as possible at rest, and in an elevated position. 

When the erysipelas terminates in gangrene, washes of a solution of the chloride of lime, 
of the chloride of soda, of a few drops of creasote diffused in water, or of a strong decoc- 
tion of black-oak bark, should be immediately employed, or the sphacelated surface may be 
covered with the charcoal or yeast poultice. A wash of a very strong solution of the sul- 
phate of copper will in some cases arrest the progress of the gangrene. 

When convalescence has been established, some light mineral tonic or the mineral acids, 
largely diluted, should be administered. The child should be allowed a nourishing diet ; 
he should be daily immersed in a warm or tepid bath, and enjoy a dry, fresh, wholesome 
atmosph e re . — C . ] 

Very closely connected with erysipelas, and continually confounded with it, is ery- 
thema. It also consists in superficial redness of some portion of the skin ; but is not 
attended with inflammation of the areolar texture under the skin ; nor with vesica- 
tion ; nor, in general, with fever ; nor is it peculiar to the face and head. 

There are numerous varieties of erythema described by writers on cutaneous dis- 
orders, to whom J must refer you for an account of them. "Wiilan and Bateman ; 
Wilson ; Willis ; Rayer ; Alibert ; and Biett, as his practice and lessons are re- 
ported by two of his pupils. 

The only variety on which I am disposed to say a word, is one which is attended 
with more or less febrile disturbance. I mean what is called erythema nodosum'. 

This curious affection occurs much more often in young women than in any other 
persons ; som.etimes in feeble boys. The eruption is commonly preceded for a few 
days by indisposition, and some slight degree of fever. Then red elevated spots 
come out, on the fore part of the legs, and occasionally, but very rarely, on the arms. 
The redness appears in oval patches, of v/hich the long diameter is parallel to the 
axis of the limb. They are pretty large patches, an inch and half long, and an 
inch broad perhaps, and they evidently project and form bumps upon the anterior 
surface of the leg. From their look, you would suppose abscesses were about to 
form ; but after lasting a few days, the red colour fades, or rather changes to a blue, 
and the protuberances gradually subside. This eruption seems sometimes connected 
with disturbance of the menstrual functions. Rayer has seen it occur in connection 
with acute rheumatism. So have I. A patient of mine in the hospital was attacked 
with acute rheumatism of the joints immediately upon the cessation of erythema 
nodosum. In another this order was reversed. 

Now I am persuaded that, after an aperient, rest, the horizontal posture, and 



URTICARIA. 



1013 



quina, constitute the proper treatment of this affection. I had once a housemaid, in 
whom the disorder appeared, and was attended with unusually high fever, and much 
indisposition. I treated her, therefore, antiphlogistically ; i. e., I kept her on low 
diet, and gave purgatives ; but the disease went on. Fresh knots came out as the 
old ones faded. At length, T do not remember why, I prescribed some quina for 
her; and the improvement was immediate, and very striking. She relapsed, hov/- 
ever, once or twice, upon leaving off the bark ; but by persisting subsequently in 
its use for some days after she appeared to be well, a permanent cure was effected. 
Since that time — now ten or twelve years ago — I have seen a good many exam- 
ples of erythema nodosum, and I have treated them all alike ; viz., first with an 
aperient, and then with the sulphate of quina : and they have all rapidly got well. 
Probably they would have recovered nearly as soon under some other tonic treat- 
ment ; but I have been so well satisfied with this, since I began it, that I have felt 
no temptation to try any other. 

There is a rash which is w^ell known, and very tormenting, and therefore not 
without interest, although it is almost always without danger; I mean urticaria. It 
is arranged by CuUen among the exanthemata; but it does not properly belong to 
the group to which I would restrict that name, for it is not contagious, and it may 
happen to the same person a hundred times over. The eruption consists of what, 
from analogy, are called wheals ; i. e., of little solid eminences, of irregular outhne, 
but generally roundish or oblong, and either white or red, or (which is most common) 
both red and white ; the whiteness occupying steadily the central and most project- 
ing part of the spot, or becoming manifest there when the integuments are put upon 
the stretch. The rash is accompanied with intense heat, a burning and tinghng in 
the affected spots, and great itching and irritation. 

In truth, both the appearances upon the skin, and the sensations that attend them, 
are very much like the appearances and feelings produced by the stinging of nettles. 
Hence its trivial name, nettle-rash ; which is, indeed, the same in meaning with the 
scientific appellation, urtica being the Latin for a nettle. Similar appearances follow 
almost immediately upon a smart blow with a ca;ne, or with the lash of a whip, on 
the skin. Red stripes or wheals arise, and within the reddened surface one or more 
elevated spots of a white colour are visible. 

•'here are two varieties of urticaria : one in which the complaint runs a short 
f se, and soon subsides, and may be considered acute ; another in which it is 
CiJionic, and either persistent or intermittent. The acute form is attended with fever- 
ishness, which sometimes begins two or three days, but commonly not more than a 
few hours, before the eruption ; or the fever and the rash may commence together. 
In most cases, perhaps in all, the disorder is intimately linked with some derange- 
ment, manifest or latent, of the digestive organs ; and it may often be traced to the 
use of particular articles of food. It is very curious that the contact of certain sub- 
stances with the mucous membrane of the alimentary canal should affect the external 
tegument precisely in the same manner as the virus of the nettle, and some other 
irritants, when these are applied to the skin itself. The ofiending articles of food do 
not produce the cutaneous affection in all persons, nor even necessarily in the same 
person at all times. But there are some edible substances which are much more 
likely than others to be followed by nettle-rash. Certain vegetable matters are very 
apt to excite the disorder in some persons : oatmeal ; almonds, especially the bitter 
almonds; any bitter kernels; particular species of strawberries ; raw cucumbers; 
mushrooms. Some of the vegetable substances used in medicine are known to have 
frequently the same effect; capivi, for example; the cubebs pepper; valerian. 
Urticaria has been brought on by drinking porter, or, most probably, by some of the 
drugs with which our porter is sophisticated. These effects are not confined to vege- 
table substances. Sht*il-fish is a common source of nettle-rash. I have known it to 
be occasioned by prawns ; crabs, sometimes, have the same unpleasant consequence ; 
and, still more, muscles. An hour or two after some one of these substances has 
been swallowed, and perhaps much sooner, nausea is fek, and oppression about the 

4k2 



1014 



URTICARIA. 



epigastrium ; the patient becomes giddy, his face and head sometimes swell, his skin 
begins here and there to burn and tingle, and presently the eruption, as I have already 
described it, breaks forth. It is attended with intolerable itching and pricking sensa- 
tions, especially at night, when the patient is warm in bed, or when the affected sur- 
face is exposed to the air. Vomiting and diarrhoea often supervene, and prove the 
natural cure of the attack. 

We read that this disorder has sometimes proved fatal ; but this must be under 
very unusual circumstances of weakness in the patient, or of some peculiar virulence 
in the exciting cause. 

The chronic form of the complaint is apt to be very obstinate and teasing. It 
comes and goes, and comes again. The evening is one of its favourite periods. In 
those who are subject to it, the itching and the wheals are readily brought on by 
scratching or rubbing the surface. This is the urticaria evanida of Willan. Dr. 
Heberden had known persons afflicted in this way for ten years together. I have 
observed nettle-rash to occur in connection with sudden and violent paroxysms of 
dyspncsa, resembling asthma fits ; so that I could not help suspecting that the mucous 
membrane of the respiratory passages was irritated after the same fashion with the 
external skin. 

Even the chronic variety of urticaria is, in some instances at least, produced by 
certain ingesta : and the peccant substance may often be detected, and the tiresome 
malady be cured, by following the simple and judicious plan recommended by Wil- 
lan ; namely, that of instructing the patient to abstain, for a while, from all his cus- 
tomary articles of diet, one by one, in their turn. This experiment does not, indeed, 
always answer. The urticaria will sometimes abide, notwithstanding ; so that, 
although it probably depends in all cases upon some disordered condition of the sto- 
mach or bowels, we cannot say that such disorder is always the consequence of 
something that has been swallowed. 

The treatment to be adopted in the acute or febrile nettle-rash, when it depends 
upon something recently received into the stomach, is that which common sense 
would suggest, and which nature often plainly indicates. We seek to expel the 
offending material by an emietic, and by purgatives ; and, this being done, the cure 
is completed. In the more chronic and recurring varieties, we endeavour, in the first 
place, by making the experiment recommended by Dr. Willan, to detect, that we may 
thenceforth interdict, any article of diet which may have caused the disorder. If 
we fail in this attempt, our object must be to correct that faulty state of the digestive 
organs, or to neutrafize that inbred poison, upon which the cutaneous affection 
depends. Laxatives and antacids are found to be the most successful means of 
attaining these ends. They may be given together, or separately. Rhubarb and 
magnesia; the carbonate and sulphate of magnesia ; castor oil. The snake-root has 
obtained some repute as a remedy for urticaria. You may prescribe, therefore, if 
you please, a scruple each of the carbonates of magnesia and of soda, in the infusion 
of serpentaria. 

External apphcations seem to be of but little avail in this disease ; and those 
which do appear to be of service, act uncertainly, and produce different effects in 
different persons. The warm bath sometimes gives ease in the severer cases. In 
the more chronic form of the disorder, spirituous washes, vinegar, sea-bathing, are 
things to be tried. And cases are related in which, when every other expedient 
has failed to give permanent relief, removal to a warmer climate has been success- 
ful. Dusting the itching surface with flour has, in my experience, afforded much 
temporary comfort. Still more effectual, perhaps, is a lotion (first recommended by 
Wilkinson, in a little work on skin diseases), composed of a drachm of the carbonate 
of ammonia, a drachm of the acetate of lead, and eight ounces of rosewater. 

I should add, that Dr. Elliotson has found bleeding very efficacious in relieving 
patients affected with acute or febrile urticaria. And you may have recourse to the 
lancet if the patient be strong and plethoric, and his pulse warrant it ; and if he be 
so impatient of the irritation as not to be willing to wait the effect of other treatment, 
which would probably be quite as effectual, though not quite so rapid. 



PRURIGO. 



1015 



Prurigo — Itching — is a cutaneous affection, bearing some analogy to urticaria, at 
least in the sensations which accompany it. And a most terrible and melancholy 
affection it often proves to be. Sometimes the parts of the skin which are the seat 
of the itching do not present any perceptible deviation from the condition of health ; 
but in the majority of instances you will find, upon close inspection, that they are 
covered with papulse, which are nearly of the same colour with the skin itself. 
Willan therefore places prurigo in the order of Papulae. He describes several 
varieties of this troublesome complaint : prurigo mitis; prurigo formicans ; prurigo 
senilis. The torment experienced by patients suffering under the severer forms of 
the malady is scarcely describable ; they scratch and tear themselves incessantly till 
the blood flows, their sleep is broken, and their lives are rendered perfectly misera- 
ble. Sometimes this itching is diffused irregularly here and there over the surface ; 
sometimes it affects the extremities only ; and frequently it has a still more limited 
habitat, occurring round the anus, when it is called pmrigo podicis ; or on the scro- 
tum, prurigo scroti; or, worst form of all, the prurigo pudendi muliebris. 

All these forms of prurigo are apt to be aggravated by heat, and by exposure to 
the air; they are, therefore, especially distressing when the patient undresses and 
goes to bed. The scratching tears away the summits of the papulas, and some 
watery fluid mixed with blood escapes, and concretes into small, thin, black scabs. 
In the prurigo formicans, the itching is combined with other painful and disagreeable 
sensations, which different patients describe in different terms : the feeling is like 
the creeping of ants, or the slinging of insects, or as if hot needles were thrust into 
the skin. The prurigo senilis, occurring, as that name implies, in old persons, is 
usually very obstinate, and often effectually destroys all comfort for the rest of the 
patient's life. 

In such cases as I have now been mentioning, great care should be taken tho- 
roughly to cleanse the surface of the body : and the diet should be rigidly plain. All 
kinds of rich sauces, hot condiments, pickles, and indigestible substances, should be 
peremptorily forbidden. Various local applications have been praised ; but they are, 
in most cases, used in vain : hme water, decoction of dulcamara, lotions composed 
of prussic acid in an emulsion of bitter almonds, a dilute solution of creasote, decoc- 
tion of stavesacre, and of digitals, ointments containing mercury, tar ointment, and a 
hundred others. In one instance lately, where the ingenuity of another practitioner 
had been fruitlessly exhausted, I was fortunate enough to effect perfect relief by 
smearing the itching surface with an ointment containing a small quantity of aconi- 
tine. Of internal remedies, sarsaparilla, alkalies, arsenic, the iodide of potassium, 
dulcamara, are the most hopeful. When these means fail, opium is our best, and 
indeed our only resource. 

The local forms of prurigo are frequently connected with local disease, and are 
most likely to be reheved by measures directed against the primary disorder. Pru- 
rigo podicis is sometimes dependent on the presence of ascarides in the rectum. The 
same troublesome affection is not an uncommon symptom of internal piles : and it 
sometimes accompanies stone in the bladder. 

The prurigo pudendi muhebris — itching of the genitals in females — is sometimes 
so constant and tormenting, and the impulse to scratch the itching part so urgent, as 
to drive the unhappy patient from society. It even gives rise, in some severe cases, 
to nymphomania, it may proceed from leucorrhoea : it is frequently a sign of uterine 
disease. It most commonly affects women in whom the menstrual discharge has 
ceased to appear. 

[We have met with it just as frequently in the menstruating female as in those in whom 
the menses had. ceased : some females are troubled with it during pregnancy and at no other 
period. — C] ^ 

I have never had an opportunity of trying the aconitine in such cases. The local 
application which has been found most serviceable is the yellow loasA, which, as you 
probably know, is a solution of corrosive sublimate in lime water, in the proportion 
of a drachm lo a pint. 

[A saturated solution of borax will give, in many cases, very prompt relief; and by a per- 
severance in its use a permanent cure may often be effected. — C] 



1016 



SCABIES. 



You will sometimes be consulted — at least I have been, on more than one occa- 
sion — about itching of the pubes and scrotum, produced by the presence of the pe- 
diculi that are vulgarly called crab-lice. The patients are sometimes quite unaware 
of the cause of the itching. You may relieve them by the wash I have just men- 
tioned ; or, by a more elegant lotion, made by dissolving corrosive subhmate in a 
httle spirit, and adding rose water. A single washing with such a lotion will destroy 
the whole colony : and the vermin become much more visible after this violent death, 
turning black, and relaxing their hold upon the skin. 

Prurigo is a convenient generic name for these cutaneous affections, of which the 
prominent feature is the teasing sensation th^t accompanies them. But, besides all 
these, there is a specific disorder, which, from the intensity of that sensation, is em- 
phatically termed the itch, and which deserves a short notice ; for it is exceedingly 
common, and exceedingly distressing, and (what is more interesting still) it is easy 
of cure. It is one of the very few complaints for which we possess a-specific or 
infalhble remedy. 

Scabies, or the itch, is, as every body knows, contagious ; but it is contagious only 
in that particular sense which implies contact. It is not producible by any effluvia 
which the atmosphere can convey : it requires, for its propagation, that the healthy 
person should touch the diseased person, or some substance which has been in con- 
tact with his unhealthy skin. Certain parts of the skin are more liable to it than 
others. It is most common at the roots of the fingers and thumbs, between them as 
it were ; on the wrists ; between the toes ; in the flexures of the joints. It may 
spread to almost every part of the trunk or of the extremities ; but all observers 
agree in stating that it is seldom or never seen upon the face and head ; a curious 
but unaccountable exemption. 

The eruption is at first papular, and then vesicular, presenting a number of pointed 
watery heads. When the inflammation is aggravated by intemperate habits, or by 
the scratching from which the patient is unable to refrain, the vesicles are liable to 
be converted into pustules : and this has needlessly been made a separate species of 
itch, scabies purtdenta, pocky itch: you see large pustules, filled with a yellow viscid 
matter, standing on an inflamed base. If you are not aware of these varieties and 
changes, you may make unlucky errors of diagnosis; afTront your patient by telling 
him he has the itch when he has it not; or suffer him unconsciously to betray and 
shame himself by communicating it to others, when he has. You will easily under- 
stand how it has come to be considered a disgrace to have the itch : for it is fostered 
and propagated in most unfashionable places, amidst poverty, vulgarit)^ and fikh. 
Yet the most dehcate and high-bred lady may contract the distemper ; and when 
once it is contracted, it will go on indefinitely, through life, unless proper means are 
adopted for its cure. It never gets well if left to itself. 

One very curious point in this discreditable malady, is its connection with a pecu- 
har insect, called accordingly the acarus scabiei. The existence of this ectozoon had 
long been affirmed and denied ; but the vexed question has at length been set at rest 
by the public demonstration of the acarus, by a M. Renucci, to a number of medical 
practitioners in Paris. It has since been often detected and exhibited here. Dr. 
Nevinsonhas lately assured me that he furnished Shaw, the naturalist, Dr. WoUaston, 
and ^others, with living itch-mites, for examination, forty years ago. One reason, 
probably, why it has often been searched for in vain, is, that the acari are not equally 
numerous with the vesicles: there is not an insect for every vesicle. Another reason 
is, that persons have not known exactly where to look for the insect. It is not in the 
pustules or vesicles ; but near them ; at the extremity of a short, small, superficial 
tunnel or furrow which runs from them. A third reason why the insect had so long 
and so often escaped detection, is to be found in its minuteness. It is barely visible 
by the naked eye; but under the microscope it is seen to be a most formidable 
monster, in outline like a tortoise, and having eight legs. I show you here its por- 
trait ; not a little, but enormously magnified. I hope to procure for 3rou the privilege 
of seeing the creature itself. The first that I can catch I will ask Professor Jones 
to show you by means of his microscope. 



HERPES. 



1017 



I There is good reason for believing that this parasitic animal is, not merely a 
' casual companion, but the veritable cause, of scabies. Various attempts have been 
j made, and made in vain, to produce the disease by inoculation of the fluid from the 
vesicles. On the other hand, transportation of the acarus has always excited the 
j eruption. 

I These facts explain how it is that the itch, though readily communicable by direct 
j contact, or by fomites, is not communicable through the medium of the air ; that 
I fomites long retain the contagious property ; and that the disease is curable by what- 
ever destroys the acari. I believe that the complaint called the mange, in dogs, 
camels, and sheep, has the same, or a similar origin, 
i Now sulphur is as sure to cure the itch as quinia is to stop an ague. I presume 
! that it kills the acarus; but whatever maybe its modus operandi,! have never 
\ known it fail to remove true scabies. It is applied externally ; and the only objec- 
' tions to its use are its disagreeable smell, and the dirtiness that belongs to ointments : 
but these inconveniences are far outweighed by its certain efficacy. Although 
many substitutes for this substance have been recommended, I pretermit them all, 
I and advise you to employ the sulphur ointment, of which you may disguise the 
smell by the addition of a little bergamot, and the colour by intermixing a small 
quantity of vermihon. 

The ointment should be carefully rubbed all over the skin, at bed-time, and most 
especially on parts visibly affected with the eruption. The patient should sleep 
enveloped in a flannel dress. The rubbing should be repeated night and morning, 
and in two or three days the complaint will be subdued. Then, thorough ablution 
with soap and warm water, and the destruction of the contaminated clothes by fire, 
I will complete the purifying process. 



LECTURE XC. 

\ Herpes; Eczema; Pompholix ; Lepra; Psoriasis ; Impetigo ; Boils ; Carbuncle; 
Purpura ; Scurvy. Conclusion of the Course, 

! If you look at the lists of genera and species appended to the various works which 
I treat exclusively of cutaneous diseases, you will find that they are exceedingly 
i numerous. But these disorders differ widely in their relative importance ; and the 
j, principles upon which their remedial management proceeds are not so greatly diversi- 
fied as these "tables of contents" might lead you to suppose. I have spoken pretty 
i fully of the most serious and interesting of these maladies — I mean of the febrile ex- 
I anthemata ; but I have no time left for pursuing in detail the host of chronic affec- 
1 lions to which the human skin, is subject. Nor do I much regret this. To become 
! expert in the diagnosis of these blemishes, and in curing such as are curable by our 
I art, you must see them with your own eyes. Verbal descriptions of their changeful 
characters are of comparatively Httle service or Interest. They are among the things 
i| that require to be "oculis subjecta fidehbus." Even pictured representations convey 
I but an inadequate notion of the morbid appearances they are designed to portray. 
I The lecturer on skin diseases should have actual patients before him, to whose bodies 
' he could point. 

I In this, the final lecture of the course, I can do no more than offer you some very 
I cursory remarks upon some of the genera into which nosologists have distributed this 
I class of disorders ; and I may premise, that the treatment of the genus includes, for 
I the most part, that of the species. 

I Vesicles are, as you know, small transparent elevations formed by a drop of 
! aqueous fluid effused beneath the cuticle. Sometimes they are thinly scattered 
: over the surface; sometimes collected into clusters: sometimes situated on a red 
patch of skin ; sometimes quite free from redness. The whole crop comes out at 
once in some cases ; in others the vesicles appear in irregular succession. They 



1018 



HERPES. 



terminate also in various ways : by the reabsorption of the liquid, and slight desqua- 
mation ; by the giving way of the cuticle, and the formation of httle scabs, under 
which new cuticle is generated ; and sometimes, though rarely, by ulceration. 

Of the vesicular class of cutaneous disorders I have already described the three 
most important; namely, cow-pox, chicken-pox, and the itch. 

Another not uninteresting genus of this class is herpes. This is a transient non- 
contagious eruption, consisting of red patches of irregular form and variable size, 
upon each of which stands a crop of vesicles. The eruption runs a definite course ; 
and its several periods — its beginning, its increase, its acme, and its dechne — are 
completed, when its progress is not interfered with, in about ten days. These cha- 
racters, once known, are easily recognized : and it is of importance that you should 
recognize them. Not that the disorder itself is of any great moment; nor that it is at 
all under the influence of remedies ; but because it may be confounded with some 
graver malady. For example, Herpes prscputialis is a very common and a yqt^ 
trifling species, affecting the foreskin ; but it might readily be mistaken for the result 
of the poison of syphilis, and so cause much alarm and distress to the subject of it, 
and entail upon him perhaps a needless course of mercury, and bring unmerited 
suspicion upon the person with whom, whether lawfully or unlawfully, he might 
have been connected. . It has nothing whatever to do with sexual intercourse ; and 
it requires no treatment beyond cold ablution, and the interposition of a piece of lint 
between the prepuce and the glans penis. In like manner another species. Herpes 
circinaius, the vesicular ringworm, is liable, when it appears upon the hairy scalp, 
to be mistaken for that pest of schools and of school-boys, the favus confertus, or 
porrigo scutulata of Willan, the common scald-head ; a complaint which is naturally- 
shunned as filthy, stubborn, and contagious. Herpes iris is a mere curiosity. In 
this species each group of vesicles is surrounded by four concentric erythematous 
rings, of different shades of colour. The rings form and fade in succession, one after 
another, by a slight extension of the inflammation each time. The spots constituting 
the eruption have been likened to small parti-coloured cockades. But the most 
singular species of all is the Herpes zoster, in which the separate patches, lie in the 
direction of a band that encircles half the circumference of the body. Hence its 
names, zoster, zona, zona ignea, and in our vernacular tongue, the shingles ; and 
even this Dr. Johnson derives from the Latin, cingulum, a girdle. 

Most commonly the zone is confined to the trunk of the body, has a somewhat 
oblique direction like a sword belt, and occupies exactly one-half of the circle, lying 
between the linea alba and the spine on one side only. Sometimes, however, it ex- 
tends from the trunks to the limbs. Thus it may begin in the loins, pass obliquely 
across the flank, and terminate at the inner part of the thigh. Or it may commence 
from the upper part of the spine, cross the shoulder, and end on the arm or forearm. 
In the year 18*33 I saw a lady affected with this strange eruption, in whom the clus- 
ters of vesicles began near the spine in the neck, passed over the scapula, then to 
the shoulder and axilla, whence the main line ran along the outer side of the upper 
arm till it reached the elbow, where it turned inwards, follov/ed the inner side of the 
forearm, went across the palm of the hand, and terminated by two or ihree patches 
upon the palmar and inner side of the ring finger. Very rarely indeed it appears on 
the limbs only. Once I have seen it limited to the thigh and leg, where it corre- 
sponded to the course of the sciatic nerve. Once I have known it spread from the 
neck, behind, up to the hairy scalp. The most common situation of the demi-cinc- 
ture is across the base of the thorax. It is a curious feature of this curious disorder, 
that, in nineteen cases out of twenty, according to Biett, it occupies the right half of 
the body. Of this singular preference of the right side, if indeed it be a general fact, 
I can give you no explanation. I have seen some fifteen cases of the complaint 
since I began to attend to that circumstance, and in ten of these the eruptioli was on 
the right side. Rayer, in the first edition of his book, said that eight cases in ten 
would be found to be on that side ; but a longer experience has reduced that propor- 
tion. Of fifty-three examples seen by himself, thirty-seven only were on the right, 
and sixteen on the left. Reil states that he has always observed it on the left half 
of the body; and Mehlis, among twenty -five patients, counted sixteen in whom the 



i ECZEMA. 1019 

! 

: left side was affected. This statistical point remains^ therefore, to be settled, if it be 
fi worth settling, by a larger induction of particular cases. The zone seldom trans- 
|! gresses the median line at either extremity, unless perhaps the redness of the 
1 1 extreme patches may extend a few lines further. It is said, however, in some ex- 
jj ceedingiy rare instances, to complete the circuit of the body. There is a vulgar but 
i erroneous notion, that the eruption proves fatal when it thus surrounds the whole of 
I the trunk ; and this notion is as old as the time of Pliny, who says, " Zoster appella- 
I' tur, et enecat si cinxerit." 

i ! The most important, because the most distressful, of the symptoms, is an intense 
'i darting pain, described by the patients as being deep-seated, very acute, and shooting 
(j through the chest. Fortunately, however, this is by no means a common incident. 
ij I have met with it in two or three cases only. Sometimes the pain precedes the 
, eruption ; more often it accompanies it ; and it is apt to last, in spite of remedies, for 
I some time after the eruption has disappeared. Mr. North tells me that, in a female 
1 patient of his, this pain continued to be severe and intractable for eighteen weeks. 
That this is a rare complication of the disorder we gather from the experience of 
M. Biett, who never once witnessed this symptom in more than 500 cases of shingles. 
The severe and intermitting character of the pain, and the peculiar direction of the 
I row of herpetic patches, lead to the behef that the whole malady may arise from some 
I fault in the nervous system. Of its causes we have no certain knowledge. It is 
) said to attack young persons more especially, and those who have fine and dehcate 
i skins, and the male more frequently than the female sex. But I suspect that 
i these assertions rest on a very loose foundation. Of the fifteen cases already men- 
tioned, ten occurred in females. One of the patients was a child two years and seven 
months gld ; another was an aged man of about seventy-five. In several instances I 
have found, upon inquiry, that the patients, being children, were in the nightly habit 
of wetting their beds. Whether this has been anything more than a casual coinci- 
dence, I do not know ; but my attention was first directed that way, some years ago, 
' by Mr. Wheeler, the apothecary at St. Bartholomew's Hospital, who told me that he 
j had often noticed the same circumstance. According to Bateman, the disorder 
"seems occasionally to arise from exposure to cold after violent exercise. Sometimes 
it has appeared critical, when supervening on bowel complaints. Like erysipelas, it 
has been ascribed by some authors to paroxysms of anger." Schwartz saw three 
cases which followed violent fits of passion ; and Plenck affirms that he had known 
it occur twice after furious anger— and a copious potation of beer. 

The duration of the eruption is from ten days to a fortnight; but it is hable to be 
considerably prolonged by troublesome ulceration, whenever the vesicles and crusts 
are prematurely chafed off by friction or pressure. 

Very little, as you must perceive, can be done, or is reqilisite in the way of treat- 
ment. The patient is to be cautioned against rubbing off the heads of the vesicles. 
Attention should of course be paid to the state of the stomach and bowels ; and the 
1 diet should be regulated. Our main business is to look on, and to endeavour to set 
f right whatever may be manifestly wrong. 

Should the eruption be attended or followed by the intense shooting pain which 
sometimes, but not often, harasses the patient, it will be right to apply opiates, by 
friction, over the affected region. I would use the aconitine ointment in such a case. 
Warm baths will also be proper : and as the pain is probably neuralgic, the carbonate 
j of iron is a remedy which ought to be tried. 

j Eczema is another genus of the vesicular class of diseases. It is characterized, 
j in its commencement, by an eruption of very minute vesicles, scarcely prominent, 
closely crowded together, and requiring a microscope sometimes to render them 
distinctly visible. They terminate either by the re-absorption of the fluid they 
contained, or by the formation of superficial moist excoriations. Eczema is not 
I contagious. 

There are several species or varieties of this form of cutaneous disorder also. It 
is sometimes produced by great heat, and particularly by the heat of the sun ; and 
this is named eczema solare, heat-spot : sometimes by the contact of irritating sub' 

I 

j 

1 



1020 



ECZEMA. 



stances with the skin, as in whjt is vulgarly called the grocer's itch, affecting the 
hands of those who are much conversant with sugar. Eczema often occurs upon the 
scalp, and constitutes, I believe, the most frequent form of what is commonly named 
scald-head, porrigo, or tinea capitis. But the most severe of all its species is that 
which has received the name Hydrargyrum, Erythema merciiriale, and Eczema 
rubrum merciiriale. This, as these names imply, is an occasional consequence of 
mercury ; an unusual consequence, no doubt, and one that happens only in a few 
pecuhar constitutions ; but you ought to know it, in case it should follow the use of 
mercury prescribed by yourselves. 

The eruption begins usually in the groins and upon the thighs. It is at first red, 
and is accompanied by much heat and itching. It soon extends, in the severer cases, 
over the whole body ; and an innumerable multitude of very minute glittering vesi- 
cles may be seen, with the aid of a magnifying glass, from the beginning. Like that 
of erysipelas, the eruption is attended with a good deal of swelling. The intumes- 
cence of the face is such as to close up the eyes : and the disorder becomes febrile, 
in its course ; for there is seldom much fever at the onset. The vesicles increase ia 
size, turn milky, burst, and pour forth an acrid exudation, that irritates and inflames 
the skin with which it comes in contact, and thus increases the local complaint. The 
distress and worry occasioned to the patient by the fetid smell of the discharge, by 
the stiffening which it causes of his body-hnen, and by the heat and itching, are, I 
conceive, the main causes of the febrile disturbance. The discharged matter is apt 
to become thick and hard, and to present the appearance of large scabs : and in this 
state the nature of the disease may very easily be understood, it being impossible to 
say, when it is seen for the first time under these circumstances, whether it was 
originally vesicular or not. 

The duration of this harassing distemper is variable. It may be over in a fort- 
night, or it may last several weeks. It terminates by the cessation of the discharge, 
and then the cuticle detaches itself in large flakes. Sometimes in this disease also 
the epidermis falls entire from the hand, like a glove. 

Without being dangerous to hfe, this disorder is apt to be obstinate. It is not 
much within the control of remedies. What little can be done is chiefly palhative. 
The mildest local applications must be used : tepid water, barley-water, strained 
gruel. The w^arm bath, when circumstances permit. Poultices are sometimes of 
much service, in preventing the hardening of the matter that exudes, and so obvi- 
ating one source of irritation. Flour, or powdered charcoal, may be sprinkled over 
the eruption in the slighter and early cases, for the purpose of absorbing the dis- 
charge. Equal parts of olive-oil and lime-water make a soothing liniment, which 
may be applied by means of a feather. The local remedies may fairly be varied, 
for sometimes one, and Sometimes another, is found to give relief. The patient's 
linen must be frequently changed, especially whenever it becomes stiff and hard with 
the exudation. 

With respect to the general treatment, opiates to procure rest, and to allay irrita- 
tion, are probably indispensable. The bowels must be kept moderately open, but 
no severe purging should be employed, for the patient must at all events undergo a 
long and weakening process, and therefore it must be our care that the treatment be 
as httle weakening as possible. In protracted cases, where there is much exhaustion, 
wine may with propriety be given ; and, almost always, good strong broths. As the 
disorder declines, some of the reputed tonics may be prescribed ; the mineral acids, 
quina, sarsaparilla. 

T need not say that, in such cases, you must be scrupulous in seeing that no more 
mercury is administered or apphed. 

A separate class of cutaneous diseases, very analogous, however, to that which we 
have been describing, is the class of bullae, or blebs. Anatomically speaking, there 
IS but little difference between the two : bullx are large vesicles. When the erup- 
tion is at its height, it is composed of hemispherical prominences of various sizes, 
from that of a pea to that of a hen's egg, and having the shape and appearance of 
the bubbles raised in a pool of water by a hard shower of rain. They are formed 



POMPHOLIX. 



1021 



by the effusion of a serous, or a sero-puriform fluid, between the true skin and the 
cuticle. You can only be sure of the diagnosis when you see the eruption in this 
stage of its progress. 

The best example of this class is that which is called by some writers Pemphigus, 
by others Pompholix. 

It is characterized by the presence of bullae, varying in their magnitude, commonly 
distinct, but numerous, springing up in successive crops, on one or more parts of the 
surface. At first these bullse are nearly transparent, and contain a thin Hmpid serum ; 
but they become gradually opaque, pearl-coloured, and ultimately many of them 
acquire a reddish tinge. 

Pemphigus has been described as being sometimes acute, sometimes chronic. 
The acute form is attended with smart fever, the bullse rise spontaneously or in 
quick succession, run their course, and disappear; and then the disease is over. 
This is a very rare form. In general the bullas continue to come out ; the complaint 
is spread over weeks, or months, or years ; and it is accompanied by httle or no 
febrile reaction. This, on the other hand, is a common form of disease. It is the 
Pompholix diutinus of Willan andBateman. The eruption often occupies all parts 
of the body at the same time, or in succession ; in other cases it is confined to a 
limited space. I have most frequently seen it on the forearms and legs. When the 
bullae are very numerous, they may give rise to some febrile symptoms, but not else. 
The complaint may be indefinitely prolonged by successive crops. 

The eruption begins in small red points, the formation of which is attended with, 
a slight pricking sensation. Some patients have likened this sensation to that whicii 
accompanies the passage of the electric spark. In the centre of each of these spots, 
the cuticle becomes hfted, while the circumference of the spot enlarges, so that bullse 
are rapidly formed, often in the space of a few hours only, as big as a hazelnut, or a 
walnut : or the blebs may even be much greater than that. Either in consequence 
of their distension, or of the pressure made upon them by the movements of the 
patient, some of these bullse burst, and a straw-coloured serum exudes. Then the 
epidermis collapses into folds and wrinkles ; or if it be detached at a part of the 
margin of the bulla, it is rolled back, so as to expose a portion of the red, painful, 
and smarting surface beneath it. Towards the third or fourth day, when the bullse 
lose their transparency, and the liquid they contain becomes reddish, those bullae 
which have not been broken sink down and wither ; the cuticle is no longer stretched ; 
but, sodden by the serous fluid, it assumes a whitish hue, becomes opaque, and forms 
at length small brownish flat crusts, of no great thickness. 

In the meantime fresh bullse appear by the side of the former ones, and pursue 
the same course ; so that generally you may see, in the same person, tense bullse con- 
taining a transparent and yellowish serum ; thin crusts ; and irregular patches of 
various size, slightly excoriated. 

This is the ordinary course of chronic pemphigus : and I say it may thus go on 
for months or years. 

The disease is most frequently observed in persons of debilitated habits. It is 
sometimes apparently the result of intemperance ; or of the use of bad or insufficient 
food. In Biett's experience it has often been coincident with the fatty Kver. When 
the disorder is chronic and uncomplicated, the treatment found useful is such as we 
might expect benefit from, knowing the constitutions in which the disease is most 
apt to occur, and the causes which seem at least to favour its occurrence, if they do 
not produce it : regulation of the bowels ; good nourishing food ; tonic medicines, 
bitters, and especially quina and the mineral acids. Biett describes this kind of 
treatment to have been very successful in St. Louis ; and that not only in old and 
worn-out subjects, but also in the young, especially when the complaint has been 
chronic. Bateman recommends the same general plan. 

Local applications have seldom been much employed, except some mild ointment 
to the excoriated parts. Biett advises emollient lotions, or even opiate washes when 
much irritation exists ; but a case recorded in the Medical Gazette, by Dr. Graves, 
of Dublin, affords a remarkable instance of a cure by local applications alone : and 

4l 



1022 



LEPRA. 



it is a case worth recollecting, although, as he justly remarks, we ought not to gene- 
rahze from a single instance. 

His patient was a boy, fourteen years old, of slender frame and delicate consti- j 
tution, yet enjoying uninterrupted health, except the cutaneous disease, which had ! 
lasted five years. During that time the succession of bullae had seldom ceased. The j 
bullae were very numerous, occupying not merely the face and extremities, but the | 
trunk also ; and they were in various stages of their progress, some healing after ; 
having burst, some of a larger size and unbroken, others small, and recent. I 

Dr. Graves observes, that from the descriptions of Bateman, and of Biett, although j 
both authors describe it correctly, we should scarcely form a notion of the occasional I 
severity of this disorder. He had seen two examples of it in young men, where the j 
irritation and suffering produced by the constant exposure of large portions of skin | 
denuded of epidermis, had operated most unfavourably on the general health, almost 
banishing sleep, and reducing the patients to a state of great debility. These cases j 
did not yield to the method of treatment recommended by authors ; and, therefore, | 
Dr. Graves determined, whenever another opportunity should occur, to have recourse ' 
to a new plan. I 

In the boy in question, therefore, he had all the bullae opened with a lancet, and ' 
the denuded surface of the corium was then touched with a stick of lunar caustic. I 
The nitrate of silver was also apphed to the skin around each bullae, for the breadth | 
of a line ; and the recent pimples, which indicated the formation of a future bulla, 
were all treated in the same way. The boy was then washed, and supphed with 
clean linen. 

This single apphcation of the nitrate of silver had not merely the effect of entirely 
destroying the morbid action in the portions of the skin which were at the time 
affected, but (what was very remarkable) no fresh bullae made their appearance after- 
wards : none at least had appeared for four months, when he wrote his account. The 
only part where a repetition of the process was required, was the palm of the hand, 
where the thickness of the cuticle rendered it more difficult to expose the diseased 
surface of the cutis to the full action of the caustic. 

It might strike you from this cure of a long standing disorder, so readily, by mere 
local means, that the disease propagated itself from one part of the surface to another, 
by a sort of re-inoculation. But it has been fully proved that the disease is not con- 
tagious. A Mr. Gaitskill engrafted himself, with impunity, with the fluid ; and i 
analyzed it, and found it apparently Hke the thin serum of hydrocephalus. Dr. | 
Graves, therefore, supposes that the cure was owing to the simukaneous destruction } 
of all the parts of the skin that were in a state of morbid action : a morbid action 
which would have been otherwise propagated to other portions of the surface, by I 
what is called the sympathy of continuity. 

The class of scaly eruptions — the squamx — is distinguished by the occurrence of j 
red spots or blotches, upon which lamina of altered cuticle form, and are thrown off, i 
and constantly renewed. You will perceive that, anatomically, this class of cutaneous ' 
disorders has a close analogy with the rashes ; and yet it is separated from them by j 
very obvious particulars. In the exanthemata of Willan and Bateman, the redness I 
is followed by desquamation ; in the squamae these two appearances co-exist : in the \ 
exanthemata the sequence of redness and desquamation takes place, in general, once 
only: in the squamae the morbid cuticle continues for an indefinite time to scale oft 
again and again, in successive fragments, from the abiding red patch of skin. 

Lepra, psoriasis, and ptyriasis, and some syphihtic eruptions, constitute the prin- 
cipal of the squamous affections. 

Lepra is a very common disorder of this class ; hence its name, lepra vulgaris. 
It consists in red scaly patches, of various dimensions, but always affecting a circular 
or elliptical shape, and scattered over different parts of the body. It commonly 
begins on the Hmbs, most usually near the joints ; just below the knees, or the 
elbows ; and Dr. William Budd has pointed out the curious fact that these patches, 
especially when they are few, and the disease is recent, are distributed sym.metrically, j 
each spot on the one limb answering in situation to a similar spot on the fellow Hmb. | 



PSORIASIS. 



1023 



This shows that the disease is a blood disease ; that it depends upon some poison, 
introduced from without, or, more probably, bled within the body. By degrees the 
patches both enlarge in size, and multiply in number, and extend along the extre- 
mities to the trunk. The eruption is seldom seen upon the hairy scalp, or upon the 
hands. As the patches enlarge they sometimes become confluent ; but even then, 
the outline of the confluent scaly space is defined by arcs of circles, and the disorder 
is sufficiently distinguishable from psoriasis. It is not easy to set these things 
before you in mere verbal description. To have seen lepra once, is to know it for 
ever. 

When the patches begin to get well, the restoration of the altered surface to its 
natural condition and appearance commences in the centre — i. e., in the spot first 
affected — and proceeds outwardly towards the circumference: so that the scaly 
redness assumes a ring-hke arrangement. This ring becomes gradually narrower and 
narrower; at length its continuity is here and there broken ; and at last it vanishes 
entirely. 

The eruption does not, however, run any definite course. Sometimes it goes 
rapidly through its phases ; in other cases it persists for a very long period. It is 
not at all contagious. 

Neither is lepra attended, in general, with much local inconvenience, nor with 
much constitutional disturbance. When the eruption is very copious and extensive, 
and especially when it is plentiful or almost continuous around the larger joints, it 
renders the movements of the limbs stiff' and difficult ; and even sometimes painful, 
from the cracking of the inflamed surface as it is stretched in the bending of the 
joint. 

But I have seldom found the lepra to exist unconnected with some disorder of the 
digestive organs. Usually the connection is that of alternation, and not of co^existence. 
The patient is dyspeptic till the eruption comes out, and then the dyspepsia is re- 
lieved : and it often returns as the leprous patches disappear. The eruption is the 
more unsightly : the dyspepsia is the more troublesome. This alternation would 
seem to mark the shifting location of the matereis morbi. 

When the patches are small, and chronic, and white, that variety is no longer 
called lepro vulgaris, but lepro alphoides ; and there certainly is another distinct 
variety, of a more blue, or Hvid, or copper colour than the ordinary ; and a result of 
the poison of syphilis. It is named accordingly syphilitic lepra. This species will 
get well under the influence of mercury ; which, so far as my observations go, does 
not cure the others. 

Psoriasis is closely allied to lepra. When it occurs in distinct patches it is often 
difficult to say to which genus the eruption belongs. In general the patches of 
psoriasis are not so broad as those of lepra ; their edges are less raised, and their 
centres less depressed ; the scales adhere more firmly ; and the patches are less uni- 
form and less circular. 

But psoriasis frequently spreads itself over large portions of the skin, and it may 
come to occupy nearly the whole surface of the body. It is then called psoriasis 
diffusa. It often renders the patient hideous to look at. The scaly incrustation is 
interspersed with chaps, furrowing the skin in all directions, and following parti- 
cularly its natural folds and angles. These cracks, when the skin is put upon the 
stretch by the movements of the patient, are apt to bleed. In these severer cases 
(which are said to be examples of psoriasis inveterata), the laminse of altered cuticle 
are thick, and very abundant. They fall off' perpetually, or are rubbed off', and may 
be shaken from the patient's clothes, or collected in handfuls from his bed. 

Both these scaly disorders, lepra and psoriasis, require the same kind of treatment. 
I believe that external apphcations are of but little use. I have tried a good many, 
and have lost all confidence in them, with the exception of the warm bath. What- 
ever tends to improve the general health, will hasten the departure of these eruptions. 
I beheve that they sometimes depend upon the presence, or the generation, of an 
excess of acid in the system ; and that they are often to be cured by alkaline reme- 
dies I am sure. I have seen many cases of psoriasis rapidly improve, and get ulti- 
mately well, under full doses of the liquor potassas ; from half a drachm to a tirachm, 



1024 IMPETIGO — BOILS. 

three or four times daily, in a glass of milk, or of water, or of beer. Another inter- , 
nal remedy from which 1 have seen manifest improvement result, is arsenic ; given | 
with the cautions, and in the doses, which I have more than once spoken of. These j 
are the two remedies of which I have the most experience ; but neither of them is I 
infallible ; and you will haA'^e to try many things in succession, for patients are very | 
desirous of getting rid c/f the disfiguring eruption, even when it does not interfere 
with their health or comfort. Now the Harrowgate waters, a strong decoction of 
dulcamara, pitch-pills (and if pitch-pills, I should suppose d fortiori creasote), | 
tincture of cantharides, and the iodide of potassium, are remedies of some renown for ■ 
these scaly diseases. Of the syphihtic lepra I repeat that mercury will prove a cure. 
In all cases the diet must be regulated, and all kinds of stimulating food abstained 
from. Dr. Ealeman knew a man who was always attacked with lepra if he took , 
spices with his food, or drank ardent spirits : and a patient of my own got rid of long- i 
standing and very troublesome psoriasis of the scrotum, upon adopting, for other 
reasons, a very abstemious and simple mode of hving. 

Among the pustular diseases of the skin there is one which assumes many forms, , 
and is termed impetigo. Whatever may be the minuter pecuharities of this erup- ' 
tion, its general characters are the following. It consists of crops of pustules, some- I 
times scattered irregularly, sometimes collected into groups. The pustules burst, or 
are broken, dry up, and scab over. The crusts are yellowish, and very friable, and 
resemble in appearance little masses of candied honey ; or sometimes they look like 
small pieces of dirty plaster. From beneath these crusts a considerable discharge 
continues to take place ; the crusts becom^e thicker and larger, and around the mar- 
gins the skin is red and raw, as it is also beneath them. 

We have, I say, various forms of this complaint ; impetigo Jigiirata, impetigo 
sparsa, &c. It often borders closely on eczema, so that authors describe an eczema 
impeti^inodes, or an impetigo eczematodes. These varieties are dehneated by 
Rayer, by Willan, and Bateman, and by others ; and knowing their character?, you 
can examine and study their appearances for yourselves. Impetigo is a non-conta- 
gious disorder. 

Sometimes this complaint occurs in an acute form, and is attended with fever. In 
such cases its removal will be accelerated by bleeding the patient ; and the blood | 
drawn will be found to present the buffy coat. Whatever local applications are | 
made should not be unctious. It is seldom that impetigo will bear, or be the better j 
for, ointments. Purgatives and alkalies internally, and a very weak spirit or alka- j 
hne lotions externally, with a scrupulous diet, constitute, I beheve, its best treatment. 
When the complaint is chronic, and the discharge copious, the oxide of zinc has : 
often a very beneficial effect. It may be dusted over the afl^ected surface, from a | 
thin muslin bag ; or it may be applied in the shape of a lotion — fifteen grains to an ' 
ounce of rose-water. You will find this a most useful lotion for that disfiguring im- 
petiginous eruption which sometimes covers the faces of children like a mask, and 
is called crusta lactea. The phrase crusta lactea is, however, very loosely employed , 
by medical men. ! 

There is a very common, and a very teasing pustular disease of the skin, usually 
called a boil, in some parts of England a. push, and by the learned furwiculus. 

First, there is a slight degree and extent of hardness to be felt, a tender knot, just 
beneath the surface, which soon begins to look red, and a small swelling arises, which 
gradually increases up to a certain size, that of a large pea, or of a hazelnut, or of a 
walnut. T^e tumour is painful, and undergoes a process of slow suppuration. 
Some time from the fourth to the eighth day it acquires a conical or pointed form, 
and its apex becomes of a white or yellow colour. At last the cuticle gives way, 
and the patient begins to congratulate himself that the little abscess is ripe, and that 
his troubles are nearly over. But he is disappointed ; an insignificant quantity of 
pus mixed with blood escapes, and leaves visii)le a mass of dead areolar tissue — a 
core as it is called — of greater diameter than the opening, which is commonly small. , 
At last,* two or three days perhaps after this, the slough is expelled, in company with | 



I 



CARBUNCLE — PURPURA. 



1025 



more pus, and a deep cup-like cavity remains, which soon, however, fills up, and 
the boil is really over. 

These little phlegmons frequent the buttocks, the thighs, the arm-pits, the nape of 
the neck, the abdomen. They may occur almost anywhere. They are apt to come 
in crops, or in a series : and any kind of irritation suffices to cause them when a 
constitutional tendency to their formation exists. I have known a piece of soap- 
plaster apphed to the skin give occasion to a long succession of boils. Poukices, 
applied to promote the suppuration of any existing furunculus, are believed to en- 
courage, by their warmth, the growth of others around it. In truth, these phlegmons 
belong primarily and essentially to the subcutaneous areolar tissue rather than to the 
skin. Dr. Prout corroborates the statement of Cheselden that they are often accom- 
panied by a saccharine condition of the urine. You know probably that, in Dr. 
Prout's theory of assimilation, the areolar tissue represents the saccharine aliment. 

The individual boils are intractable ; the state of the system which engenders them 
may perhaps be corrected. Some dab them, when nascent, with a solution of cor- 
rosive sublimate in spirit ; some support them with sticking plaster ; others apply 
poukices ; and others again cut the hard tumour through while it is yet crude. Do 
what you will, you can seldom prevent or accelerate their deliberate course ; but I 
believe that by applying leeches, or cold, you may prolong, though you cannot ar- 
rest, that course. 

Sarsaparilla, and the liquor potassse, and where the system is below par, the sul- 
phate of quina and a generous diet, are found useful. Sugar, and saccharine food 
of all kinds, should be scrupulously avoided. 

Carbuncle, alias anthrax, is a gigantic boil ; but it is far more serious than the 
common furuncle, not only in respect to its magnitude, and to the amount of suffer- 
ing which it occasions, but also on account of the constitutional vice that it betokens. 
A carbuncle is a large, flat, circumscribed, very hard, and very painful tumour, of a 
purplish red colour, and attended with a sensation of burning heat. Its ultimate 
diameter may be three or four inches, or more. It ends in the formation of a deep 
slough, of more than corresponding dimensions, and the destruction of the skin above 
it. A number of pinhole openings at length present themselves on the dark red 
surface, and disclose the immense core beneath. 

This serious complaint occurs chiefly in advanced hfe, in corpulent males, and in 
persons who have hved fully. It is frequently attended with diabetes. The tumour 
is more often situated upon the nape of the neck, or between the shoulders, than 
elsewhere. It produces high constitutional disturbance and irritation. Surgeons 
are in the habit of dividing the firm mass into quarters, by deep crucial incisions. 
This is a sharp remedy, but it purchases speedy ease by removing that tension of 
the inflamed parts whereupon the pain chiefly depends. I am persuaded, however, 
that this severe operation is done too indiscriminately. If the tension be not mani- 
fest, and there is not much complaint of pain, you had better, in my opinion, leave 
these tumours to the care of nature, and address your remedies to the system at large. 
Support is often needed ; and opiates are sometimes indispensable ; and the bowels 
must be kept clear by purgatives. 

I shall not attempt to discuss, even in this cursory and disjointed manner, any 
more of the inflammatory affections of the skin, whether acute or chronic : but I 
wish, before I conclude, to direct your attention to a peculiar morbid condition, of 
much greater interest and consequence than most of those which I have just been 
describing. I mean the malady which is best known by the appellation of purpura, 
or the purples, and which usually, though it must be confessed very incorrectly, 
is ranked among cutaneous disorders. It is strictly a hemorrhage. Its external 
phenomena are so obvious, and so well known, that I need not dwell upon them. 
Small round spots appear on various parts of the surface, generally upon the legs 
first and most plentifully, of a dull red, or of a deep purple colour. They are accom- 
panied by no local pain, by no sensation of any kind. Pressure upon them does 
not efface the colour, nor render it fainter, as it does that of inflammatory spots of the 
skin. There is scarcely ever any prominence of the purple stigmata ; but they are 
sometimes intermixed with livid blotches, with appearances exactly resembling 
65 4l2 



102Q 



SCtTRVY. 



bruises ; and both the circular spots and the ill-defined vibices undergo, before they 
disappear, the same changes of colour, from red to a greenish yellow, which a bruise 
undergoes. In fact the anatomical condition of a bruise is exactly the same with the 
condition of the diffused hvid blotches of purpura. In each case the colour is the 
result of ecchymosis. With all this, passive hemorrhages from various parts, and 
particularly from the mucous membranes, are common. 

It is clear, therefore, that this complaint cannot be regarded as a cutaneous com- 
plaint, even in the loose sense in which that epithet is sometimes applied to affec- 
tions that are really beneath the skin, but visible through it. The hemorrhage 
takes the form of red or purple spots when the quantity of blood extravasated in 
the same place is only a drop. And the spots are not peculiar to the skin, nor to 
the subcutaneous tissues, bat are found, occasionally, upon all the internal surfaces 
also, and within the substance of the several viscera. I have seen these purple 
spots on the mucous surface of the mouth, the throat, the stomach, and the intes- 
tines, on the pleurae and pericardium in the chest, on the peritoneal investment of the 
abdominal organs, in the substance of the muscles, and even upon the membranes 
of the brain, and in the sheaths of the larger nerves ; and I have known them to 
be accompanied with large extravasations of blood in most of the vital organs of 
the body. 

The superficial markings of purpura, the red and purple spots and livid blotches, 
exactly resemble the spots and bruise-like stains which characterize sea-scurvy ; 
and I confess that I formerly regarded the two affections as being identical, or as 
mere varieties of the same disorder. But it is not so. For a very full and inte- 
resting account of scurv}^ I must refer you to an essay, by Dr. Budd, in the 
Library of Practical Medicine. He has there collected from various sources, and 
exhibited in a clear hght, convincing evidence that scurvy is caused — neither by con- 
tagion, nor by cold weather, nor by impurity of the air, nor by the continued use of 
salt provisions, all of which have been alleged as sources of the disease, but — by the 
privation, for a considerable length of time, of fresh succulent vegetables. Now 
purpura often makes its appearance when there has been no deficiency of such food, 
and no remarkable abstinence from it. Scurvy is most common in winter, or the 
beginning of spring ; purpura in the fruit seasons, in summer and autumn. In 
scurvy the gums are uniformly soft, and swelled, and spongy, and bleed readily ; 
this is no necessary feature in purpura. Scurvy is marked by extreme debility and 
dejection of spirits ; it is always rendered worse by blood-letting and by mercury ; 
and it is infallibly and rapidly cured by the administration of lemon-juice, or of 
other fresh fruits and vegetables. Purpura, on the other hand, often requires vene- 
section for its cure ; is not constantly nor surely, if ever, benefited by the anti-scor- 
butic juices ; is not always attended by sponginess of the gums, nor by feebleness 
of the mind and body ; and I have seen it clear speedily away upon the superven- 
tion of mercurial salivation and hypercatharsis. 

Lemon-juice is really a specific against scurvy, whether it be employed as a pre- 
ventive or as a remedy. It supphes something to the blood which is essential to its 
healthy properties. Its virtues were known in this country full two hundred years 
ago, as appears by the work entitled The Surgeon's Mate, or Military and Domes- 
tic Medicine, by John Woodall, iVIaster in Surgery: London, 1636. But the merit 
of making the fact generally known, and of procuring the systematic introduction of 
lemon-juice into nautical diet, by an order from the Admiralty, is due to Dr. Blair 
and Sir Gilbert Blane, in their capacity of Commissioners of the Board for ^ick and 
wounded seamen, in 1795. " The effect (says Sir John Herschel) of this wise mea- 
sure may be estimated from the following facts. In 1780 the number of cases of 
scurvy received into Haslar Hospital was 1457 : in 1806 one only, and in 1807 one" 
He adds, " there are now many surgeons in the navy who have never seen the 
disease." 

Dr. Budd, however, has assured me that the Dreadnought hospital-ship, at Green- 
wich, is often full of cases of scurvy ; most of the patients so affected having just 
arrived in mer chant-ships ^ from a long voyage. This surely ought not to be. 



SCURVY. 



1027 



It could not be if the owners of those vessels knew how easily, surely, and cheaply, 
this truly dreadful scourge may be averted. 

Scarcely less— if indeed less at all — of anti-scorbutic virtue, belongs, fortunately, 
to that common esculent root, the potato. Raw potatoes have long been in good 
repute, both for the cure and for the prevention of scurvy : but raw potatoes are 
neither palatable nor easy of digestion ; and it is a great discovery, which we owe to 
the sagacity of Dr. William Baly, that this vegetable is equally effective for these 
purposes, when cooked. During some months of continued observation of the pri- 
soners confined in the Penitentiary at Milbank, I had remarked, without being able 
to account for it, that among the small number of soldiers, committed for compara- 
tively short periods, for offences against military discipline, scurvy was not uncom- 
mon ; whereas I noticed it in one instance only among the much more numerous 
class of convicts, whose term of imprisonment Avas considerably longer. Dr. Baly 
was afterwards appointed Physician to the Penitentiary, and the same curious fact 
soon caught his attention : and he has traced the cause. By the examination and 
comparison of various dietaries — those, namely, which have been adopted at different 
periods in the Penitentiary itself, those which, at the same period, were prescribed 
respectively for the mihtary offenders, and for the ordinary convicts, and those in use 
in sundry other gaols in which scurvy has occurred with different degrees of fre- 
quency — he has shown, most satisfactorily, that the liability to the malady has a strict 
relation to the amount of succulent vegetables consumed by the prisoners, and espe- 
cially of potatoes. " Wherever this disease has prevailed, there the diet of the 
prisoners, though often abundant in other respects, has contained no potatoes, or only 
a very small quantity. In several prisons, the occurrence of scurvy has wholly 
ceased on the addition of a few pounds of potatoes being made to the weekly dietary. 
There are many prisons in which the diet, from its unvaried character, and the 
absence of animal food, as well as green vegetables, is apparently most inadequate 
to the maintenance of health ; and where, nevertheless, from its containing abundance 
of potatoes, scurvy is not produced." 

Now potatoes are food as well as medicine, and they are a cheap kind of food, 
and it may be hoped that a more general knowledge of their anti-scorbutic properties, 
even when cooked, will abolish this wretched complaint, whenever a good supply 
of them is obtainable. Dr. Baly believes that from three to six pounds, weekly, for 
each person, would suffice. He thus accounts for their salutary influence. 

"A glance at the chemical analysis of the potato at once explains its anti-scorbutic 
virtue. The various fruits, succulent roots, and herbs, which have the property of 
preventing and curing scurvy, all contain, dissolved in their juices, one or more 
organic acids — such as the citric, tartaric, and mahc acids. Sometimes these acids 
exist in the free state, but more generally they are combined with potash, or hme, 
or with both these bases. Now potatoes have been submitted to most elaborate 
chemical examination by Einhoffand Vauquelin ; and by both these chemists they 
have been found to contain a vegetable acid in considerable quantity. According to 
Einhoff, this acid is the tartaric combined with potash and hme. According to 
VauqueHn it is the citric partly in combination with those bases, and partly in the 
free state. The farinaceous seeds, as wheat, barley, oats and rye, which are destitute 
of anti-scorbutic property, contain no organic or vegetable acids." 

The same causes which give rise to sea scurvy will produce precisely the same 
effect on land. Of this I must give you one illustration from my own case-book. In 
August, 1830, 1 admitted into the Middlesex Hospital a blacksmith, thirty-five years 
old, covered with round purple spots of various sizes, and with irregular blotches of 
ecchymosis. He had vomited blood on the preceding day. He was continually 
coughing up blood at the time of his admission, and his wife estimated the whole 
quantity that he had then lost to be more than half a pailful. The interior of his 
mouth and palate was pouring forth blood from a number of livid fungous tumours, 
formed by the extravasation of blood into the areolar tissue beneath the membrane, 
and the subsequent rupture of that membrane. He was passing blood by the bowels 
also ; and his urine was loaded with blood. 

Here were the symptoms of scurvy strongly marked. In the man's history we 



0 



1028 



SCURVY. 



could trace its peculiar came. He had long been subsisting on very poor anct 
insufficient nutriment, seldom eating any meat, but living almost entirely on tea, 
coffee, and bread and butter. He had been too ill and weak to work regularly, yet 
he had been obliged occasionally to over-exert himself to obtain a scanty supply 
of food for himself, his wife, and a large family of children. He had been a 
settled dram-drinker, but for some time had taken much less of that stimulus ; 
merely because he had not the means of procuring it. His pulse was frequent and 
feeble. 

I had not much hope that this patient could be saved by any treatment. He was 
immediately put upon a diet of roast meat, and began to take daily half a pint of 
fresh lemon-juice diluted with a pint and a half of water. This plan, with some tonic 
medicine, was commenced on the 3d of August. He improved at once. On the 
8th all the hemorrhage had ceased ; the fungous tumours in the mouth had disap- 
peared, leaving small scars in the places they had occupied; and the discoloration 
of the skin was almost gone. The amendment was so striking and rapid, and so 
immediately consequent upon the institution of the treatment, that no room was left 
for mistaking recovery for cure. 

It is chiefly by investigating the previous history of the patient, and by noting the 
degree of strength that he possesses, and the condition of his pulse, that we are 
guided in our diagnosis of ambiguous cases. The late Dr. Parry, of Bath, was one 
of the first to point out the efficacy of abstinence, venesection, and purgatives, in 
some instances, at least, of purpura. I may refer you to an example of this kind 
detailed in the Medical Gazette for the 5th of April, 1828. It occurred in one of 
Dr. Latham's hospital patients ; and several of the symptoms were very like those 
I have just been relating. In particular the whole tongue was livid, one half of it 
presenting the appearance of a large, black, bleeding fungus ; and on the inner 
surface of each cheek were several black fungoid patches. The patient was void- 
ing also unmixed blood from the bowels. In this case there was no evidence of the 
operation of any debilitating cause, and the pulse, though frequent, was hard. 
Bleeding from the arm always gave relief to his uneasy sensations : he was purged 
also, and put upon low diet. Under this plan he steadily improved, and in four or 
five days no vestige of the complaint remained except the fading spots. For some 
time afterwards, however, " the frequent use of active purgatives, and a rigid re- 
striction to a low diet, were necessary to obviate costiveness, and to keep down the 
circulation, which had a tendency to become over-active." 

You are not to suppose that all cases of purpura bear this sthenic character, or 
require these heroic remedies. Your treatment must be guided by the previous 
circumstances and habits of the patient, by the state of his pulse, and by the other 
symptoms which accompany the purple spots. And when you are in doubt whai 
plan to pursue, make a cautious tentative bleeding. Take away a couple of ounces 
at a time, into a wineglass, note carefully the appearance of the blood itself, and the 
effect of the blood-letting upon the patient ; and then go on more boldly, or abstain 
thenceforth altogether from the lancet, according to circumstances. In many cases 
your chief reliance will be placed in the watchful employment of purgatives. These 
have been highly recommended by Dr. Harty, of Dubhn, as having proved eminently 
successful in his practice. The late Dr. Whitlock Nicholl, and others, have spoken 
in terms of strong praise of the oil of turpentine, administered in moderate and re- 
peated doses, as a remedy in purpura. 

I have adverted to one peculiar source of danger in purpura, the hazard that blood 
may be effused in some vital organ where even a slight amount of hemorrhage suffices 
to extinguish hfe. Dr. Bateman states that he had seen three instances in which 
persons were carried off, while affected with purpura, by hemorrhage into the lungs. 
During the course of one week, in the year 1825, I was present at two inspections 
in the dead house of St. Bartholomew's Hospital, illustrative of the same point in 
respect to another vital organ, and involving a question in forensic medicine. The 
subjects of examination were both of them women of middle age, who had been 
brought into the hospital covered with purple spots and bruise-like discolorations, 
and suffering hemorrhage from the mucous membranes. Each of these women de- 



CONCLUSION. 



1029 



clared that the apparent bruises were marks of beatings received from her husband. 
One of them became suddenly hemiplegic a little while before she died. Of the 
manner of dissolution in the other case I am not sure. In both instances a consider- 
able quantity of blood was spread over the surface of the brain, between its mem- 
branes ; and in one of them blood had been shed also into the cerebral substance, 
which it had extensively lacerated. 

It may be worth mentioning that in one of these corpses there were indications, 
either of unusually rapid putrefaction after death, or (what I think more probable) 
of some degree of decomposition even before life was extinct. This woman died 
in the evening, and the body was examined the next day, twelve or fourteen hours 
afterwards. A quantity of fetid gas escaped from the cavity of the abdomen as 
soon as it was opened, and small bubbles of air were seen to ooze from the areolar 
tissue of various parts of the body. Even when incisions were made into the liver, 
air frothed up, as it might do, under ordinary circumstances, from a section of the 
lungs. 

I have no time left for discussing the pathology of these complaints. They are 
eminently blood-diseases. In scurvy the blood is starved of some essential ingre- 
dient, which the juice of lemons, and other fresh succulent vegetables, readily sup- 
plies and renews. When drawn from a vein the blood is often visibly unnatural. 
A very 'small quantity was taken before I saw him, from the arm of the blacksmith 
whose case I just now mentioned. After standing for some time, it continued to fill 
the whole area of the vessel in which it had been received, without any apparent 
contraction, or separation of serum. On its flat upper surface was a thick, gray, 
semi-transparent jelly, and beneath this there was, strictly speaking, no coagulum, 
but a black semi-fluid substance of the consistence of syrup. Huxham describes 
similar appearances. " The blood of such persons (says he), when it hath been 
drawn o^, always appears a mere gore, as it were, not separating into crassamentum 
and serum as usual, but remaining in a uniform half coagulated mass, generally of 
a livid or darker colour than usual, though sometimes it continues long very florid ; 
but it alwaj'-s putrefies very soon." In another place, when describing a particular 
case, he says, " I found that neither of the portions of the blood that had been drawn 
had separated into serum and crassamentum as usual, though it had stood many 
hours ; but continued, as it were, half coagulated, and of a bluish hvid colour on 
the top. It was most easily divided on the slightest touch, and seemed a purulent 
sanies rather than blood, with a kind of sooty powder at bottom." 

Dr. Budd, however, states that in some cases of scurvy the separation of blood into 
serum and clot is as perfect, and takes place as readily, as in healthy blood. 

When you recognize the disease as genuine scurvy, and trace a previous absti- 
nence, whether forced or voluntary, from fresh vegetables, the treatment is plain ; 
you must supply the kind of nutriment which lias been defective, and support 
your patient's strength in such other ways as the circumstances of the case may 
dictate. 



And now, gentlemen, I must needs stop. Here ends my course. And if this 
were all I had to say, I should say it with something like glee, and you, no less than 
myself, would rejoice that at length a breathing-place and holiday had arrived. But 
I cannot feel so when I add that this is the last lecture, not of this course merely, but 
the last of any kind, that I am ever Hkely to dehver in King's College. I cannot 
say this without concern and regret. 

I am quite aware that my lectures have been in many respects imperfect. They 
have been very unequal to my own wishes. But they have been as full, and as 
carefully weighed, as my broken leisure, and irregular opportunities, and slender 
ability, would permit. I can only hope that at any rate I have not misled you. If 
I have been intelligible, if I have drawn such a sketch of a great and difficult subject 
as may help you in studying it for yourselves, I have achieved my task. I told you, 
in the outset, that I could not here teach you the practice of physic, but only its 
principles. It would be idle for me to speculate further upon the success of my 
endeavours. You are to be the judges of that matter. Whatever rules and precepts 



1030 



CONCLUSION. 



[ have laid down, you will soon test by your own experience, and adopt or reject 
them accordingly. The well-known maxims of Bacon apply with especial truth to 
medical instructors and their pupils. " Etsi non displiceat regula, oportet discentem 
credere ; huic tamen conjungendum est, oportet jam edoctum judicio suo uti ; dis- 
cipuJi enim debent magistris temporariam solum fidem, judiciique suspensionem, 
donee penitus imbiberint artes : non autem plenam Hbertatis ejurationem, perpe- 
tuamque ingenii servitutem." 

Retiring reluctantly from this place, in obedience to the force of circumstances, 
there are yet many things to comfort and console me. It is a great satisfaction to 
reflect that I have never had any serious disagreement with yourselves ; have never 
received any but the most respectful and kind treatment either from my present or 
from any preceding class. I have reason to thank you — and I do thank you — for 
the courtesy and attention you have at all times shown me. It is a source of gratifi- 
cation also that I carry with me the good will, as I believe, of my excellent colleagues ; 
and that I go without having forfeited any of that confidence which the Council first 
reposed in me as their servant, when they offered me, without solicitation, the chair 
I now resign. 

Had I been a few years younger, unembarrassed by previous official engagements, 
and somewhat more at leisure than I am, I should have been glad and proud to have 
attached myself to the new hospital, and to have laboured still in the cause of King's 
College, and of its Medical School. But it is otherwise ordered : and I will men- 
tion, as the last source of consolation in taking leave of you, my conviction that to 
you my loss (if, without presumption, I may so venture to speak of my resignation,) 
will be more than supplied by my successor. I know that gentleman well. I know, 
indeed the world knows, his talents. He was highly distinguished in the Senate 
House at Cambridge. He has since devoted, and will continue to devote, the powers 
of a very strong intellect, in the investigation of disease. Dr. Budd is one of the most 
strenuous cultivators of our science that I am acquainted with : and I am confident — 
without any affectation of modesty — that he will soon give a much better course of 
lectures than you have heard from me. That you may prosper in his instruction, 
and afterwards ; that by the humane exercise of our noble calhng you may do good 
in your generation, to others, and so to yourselves ; is my earnest desire and prayer. 
I hope it is unnecessary for me to assure you that I shall always continue to take a 
lively interest in your welfare individually; and that it will give me sincere pleasure 
if I shall find any future opportunity of rendering you any service. Gentlemen, I 
do not like this sort of parting, and I will not further protract the pain that beloBgs 
to it ; but bid you finally, and most cordially — Farewell. 



INDEX. 



Abdomen, diseases of the, 737. 

dropsy of the, 741. 

mode of examining, 728. 

paracentesis of the, 751. 

regions of, 728. 

tumours of the, 749. 
Abdominal dropsy, 740. 

palpitation, 729. • , 

percussion, 729, 742. 

respiration, 521. 

tumours, 749, 904. 
Abscess, 110. 

of the brain, 256. 
liver, 842. 
lungs, 561. 
Abscesses, disseminated, 710. 
Acute inflammation, 124. 
Adhesive inflammation, 108. 
^gophony, 527. 
Ague, 435. 

cake, 856. 

Air, impurity of a cause of disease, 75, and 

[note'\, 76. 
Air passages, foreign bodies in the, 656. 
Albuminous urine, 877. 

nephritis, 886. 
Alveolar cancer, 138. 
Amaurosis, 213. 
Amygdalitis, 485. 
Anaemia, 42, 50. 

accidents and diseases attended by, 51. 

anatomical characters, 50, 

death by, 50. 

phenomena, 51. 
Anaesthesia, facial, 336, 343. 

of other parts, 344. 
Anasarca, 169, 887, 999. 

cardiac, 174, 888. 

with pulmonary disease, 173, 890. 

renal, 174, 891. 

treatment, 178, 892. 
Aneurism, thoracic, 700. 

of the heart, 661—674. 
Angina maligna, "995. 

parotidoea, 479. 

pectoris, 679. 
Anthrax, 1025. 
Anorexia, 776. 

Antimony in inflammation, 155. 
Antiphlogistic regimen, 142. 
Anus, artificial, 791. 
Aorta, diseases of the, 662, 675, 700. 



Aphthae, 482. 

pathology of [note'], 483. 
Apnoea, anatomical characters, 53. 

causes of, 52. 

death by, 51. 

diseases in which it occurs as a mode of 
death, 54. 

general pathology of, 53. 

phenomena, 52. 
Apoplexy, 298. 

diagnosis, 299, 327. 

phenomena, 304, 308. 

morbid anatomy, 313. 

treatment, 328. 

pulmonary, 611. 
Arachnitis, 237. 

Arachnoid membrane, inflammation of, 237. 
Areolar tissue, inflammation of, 119. 

induration of, 120. 

dropsy of, 169. 
Arterial tissue, effects of inflammation on, 122. 
Arthritic ophthalmia, 209. 
Artificial anus, 791. 
Ascaris lumbricoides, 826 — 837. 

vermicularis, 826—837. 
Asiatic cholera, 805. 
Ascites, 740. 

causes, 744. 

diagnosis, 741. 

treatment, 748. 
Asphyxia, death from, 52. 
Asthenia, anatomical characters, 50. 

death by, 51. 

diseases in which it occurs as a mode of 

dying, 51. 
phenomena, 51. 
Asthma, 621. 

associated organic changes, 719. 
grinders, 647. 
hay, 545. 

spasmodic, 621, 623, 716. 
thymic, 512. 
Atmospherical temperature a cause of disease, 
60. 

Atrophy, 30—31. 

of the brain, 260. 
Auscultation, general account of, 521. 

Bastard croup, 512. 
Bayle, granulations of, 626. 
Belladonna as a preventive of scarlet fever 
[w/e], 1003. 

(1031) 



1032 



INDEX. 



Bellows sound of the heart, 665. 
Belly, dropsy of the, 740. 
Biliary concretions, 850. 
Bilious remittent fever [note'\, 964. 
Bleeding from lungs, 608, 638. 

stomach, 766. 
Blisters, as a remedy in inflammation, 159. 
Blood, bufiy coat of, 95—102. 

diseases of, 39. 

spitting of, 638. 

state of in inflammation [notej, 104. 

urination of, 899. 

vomiting of, 766. 
Blood-letting, as a remedy in inflammation, 143. 
Blood-vessels, state of in inflammation, 99. 
Bloody urine, 899. 

flux, 816. 
Boils, 1024. 

Bowels, inflammation of, 784. 

mechanical obstruction of, 786, 787, 788. 

perforation of, 734. 
Brain and nervous system, diseases of the, 220. 

abscess of, 257. 

atrophy of the, 261. 

cancer of the, 258. 

dropsy of the, 278. 

efiects of pressure on the, 225, 309. 

hemorrhage in the, 299, 300, 316. 

hypertrophy of the, 259 Ijiotej. 

induration of the, 258. 

inflammation of the, 123, 239. 

meningitis of the, 237. 

mortification of the, 124. 

softening of the, 255. 

suppuration of the, 256. 

tubercles of the, 258, 269, and [note']. 

tumours in the, 258. 

tapping, 285. 
Branks, 480. 

Breathing, abdominal, 521. 

bronchial, 527, 563. 

cavernous, 634. 

puerile, 526, 565. 

thoracic, 519. 

vesicular, 527, 530. 
Bright's kidney, 878. 

anatomical characters, 878. 

signs of, 879. 

changes in the urine, 879. 
in the blood, 881. 

course of the disease, 882. 

secondary afiections, 882. 

causes, 883. 

nature, 884. 
Bronchi, dilated, 551. 
Bronchial respiration, 527, 563. 

polypi, 121, 549. 
Bronchitis, acute, 529 — 537. 

morbid anatomy, 539, 551. 

treatment, 535. 

chronic, 537 — 547. 

varieties of, 548. 

prevention, 534. 
Bronchocele, 469. 
Bronchophony, 527, 565. 



Buffy coat of blood, 95 — 102. 
Bulls, 925, 1021. 

Calculi, renal, 858. 
Cancer, 135. 

alveolar, 138. 

colloid, 138. 

encephaloid, 138. 

intimate structure, 139, and 137 [note]. 

origin, 139. 

propagation, 140. 

treatment, 141. 

varieties, 137, and [note]. 

of the brain, 258. 
lungs, 656. 
stomach, 762. 
Canine madness, 368. 
Capillaries, state of in inflammation, 99. 
Carbuncle, 1026. 
Carcinoma of the stomach, 762. 
Cardiac dropsy, 170, 174, 889. 
Cardialgia, 778. 
Carditis, rheumatic, 683. 
Carnification of the lungs, 583. 
Catalepsy, 424. 
Causes of disease, 57. 

cold, 65. 

exciting, 58. 

heat, 61. 

hereditary predisposition, 77. 

impurity of the air, 75. 

predisposing, 58. 

seasons, 73. 
Catarrh, 528. 

chronic, 547, 548. 

dry, 622. 

epidemic, 539, 

senile, 537. 

summer, 545. 
Catarrhal ophthalmia, 181. 
Catarrhus gestivus, 545. 
Cavernous respiration, 633. 
Cellular tissue, dropsy of, 169, 

induration of, 120. 
Cerebral diseases, 229. 

hemorrhage, 299, 301, 316. 
Cerebro-Spinal Meningitis, 292 [note]. 
Chemosis, 185. 
Chicken-pox, 991. 
Child-bed fever, 731. 
Child-crowing, 512. 
Cholera, sporadic, 798. 

epidemic, 805. 

morbid anatomy, 806. 
mode of propagation, 807. 
modes of attack, 809. . 
treatment, 811. 

infantum, 811 [7iote]. 
Chorea, 399. 

Chronic inflammation, 124. 
Chylous urine, 897. 

Circulation, disturbance of as a symptom of dis- 
ease, 90. 
Cirrhose liver, 120, 744—845. 
Coagulable lymph, 107. 



INDEX. 



1033 



Cold, a cause of disease, 65. 

as a remedy in inflammation, 158. 
in the head, 530. 
chest, 529. 
Colic, 784—792. 
from lead, 792. 

symptoms, 795 [note]. 
treatment, 796. 
Colloid cancer, 138. 
Coma, death by, 52, 55, 300. 
phenomena, 55. 

diseases in which it occurs as a mode of 
dying, 56. 
Concretions, biliary, 850. 

intestinal, 823. 

renal, 858. 
Congestion, 41. 

active, 45. 

local, 43. 

mechanical, 45. 

passive, 47. 

Conjunctiva, inflammation of, 181,185,191, 196. 
Consumption, 626. 

curability of [note], 644. 
Contagion, 928, 949. 
Continued fever, 935. 
Convulsions, Salaam, 414 [note]. 
Cord, spinal, general pathology of, 288. 

inflammation of, 290. 
Coryza, 530. 

Cough, a symptom of disease, 89, 520. 
hysterical, 4-18. 

nocturnal, periodic, 516 [note]. 
Coup de soleil, 64. 
Crepitation, a sign of disease, 531. 
Cretinism, 475. 
Croup, 502. 

bastard, 512. 

false, 515 [note]. 

spasmodic, 512, and [note], 515. 

causes of, 515. 

diagnosis, 512 [rzo^e]. 

prognosis, 507. 

symptoms, 503. 

treatment, 507. 

tracheotomy in, 510 [no^e]. 
Cutaneous diseases, 924. 
Cutaneous tissue, inflammation of, 121. 
Cynanche laryngitis, 49 L 

maligna, 994. 

parotidea, 479. 

tonsillaris, 485. 

trachealis, 502. 
Cysticercus cellulosus, 829. 

Dance of St. Vitus, 405. 
Death, sudden, pathology of, 48. 
by anaBmia, 50. 

apnoea, 52. 

asthenia, 50. 

coma, 55, 300. 

inanition, 51. 

syncope, 51. 
Debility, a symptom, 88. 
Delirium of drunkards, 245. 

4 



Delirium tremens, 245. 

treatment, 250, 254 [note]. 

in continued fever, 938. 
Devonshire colic, 793. 
Diabetes, 868. 
Diagnostic signs, 80, 83. 
Diarrhoea, 798. 

adiposa, 822. 

chronic, 800 [note]. 

crapulosa, 798. 
Diathesis, lithic, 862. 

oxalic, 865. 

phosphatic, 862. 

scrofulous, 126, 134. 
Dietetic rules for dyspeptics, 782. 
Digitalis, as a remedy in inflammation, 156. 
Disease defined, 18. 
Digestion, physiology of, 774. 
Dilatation of bronchi, 551. 

heart, 674. 

oesophagus, 725. 
Diuresis, chronic, 876. 
Disease, causes of, 57. ^ 

hereditary tendency to, 59, 77. 
Diseases of the abdomen, 727. 

aorta, 652, 675, 700. 

blood, 39. 

brain and nervous system, 220. 

Bright's, 878. 

cerebral, 229. 

cutaneous, 896. 

eye, 180. 

fluids, 39. 
. gall bladder, 855. 

heart, 660. , 

intestines, 784. 

kidneys, 856. 

liver, 841. 

lungs, 528. 

oesophagus, 722. 

pancreas, 856. 

skin, 924. 

spleen, 856. 

stomach, 753. 

thorax, 518. 

veins, 707. 
Displacement of parts, 38. 
Dizziness, a symptom, 85. 
Dracunculus, 831. 

Dropsy, general pathology of, 168 — 170, 888* 
Dropsy, varieties, 171. 

phenomena, 174. 

prognosis, 178. 

treatment, 178. 
■ of the areolar tissue, 169, 887. 

of the belly, 741. 

of the brain, 277. 

cardiac, 174, 889. 

chest, 582. 

ovarian, 741—746, 749. 
renal, 173. 

after scarlet fever, 997. 
Drunkards, delirium of, 245. 
Dura mater, inflammation of, 231. 
Dying, modes of, 48. % 
M 



1034 



INDEX. 



Dysentery, 814. 

causes, 814. 

phenomena, 815. 

morbid anatomy, 817 [nofe]. 

treatment, 818 [note']. 

chronic, 821 [note']. 
Dyspepsia, 757, 774. 
Dyspeptics, dietetic rules for, 783. 
Dyspnoea, a symptom, 90, 519. 

general pathology, 519. 

Ecstacy, 425. 
Eczema solare, 1020. 

rubrum mercuriale, 1020. 
Effusion of serum from inflammation, 106. 

coagulable lymph, 107. 

pus, 109. 
Egyptian ophthalmia, 184, 186. 
Exhalation, hemorrhage from, 160. 
Emaciation, a symptom, 91. 
Emphysema of the lungs, 553, 618. 

interlobular, 618, 624. 

sub-pleural, 624. 

vesicular, 618. 
Empyema, 110. 
Encephalitis, 239, 

phenomena, 240. 

morbid anatomy, 241. 

treatment, 242. 
Encephalon, inflammation of, 240. 
Encephaloid cancer, 138. 
Endocarditis, rheumatic, 683. 
Endocardium, morbid states of, 676. 
Engorgement of the lungs, 559, 
Enteritis, 784. 

diagnosis, 785. , 
Entozoa, 825. 

mo^e of production, 833. 
Epidemic catarrh, 539. 

cholera, 805. 
Epilepsy, 379. 

phenomena, 380. 

varieties, 381. 

pathology, 386. 

morbid anatomy, 387. 

treatment, 393. 

feigned, 391. 
Epistaxis, 468. 

Erysipelas, phlegmonoides, 199. 
Erysipelas, 1004. 

in young infants, 1010 [note]. 
Erythema, 121, 1014. 

nodosum, 1014. 
Events of inflammation, 106. 
Examination of abdomen, 728. 
Exanthemata, 925. 
Exciting causes of disease, 58. 
Eye, diseases of the, 180. 

Face-ache, 433. 

Facial anaesthesia, 336, 343. 

neuralgia, 429. 

paralysis, 337. 
Falling sickness, 379. 
False membranes of the pleura, 580, 



False membranes of the trachea, 516. 
Fatty transformation of tissues, 36. 

liver, 632, 845. 
Fever, inflammatory, 93, 115. 

continued, 934. 

hay, 545. 

hectic, 94, 116, 610. 

intermittent, 435. 

puerperal, 730. 

remittent, 964 [note]. 

scarlet, 994. 

typhoid, 95, 934. 
Filaria medinensis, 831. 
Flatulence, 777. 
Fluids, diseases of, 39. 
Fluxes, 796. 
Fungus haematodes, 141. 
Furunculus, 1025. 

Gall-bladder, diseases of, 855. 

Gall-stones, 850. 

Gangrena Senilis, 114, 

Gangrene, from inflammation, 112 — 119. 

of the lungs, 562. 
Gastric hemorrhage, 766. 
Gastritis, acute, 753, 

phenomena, 754, 

morbid anatomy, 755. 

treatment, 757, 

chronic, 757. 

acute, of infants, 760 [note]. 
Gastrodynia, 779. 
Generation, spontaneous, 833, 
Giddiness, a symptom, 85. 
Glottis, oedema of, 500. 
Goitre, 469. 

Gonorrhoeal ophthalmia, 191, 
Gout, 922, 

Granulations of Bayle, 626, 
Gravel, fit of the, 859, 

different kinds of, 860, 
Gravedo, 529. 

Gray and red softening of the lungs, 561. 
Grinder's asthma, 647. 
Grippe, 539. 
Guinea worm, 831. 
Gutta serena, 213. 

Haematemesis, 766. 

hysterical, 419. 

vicarious, 767. 
Haematuria, 899, 
Haemoptysis, 638, 

hysterical, 419. 
Hemorrhages, general pathology, 159. 

active and passive, 162. 

diagnosis, 166. 

habitual, 161. 

treatment, 166, 

vicarious, 162. 
Hemorrhage, a result of inflammation, 107. 

of the brain, 298, 300, 316. 

cerebral, 298, 300, 316. 

gastric, 766. 

nasal, 467. 



INDEX. 



1035 



Hemorrhage, pulmonary, 608. 

spinal, 332. 

vesical, 899. 

vicarious, 161, 768. 
Hay-asthma, 545. 
Headache, sick, 780. 
Health, what is, 18. 
Heart, diseases of, 660. 

aneurisms of, 661, 674. 

bellows sound of, 666. 

dilatation of the, 674. 

dropsy from, 172. 

hypertrophy of, 660, 671. 

morbid sounds of, 666. 

natural sounds of, 663. 

palpitation of, 668. 

rupture of, 674. 

valvular disease of, 675. 
Heart-burn, 778. 
Heat a cause of disease, 61 — 63. 

a symptom of inflammation, 96. 
Hectic fever, 94, 117, 638. 
Hemicrania, 434. 
Hemiplegia, 310, 333. 
Hepatic abscess, 842. 
Hepatization of the lungs, 32, 560. 
Hepatitis, acute, 841. 

treatment, 843, and [note] 852. 

chTonic, 845. 
Hereditary disposition to disease, 59, 77. 
Herpes, 1017, 1018. 

circinatus, 1018. 

iris, 1018. 

prseputialis, 1018. 

zoster, 1018. 
Hobnail liver, 120, 745, 845. 
Hooping cough, 552. 

pathology of, 555 [note]. 
Hydatids, 829. 
Hydrargyrum, 1020. 
Hydrocephalus, acute, 263. 

chronic, 278. 

spurious, 278. 
Hydrophobia, 360. 

phenomena, 361. 

causes, 366. 

morbid anatomy, 374. 

in the dog, 372. 

pathology, 374. 

treatment, 374. 

prevention, 377. 
Hydrothorax, 582. 
Hyperaemia, 41. 
Hypertrophy, 26—30. 

of the brain, 259. 

heart, 660, 671. 
thyreoid gland, 469. 
Hypochondriasis, 781. 
Hysteria, 413. 

phenomena, 414. 

diagnosis, 414. 

pathology, 415. 

treatment of, 421. 



Hysterical affection of joints, 419. 
cough, 417. 
haematemesis, 418. 
laryngitis, 417. 
palsy, 417. 
peritonitis, 417. 

Icterus, 847. 
Ileus, 784. 
Impetigo, 1024. 

Impure air, a cause of disease, 75. 
Inanition a cause of death, 51. 
Indigestion, 757, 774. 
Induration, 32. 

of the areolar tissue, 120. 

of the brain, 258. 

of the cellular tissue, 120. 
Infants, purulent ophthalmia of, 196. 
Infiltration of the lungs, purulent, 561. 

tubercular, 629. 
Inflammation, general account of, 92. 

acute, 124. 

adhesive, 108. 

arachnoid, 237. 

areolar tissue, 119. 

arteries, 122. 

bowels, 784. 

brain, 123, 241. 

chronic, 124. 

conjunctiva, 181, 195. 

cutaneous tissues, 121. 

dura mater, 231. 

encephalon, 240. 

events of, 105. 

eye, 181. 

fibrous tissue, 906. 
hectic fever from, 117. 
intestines, 784. 
iris, 202. 
kidneys, 856. 
larynx, 491. 

liver, 842. >• 
lungs, 559. 

mucous membrane, 121. 
oesophagus, 726 [note]. 
of the several tissues, 119. 
parotid, 479. 
pericardium, 683. 
peritoneum, 729. 
phenomena, 93. 
pia mater, 237 
, pleura, 579. 
pyrexia, 115. 
retina, 213. 
serous tissue, 120. 
skin, 120. 

spinal cord, 290—295. 

state of minute blood-vessels in, 100 [no^c]. 

stomach, 753. 

synovial membrane, 120. 

thorax, 518. 

tonsils, 485. 

trachea, 502. 



1036 



INDEX. 



Inflammation, treatment, 143. 

typhoid fever, 117. 

varieties of, 124. 

veins, 122, 707. 
Inflammatory fever, 94, 115. 
Influenza, 539. 

Inoculation of small-pox, 981. 

Intellect, affections of, symptom of disease, 87. 

Intermittent fever, 435. 

exciting cause, 440. 

pathology, 448. 

phenomena, 435. 

prophylaxis, 465. 

species, 437. 

treatment, 456. 
Interlobular emphysema, 620, 624. 
Intestinal concretions, 823. 

worms, 825. 
Intestines, diseases of the, 784. 

inflammation of, 784. 

perforation of, 734. 
Iritis, 202. 

syphilitic, 209. 
Ischuria renaUs, 866. 
Itch, 1016. 

Itching, a symptom, 84. 

Jaundice, 847. 

phenomena, 847. 
pathology, 848 — 8*52 [note]. 
prognosis, 852. 

treatment, 852 [jiotej, 854 text. 

Kidney, diseases of, 856. 
Bright's, 859. 
inflammation of, 856. 
suppuration of, 858. 

Laryngismus stridulis, 513. 
Laryngitis, 491—500. 

hysterical, 417. 

spasmodic, 515 [note]. 
Larynx, acute inflammation of, 491. 

chronic " 500. 

syphilitic ulceration of, 500. 

warty growths of, 501. 
Laryngeal oedema, 499. 

phthisis, 614—632. 

ulceration, 500, 614, 632. 
Laryngeo-tracheitis, 502 [note]. 
Lead colic, 792. 

palsy, 793. 
Lecturer on medicine, duties of a, 24. 
Lepra, 1022. 
Life, conditions of, 48. 
Lithic diathesis, 852. 
Liver, diseases of, 841. 

abscess of, 842. 

cirrhose, 120, 745, 845. 

fatty, 632, 845. 

hobnail, 120, 745, 845. 

inflammation of, 842. 



Liver, suppuration of, 842. 
Lobular pneumonia, 560. 
Locked jaw, 352. 
Lumbricoid worms, 826 — 838. 
Lungs, diseases of the, 528. 

abscess of, 561. 

cancer of, 656. 

carnification of, 583. 

consumption of, 626. 

emphysema of, 553, 618. 

engorgement of, 559. 

gangrene of, 561; 

hemorrhage from, 504. 

hepatization of, 32, 560. 

inflammation of, 559. 

melanosis of, 652. 

cedema of, 625. 

purulent infiltration of, 561. 

red and gray, softening of, 561. 

sounds of, 521. 

splenization of, 559. 

tubercles of, 675. 

tubercular, infiltration, 629. 
Lymph, coagulable, 107. 

Maculae, 924. 
Malaria, 441. 

circumstances which influence, 450. 

condition, necessary to produce, 442. 

efiects of, on human body, 446. 

influence of soils in evolving, 447. 

ultimate efiects of, 454. 
Malignant cholera, 805. 
Measles, 993. 

Medicine, principles of, 22. 

duties of a lecturer on, 23. 
Melsena, 769. 
Melanosis, true, 652. 

spurious, 654. 
Meningitis of the brain, 237. 

cerebro-spinal, 292 [note]. 

encephalica, 287 [«o^e]. 

spine, 290. 

tubercular, 264. 
Mercury, a remedy in^ inflammation, 152. 
Metastasis, 105. 
Mercurial eczema, 1020. 

tremor, 412. 
Miliary tubercles, 626. 
Modes of dving, 48. 
Morbilli, 993. 
, Mortification, 95, 112, 119. 
I of the brain, 123. 
Mucous membrane, inflammation of, 121. 

morbid anatomy of, 551. 
Mucous rattle, 532. 
Mumps, 480. 

Murmur, respiratory, 526, 530. 

bellows, 666. 
Musc£s volitantes, a symptom, 86, 238. 
Muscular tissue, inflammation of, 123. 

Nasal hemorrhage, 467. 



INDEX. 



Nausea, a"symptom, 85. 
Nephralgia, 856. 
Nephritis, 856. 

albuminous, 886. 
Nervous system, diseases of, 220, 

physiology of, 220. 

pathology of, 224. 
Nervous tissue, inflammation of, 123. 
Nettle rash, 1013. 
Neuralgia, 426. 

facial, 429. 
Nutrition, lesions of, 38. 

Obliteration of veins, 712. 

Obstruction of bowels, mechanical, 785, 786, 788. 

CEdema, 171. 

of the glottis, 500. 

lungs, 625/ 

laryngeal, 499. 
CEsophagus, diseases of, 722. 

dilatation of, 725. 

inflammation of, 726 ^note"]. 

stricture of, 722. 
Old persons, catarrh of, 537. 
Opium, a remedy in inflammation, 157. 
Ophthalmia, arthritic, 210. 

catarrhal, 181. 

Egyptian, 185, 186. 

gonorrhoeal, 190. 

purulent, 184. 

purulent in infants^ 196. 

pustular, 198. 

iheumatic, 210. 

strumous, 198. 
OrthopncEa, a symptom, 88. 
Ovarian dropsy, 741, 745, 749, 
Ovaries, extirpation of, 749. 
Oxalic diathesis, 864. 

Pain, a symptom, 84, 95. 
Painter's colic, 792. 
Palpation of the abdomen, 729. 
Palpitation, 669. 
Palsy, 310, 332. 

facial, 337. 

from lead, 793. 

hysterical, 417. 

local, 336. 

shaking, 410. 
Pancreas, diseases of the, 856. 
Papulae, 924. 

Paracentesis thoracis, 597. 

abdominis, 751. 
Paralysis agitans, 410. 

facial, 337. 

from lead, 793. 

of one side, 310, 333, 

partial, 336. 
Paraplegia, 310, 333, 
Parotitis, 479. 
Pathology, 26. 

of sudden death, 49, 



1037 

Pectoriloquy, 527—635, 
Pemphigus, 1021. 
Percussion of thorax, 522. 

of abdomen, 729, 742. 
Pericarditis, 683. 

Pericardium, diseased conditions of, 537. 
Periodicity, 448. 
Peripneumonia notha, 537. 
Peritonitis, acute, 729. 

treatment, 736. 

chronic, 740. 

hysterical, 416. 

tubercular, 739, 
Pertussis, 552. 
Petechia, 649. 

Phlegmasia dolens, 122, 171, 708, 
Phlebitis, 123, 707. 
Phosphatic diathesis, 864. 
Phrenitis, 239. 
Phthisis, 626. 

auscultatory signs, 633. 

its connection with tubercles, 626. 

diagnosis, 641. 

general symptoms, 635. 

granulations of Bayle, 643. 

intercurrent pleurisy, 631, 

laryngeal, 500, 615, 632, 

statistics, 646. 

treatment, 648. 

varieties, 642. 

vomicae, 630. 
Physician, duties and responsibilities of a, 25. 
Pia mater, inflammation of, 237, 
Pictonum, colica, 792. 
Pimples, 924. 
Plague, 1004. 
Plethora, 41, 43. 
Pleura, inflammation of, 580. 

morbid anatomy, 580. 

false membranes of, 580. 
Pleurisy, 580. 

Pleuro-pneumonia, 559, 580, 
Pneumonia, 559. 

in children, 574 ^note], 

lobular, 561, 842. 

morbid anatomy, 562, 

prognosis, 570. 

treatment, 571. 
Pneumonia notha, 537. 

typhoid, 602 [note]. 
Pneumo-thorax, 593. 
Podagra, 912. 

Polypi, bronchial, 121, 548. 

Polysarcia, 28. 

Pompholix, 1021. 

Predisposing causes of disease, 58. 

Predisposition, hereditary, 77. 

Pressure on the brain, eflTects of, 225, 309, 

Principles of medicine, 22. 

Prognostic signs, 81, 83, 

Proximate causes, 57, 

Prurigo, 1014. 

Psoriasis, 1013. 



4M3 



1038 



INDEX. 



Ptyalism, spontaneous, 481. 

Puerile respiration, 526, 565. 

Puerperal fever, 731. 

Pulmonary tissue, inflammation of, 559. 

Pulmonary apoplexy, 613. 

consumption, 626. 

emphysema, 618. 

hemorrhage, 608. 

vesicles, dilatation of, 621. 
Pulse, indications of, in disease, 90. 
Purging, as a remedy in inflammation, 151. 
Purpura, 1026. 
Purulent ophthalmia, 184. 

tpf infants, 195. 

infiltration of the lungs, 561. 
Pus, 109. 
Pustul®, 924. 
Pustular ophthalmia, 198. 
Pyrexia, w^ith inflammation, 94, 115. 
Pyrosis, 779. 

Quinsy, 485. 

Babies canina, 368, 372. 

Ramollissement of the brain, 255. 

Red and gray softening of the lungs, 561. 

Redness, a symptom of inflamn^ation, 98. 

Regimen, antiphlogistic, 142. 

Regions of the thorax, 524. 

abdomen, 728. 
Remittent fever, 964 [no^e]. 
Renal dropsy, 173. 

calculi, 859. 
Resolution, an event of inflammation, 94 — 106. 
Respiration, abdominal, 521. 

bronchial, 527. 

cavernous, 634. 

natural sounds of, 531. 

puerile, 526. 

thoracic, 519, 730. 

vesicular, 530. 
Respiratory murmur, 526, 531. 
Retinitis, 214. 
Revaccination, 989. 
Rheumatic ophthalmia, 18^ — 210. 

carditis, 683. 
Rheumatism, acute, 906. 

-varieties, 907. 

connection with disease of heart, 683. 

chronic, 911. 
Rhonchus, 531 — 563. 
Round worms, 826. 
Rubeola, 993. 

St. Vitus' dance, 405. 
Salaam convulsions, 414 [wo/e]. 
Salivation, spontaneous, 481. 
Scabies, 1016. 
Scarlet fever, 996. 

species, 996. 

diagnosis, 997. 

symptoms, 997. 



Scarlet fever, sequelse of, 999. 

treatment, 1000. 

prophylaxis, 1003. 
Sciatica, 434. 
Scirrhus, 138. 

Scrofula, agency of impure air in production of, 

76 [note]. 
Scrofulous diathesis, 126 — 134. 

inflammation, 126. 

ophthalmia, 198. 
Scurvy, 1026. 

Seasons, influence of the, 73. 

Senile catarrh, 537. 

Sensations, morbid, as symptoms, 86. 

Serous tissues, inflammation of, 120. 

Serum, effusion of, 106. 

Shaking palsy, 410. 

Sibilus, 530. 

Sick headache, 780. 

Signs of disease, 82. 

Scirrhus, a symptom, 85. 

Skin, inflammation of, 121. 

Sloughing, 95. 

Small-pox, 975. 

complications, 977. 

diagnosis, 976. 

species, 977. 

symptoms, 976. 

treatment, 988. 
Sneezing, a symptom, 89. 
Softening, 34. 

of the brain, 255. 

of the heart, 674— 681. 

red and gray of the lungs, 561. 

spine, 298. 

of the stomach, 756, 760 [7iote]. 
Solids, alterations of the, in disease, 26,-, 

change of situation in the, 38. 
Sore-throat, inflammatory, 485. 

malignant, 995. 
Sounds of the lungs, 521. 

heart, 663, 666. 
Spasm, a symptom, 88. 
Spasmodic asthma, 621, 623, 716. 

cholera, 805. 

croup, 512 [notej. 

diseases, 345. 

laryngitis, 615 [note]. 

stricture of oesophagus, 724. 
Sphacelus, 113, 119. 
Specific inflammation, 125. 
Spinal cord, pathology of, 288. 

physiology of the, 288. 

inflammation of, 290, 292. 
Spinal hemorrhage, 332. 

meningitis, 291. 
Spleen, diseases of, 856. 
Splenization of the lungs, 560. 
Spontaneous generation, 834. 

salivation, 481. 
Spotted fever, 940. 
Spitting of blood, 638, 
Spurious croup, 512. 



INDEX. 



Spurious hydrocephalus, 276. 
Squamffi, 924, 1022. 
Starvation, death by, 52. 
Stomach, diseases of the, 753. 

cancer of the, 762. 

hemorrhage from the, 766. 

inflammation of the, 753. 

perforation of the, 735. 

softening of the, 756—760 [note]. 

ulceration of the, 735, 758. 
Strictures of the oesophagus, 723. 
Strongulas gigas, 832. 
Strumous diathesis, 133. 

ophthalmia, 198. 
Sub-pleural emphysema, 624. 
Succussion, 528. 
Sudamia, 649. 

Sudden death, pathology of, 49. 
Suffocation, death by, 52. 
Summer catarrh, 545. 
Summer complaint of infants, 811 [note]. 
Suppression of urine, 866. 
Suppuration, 94, 109. 

of the brain, 256. 

diffuse of the lungs, 561. 

of the kidney, 858. 

of the liver, 842. 

of the spine, 298. 
Swelling, a symptom of inflammation, 99. 
Symptoms, general account of, 79. 

diagnostic, 80. 

prognostic, 81. 

pathognomonic, 83. 
Syncope, death by, 51. 

anginosa, 680. 
Synovial membrane, inflammation of, 120. 
Syphilitic ulceration of the larynx, 500. 

iritis, 209. 

Tabes mesenterica, 129. 
Taenia, 827. 
Tape worm, 827—838. 
Tapping the brain, 284. 
Teguraentary membranes, inflammation of, 121. 
Temperature, vicissitudes of, a cause of disease, 
69. 

Tetanus, 345. 

Thorax, diseases of, 517. 

auscultation of, 521. 

inflammation of, 517. 

paracentesis of, 597. 

percussion of, 522. 

regions of, 524. 
Thoracic respiration, 621, 730. 

aneurisms, 700. 
Thrush, 482. 
Thymic asthma, 512. 
Thyreoid glands, hypertrophy of, 469. 
Tic douloureux, 429. , 
Tinnitus aurium, a symptom, 87. 
Tissues, effects of inflammation in the, 119. 

atrophy of, 30. 

hypertrophy of, 26. 



Tissues, induration of, 32. 

softening of, 33. 

transformation of, 35. 
To and fro sound of heart, 687. 
Tonsillitis, 485. 
Tonsils, inflammation of, 485. 
Tonsils, enlarged, 491, and [notej. 
Tormina, 784. 

Trachea, false membranes of, 506. 

foreign bodies in, 656. 

inflamed, 502. 
Tracheitis, 502. 

Tracheotomy in croup, 510, and [no^e]. 

laryngitis, 494. 
Transformation of tissues, 35. 
Traumatic tetanus, 347. 
Tremor, a symptom, 88. 

mercurial, 412. 
Trembles, 412. 
Trichina spiralis, 830. 
Tricocephalus dispar, 827. 
Trismus, 346. 
Tubercle, 126. 

forms of, 129 [note]. 

diffusion of in children, 131 [note]. 

of ihe brain, 258 — 269, and [note], 
lungs, 626. 
peritoneum, 739. 
Tuberculffi, 925. 

Tubercular infiltration of lungs, 629. 

meningitis, 264. 

morbid anatomy, 268, and [note], 

peritonitis, 739. 

phthisis, 626. 
Tumours of abdomen, 749, 904. 

in brain, 258. 
Typhoid fever, 95, 935. 
Typhoid pneumonia, 602 [note]. 

Ulceration, 95, 111. 

laryngeal, 501, 615, 632. 

of the stomach, 735, 757. 

syphilitic, of the larynx, 501. 

tubercular " " 631. 
Urine, albuminous, 877. 
" bloody, 898. 

chylous, 897. 

diabetic, 868. 

morbid conditions of, 862 — 868, 877. 
retention of, hysterical, 420. 
saccharine, 868. ^ 
suppression of, 866. 
Urticaria, 1013. 

varieties, 1013. 
treatment, 1014. 

Vaccination, 982. 

Valves of the heart, diseases of, 675. 

Varicella, 991. 

Variola, 975. 

Veins, diseases of, 707. 

inflammation of, 122, 707. 
■ obliteration of, 712. 



INDEX. 



1040 

Venesection, 143. 

Venous tissue, under inflammation, 122. 
Vertigo, a symptom, 85. 
Vesiculas, 925, 1017. 
Vesicles of the lungs, dilated, 621. 
Vesicular emphysema, 619. 

respiration, 527, 531, 564. 
Vicarious hemorrhage, 162, 767. 
Vicissitudes of temperament a cause of disease, 68. 
Viscera, inflammation of the, 120. 
Vomicffi, 628—630. 
Vomiting, 776. 
Vomiting of blood, 766. 

hysterical, 418. 



Warmth, external, a remedy in inflammation, 
158. 

Warty growth of larynx, 501. 
Wasting, a symptom, 91. 
Water brash, 779. 

stroke, 266. 
Worms, 825. 

varieties, 825. 

round, 826. 

flat, 827. 

mode of production, 832. 
symptoms of, 837. 
treatment, 838. 
Zona ignea, 1018. 



THE END. 



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I.EA «& BI^AI^CMARD, PhiladelpMa, 



DICTIONARIES AND JOURNALS. 

American Journal of the Medical Sciences, quar- 
terly, at $5 a year. 

Cyclopaedia of Practical Medicine, by Forbes, 
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Dunglison's Medical Dictionary, 6th ed., 1 vol. 
imp.8vo.,804 large pages, double columns. 

Hoblyn's Dictionary of Medical Terms, by Hays, 
1 vol. large 12mo., 402 pages, double columns. 

Medical News and Library, monthly at $1 a year. 
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Anatomical Atlas, by Smith and Horner, large 
imp. 8vo., 650 figures. 

Horner's Special Anatomy and Histology, 7th 
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Horner's United States Dissector, 1 vol. large 
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Wilson's Human Anatomy, by Goddard, 3d edi- 
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Wilson's Dissector, or Practical and Surgical 
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PHYSIOLOGY. 

Carpenter's Principles of Human Physiology, 1 
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Carpenter's Elements, or Manual of Physiology, 
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Connection between Physiology and Intellectual 
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Dunglison's Human Physiology, 6th edition, 2 
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Harrison on the Nerves, 1 vol. 8vo., 292 pages. 

Miiller's Physiology, by Bell, I vol. 8vo., 886 pp. 

Roget's Outlines of Physiology, 8vo., 516 pages. 

Todd and Bowman's Physiological Anatomy and 
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PATHOLOGY. 

Andral on the Blood, 1 vol. small 8vo., 120 pages. 

Abercrombie on the Stomach, new edition, 1 vol. 
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Abercrombie on the Brain, new edition, 1 vol. 
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Alison's Outlines of Pathology, &c., 1 vol. 8vo., 
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Berzelius on the Kidneys and Urine, 8vo., 180 pp. 
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Budd on the Liver, 1 vol. 8vo., 392 pages, plates 

and wood-cuts. 
Burrows on Cerebral Circulation, 1 vol. Svo., 

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Billing's Principles, 1 vol. 8vo., 304 pages. 
Bird on Urinary Deposits, 8 vo., 228 pages, cuts. 
Hasse's Pathological Anatomy, Svo., 379 pages. 
Hope on the Heart, by Pennock, a new edition, 

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Hughes on the Lungs and Heart, 1 vol. 12mo., 

270 pages, with a plate. 
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Philips on Scrofula, 1 vol. 8vo., 350 pages. 
Prout on the Stomach and Renal Diseases, 1 vol. 

Svo., 466 pages, colored plates. 
Ricord on Venereal, new ed., 1 vol. 8vo., 256 pp. 
Vdgel's Pathological Anatomy of the Human 

Body, I vol. Svo., 536 pages, col. plates. 



Walshe on the Lungs, 1 vol. 12mo., 310 pages. 
Wdson on the Skin, 1 vol. Svo., new ed., 440 pp. 

Same work, with colored plates. 

Williams' Pathology, or Principles of Medicine, 

2d edition, 1 vol. 8vo. Nearly ready. 
Williams on the Respiratory Organs, by Clymei 

1 vol. 8vo., 500 pages. 

PRACTICE OF MEDICINE. 
Ashwell on the Diseases of Females, by Goddard, 

1 vol. 8vo., 520 pages. 
Bartlett on Fevers, new edition, much enlarged; 

a complete work on the Fevers of the U. S. 

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Benedict's Compendium of Chapman's Lectures, 

1 vol. 8vo., 258 pages. 
Chapman on Thoracic and Abdominal Viscera, 

&c., 1 vol. 8vo., 384 pages. 
Chapman on Fevers, Gout, Dropsy, &c. &c., 1 vol. 

8vo., 450 pages. 
Colombat de L'ls^re on Females, translated and 

edited by Meigs, 1 vol. 8vo., 720 pages, cuts. 
Condie on the Diseases of Children, 2d edition, 1 

vol. 8vo., 658 pages. 
Churchill on the Diseases of Females, by Huston, 

4lh edition, 1 vol. 8vo., 604 pages. 
Clymer and others on Fevers, a complete work 

in 1 vol. Svo. 600 pages. 
Dewees on Children, 9th ed., 1 vol. 8vo., 548 pp. 
Dewees on P'emales, 9th edition, 1 vol.8vo.,532 

pages, with plates. 
Dunglison's Practice of Medicine, 3d edition, 2 

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Esquirol on Insanity, by Hunt, Svo. 496 pages. 
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Watson's Principles and Practice of Physic, 3d 

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Brodie on Urinary Organs, 1 vol. Svo. , 214 pages. 

Brodie on the Joints, 1 vol. Svo. 216 pages. 

Brodie's Lectures on Surgery, 1 vol. Svo., 350 pp. 

Chelius' System of Surgery, by South and Norris, 
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Cooper on Dislocations, and Fractures, 1 vol. Svo. 
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Cooper on Hernia, 1 vol. imp. Svo., 428 pp., pl'ts. 

Cooper on the Testis and Thymus Gland, 1 vol. 
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Cooper on the Anatomy and Diseases ofthe Breast, 
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Druitt's Principles and Practice of Modern Sur- 
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Durlacher on Corns, Bunions, &c. 12mo., 134 pp. 

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Guthrie on the Bladder, 8vo., 150 pages. 

Harris on the Maxillary Sinus, Svo., 166 pp. 

Jones' (Wharton) Ophthalmic Medicine and Sur- 
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5 



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Griffith's Medical Botany, a new work, 1 large 

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Churchill's Theory and Practice of Midwifery, by 

Huston, 2d ed., 1 vol. 8vo., 520 pp., many cuts. 
Dewees' System of Midwifery, 11th ed., 1 vol. 

8vo. 660 pages, with plates. 
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Ramsbotham on Parturition, with many plates, 1 

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Dunglison on Human Health, 2d ed.,8vo., 464 pp. 
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Graham's Elements of Chemistry, 1 vol. 8vo., 750 

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Griffith's Chemistry of the Four Seasons, 1 vol. 

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Practical Organic Chemistry, 18mo., paper, 25 cts. 
Simon's Chemistry of Man, 8vo., 730 pp., plates. 
MEDICAL JURISPRUDENCE, EDUCATION, &c. 
Bartlett's Philosophy of Medicine, 1 vol. 8vo., 

312 pages. 

Dunglison'sMedical Student, 2d ed. 12mo. ,312pp. 
Man's Power over himself to Prevent or Control 
Insanity, 18mo. paper, price 25 cents. 



Taylor's Medical Jurisprudence, by Griffith, 1 

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Taylor's Manual of Toxicology, by Griffith, 1 vol. 

8vo. Now ready. 
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NATURAL SCIENCE, &c. 
Arnott's Elements of Physics, new edition, 1 vol. 

8vo., 484 pages, many cuts. 
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12mo. volume, with numerous cuts, 382 pages. 
Brewster's Treatise on Optics, 1 vol. 12mo., 423 

pages, many cuts. 
Babbage's " Fragment," 1 vol. 8vo., 250 pages. 
Buckland's Geology and Mineralogy,'2 vols. 8vo.,. 

with numerous plates and maps. 
Bridgewater Treatises, with many plates, cuts, 

maps, &c., 7 vols. 8vo., 3287 pages. 
Carpenter's Popular Vegetable Physiology, 1 vol. 

royal 12mo., many cuts. 
Hale's Ethnography and Philology of the U. S. 

Exploring Expedition, in 1 large imp. 4to. vol. 
Herschell's Treatise on Astronomy, 1 vol. 12mo. 

417 pages, numerous plates and cuts. 
Introduction to Vegetable Physiology, founded 

on the works of De Candolle, Lindley, Slc. 

l8mo., paper, 25 cents. 
Kirby on Animals, plates, 1 vol. 8vo., 520 pages. 
Kirby and Spence's Entomology, from 6th Lon- 
don ed., 1 vol. 8vo., 600 large pages; plates, 

plain or colored. 
Philosophy in Sport made Science in Earnest, 1 

vol. royal ISmo., 430 pages, many cuts. 
Roget's Animal and Vegetable I^hysiology, with 

400 cuts, 2 vols. Svo., 872 pages. 
Trimmer's Geology and Mineralogy, 1 vol. 8vo., 

528 pages, many cuts. 

VETERINARY MEDICINE. 
Claterand Skinner's Farrier, 1 vol. 12mo., 220 pp. 
Youatt's Great Work on the Horse, by Skinner, 

1 vol. 8vo., 448 pages, many cuts. 
Youatt and Clater's Cattle Doctor, 1 vol. 12mo., 

282 pages, cuts. 
Youfttt on the Dog, by Lewis, 1 vol. demy 8vo., 

403 pages, beautiful plates. 
Youatt on the Pig, a new work with beautiful il- 
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NEW MEDICAIi A^SIi SCIENTIFIC BOOKS. 

Lea Sf Blanchard have at press and preparing /or publication thefollowing works. 
Carpenter's Comparative Anatomy and Physiology, revised by the author, with beautiful steel plates. 
Carpenter's Animal Physiology, 300 beautiful wood-cuts. 

MuLLER's Physics and Meteorology, 1 vol. 8vo., 550 wood-cuts and 2 colored plates. Nearly ready. 
Knapp's Technology, with numerous wood-cuts. 

Weisbach's Principles of Mechanics applied to Machinery and Engineering, 1 vol. 8vo., illustrations. 
MoHR and Redvpood's Practical Pharmacy, with many illustrations. Revised by W. Proctor, Lec^ 

turer in the Philadelphia College of Pharmacy. 
A New Work on the Diseases and Surgery of the Ear, with illustrations. 
Bird's Natural Philosophy, from a new Lond. ed., in 1 vol. royal 12mo. with wood-cuts. 
Dana on Corals, imp. 4to., with an Atlas of Maps, being vols. 8 and 9 of the U. S. Ex. Expedition. 
Churchill on the Management and more Important Diseases of Infancy and Childhood, in I vol. Svo. 
Solly on the Human Brain, its Structure, Physiology and Diseases. 

Spooner on Sheep, with numerous wood-cuts. Metcalf on Caloric, in 1 large Svo. volume. 

Malgaigne's Operative Surgery, with numerous wood-cuts. 

QuAiN's Elements of Anatomy, by Dr. Sharpey, with many illustrations. 

De La Beche's new work on Geology, with numerous wood-cuts. 

The Universal Formulary and Pharmacy, by R. E. Griffith, M. D., in 1 vol; Svo. 

An Analytical Compend of the Various Branches of Practical Medicine, Surgery Anatomy, Mid 
wifery, Diseases of Women and Children, MateriaMedica and Therapeutics, Physiology, Chemistry 
and Pharmacy, by John Neill, M. D., and F. Gurney Smith, M. D., with numerous illustrations. 

A Cyclopedia of Anatomy and Physiology, based on the large work of Todd, in 2 vols, large Svo. 

The Universal Dispensatory, with many wood-cuts, in 1 large Svo. volume. 

Sargent on Bandaging, and other Points of Minor Surgery, in 1 vol. 12mo., with wood-cuts. 

Elements of General Therapeutics, &c., by Alfred Stillfe, M. D., in 1 vol. 8vo. 

Coates' Popular Medicine, a new edition, fully revised and brought up, in 1 vol^lfirge 12mo. 

Professor Meigs' New Work on Females ; their Diseases and their Remedies, in a Series of Let- 
ters to hie Class, in 1 vol. Svo. 

Together with various other works. 



6 



LEA & BLANCHARD'S PUBLICATIONS. 



NOW COMPLETE. 

THE GREAT SURGICAL LIBRARY. 

A SYSTEM or SURGERY. 

BY J. M. CHELIUS, 

Doctor in Medicine and Surgery,JPublic Professor of General and Ophthalmic Surgery, etc. etc. in the Uni- 
versity of Heidelberg. 

TRANSLATED FROM THE GERMAN, 

AND ACCOMPANIED WITH ADDITIONAL NOTES AND OBSERVATIONS, 
BY JOHN F. SOUTH, 

Surgeon to St. Thomas' Hospital. 
EDITED, WITH REFERENCE TO AMERICAN AUTHORITIES, 
BY GEORGE W. NORRIS, M. D. 
Now complete in three large 8vo. volumes of nearly twenty- two hundred pages, or in 17 numbers, at 50 cents. 

This work has been delayed beyond the time originally promised for its completion, by the very extensive 
additions of the translator. In answer to numerous inquiries, the publishers now have the pleasure to pre- 
sent it in a perfect state to the profession, forming three unusually large volumes, bound in the best manner, 
and sold at a very low price. 

This excellent work was originally published in Germany, under the unpretending title of "Handbook to 
the Author's Lectures." In passing, however, through six successive editions, it has gradually increased 
in extent and importance, until it now presents a complete view of European Surgery in general, but more 
especially of English practice, and it is acknowledged to be well fitted to supply the admitted want of a com- 
plete and extended system of Surgery in ail its branches, comprehending both the principles and the prac- 
tice of this important branch of the healing art. Since Benjamin Bell's great work, first published in 1783, 
and now almost obsolete, no thorough and extended work has appeared in the English language, occupying 
the ground which this is so well calculated to cover. 

The fact of this work being carried to six editions in Germany, and translated into no less than eight lan- 
guages, is a sufficient evidence of the ability with which the author has carried out his arduous design. 

This translation has been undertaken with the concurrence and sanction of Professor Chelius. The trans- 
lator, Mr. John F. South, appears to have devoted himself to it with singular industry and ardor, and to have 
brought it up almost to the very hour of publication His notes and additions are very immerous, embodying 
the results and opinions of all the distinguished surgeons of the day, Continental, English and American. 
The leading opinions of John Hunter, on which Modern English Surgery has been raised, are set forth ; the 
results of the recent microscopical discoveries, especially in reference to inflammation, will be found here, 
together with many other practical observations, placing the work on a level with the present state of Sur- 
gery, and rendering it peculiarly useful, both to the student and practitioner. 

The labors of the English translator have been so numerous and important, that there is but little which 
remains to be supplied by the American editor. Dr. G. W. Norris has consented, however, to superintend 
the passage of the workj through the press, and supply whatever may have been omitted in relation to the 
Surgical Literature of this country. 

The Medical Press and profession, both in England and in this country, have joined in 
praise of this great work.as being more complete than any other, and as affording a complete 
library of reference, equally suited to the practitioner and to the student. 

" We strongly recommend all surgical practitioners and students, who have not yet looked into this work, 
to provide themselves with it without delay, and study its pages diligently and deliberately." — The Edin- 
burgh Medical and Surgical Journal. 

•'Judging from a single number only of this work, we have no hesitation in saying that, if the remaining 
portions correspond at all with the first, it will be by far the most complete and scientific System of Surgery 
in the English language. We have, indeed, seen no work which so nearly comes up to our idea of what 
such a production should be. both as a practical guide and as a work of reference, as this ; and the fact that 
it has passed through six editions in Germany, and been translated into seven languages, is sufficiently.con- 
vincing proof of its value. It is methodical and concise, clear and accurate, omitting all minor details and 
fruitless speculations, it gives us all the information we want in the shortest and simplest form." — The New 
York Journal of Medicine. 

Nor do these parts, in any degree, fall short of their predecessors, in the copiousness and value of their 
details. The work certainty forms an almost unique curiosity in medical literature, in the fact that the 
notes occupy a larger portion of the volume than the original matter, an arrangement which is constantly 
appearing to render the text subsidiary to its illustrations. Still this singularity of manner does not at all 
detract from the value of the matter thus disposed." — The Lcndon Medical Gazette. 

'* This work has long been the chief text-book on Surgery in the principal schools of Germany, and the 
publication of five editions of it in the original and of translations into no less than eight foreign languages, 
shows the high estimation in which it is held. As a systematic work on Surgery it has merits of a high order. 
It is methodical and concise — and on the whole clear and accurate. The most necessary information is 
conveyed in the shortest and simplest form. Minor details and fruitless speculations are avoided. It is in 
fact, essentially a practical book. This work was first published nearly twenty years ago, and its solid and 
permanent reputation has no doubt led Mr. South to undertake the present translation of the latest edition 
of it, which, we are informed, is still passing through the press in Germany. We should have felt at a loss 
to select any one better qualified for the task than the translator of Otto's Compendium of Human and Com- 
parative Pathological Anatomy — a surgeon to a large hospital whose industry and opportunities have 
enabled him to keep pace with the improvements of his time." — r7(« Medico-Chirurgical Review. 

" Although Great Britain can boast of some of the most skillful surgeons, both among.her past and her present 
professors of that branch of medical science.no work piofessingto be a complete syst'em of Surgery has been 
published in the British dominions since that of Benjamin Bell, now more than half a century old. 

This omission in English medical literature is fully and satisfactorily supplied by the translation of Profes- 
sor Chelius's System of Surgery by agentleman excellently fitted for the task, both by his extensive reading, 
and the opportunities of practical experience which he has enjoyed for years as surgeon to one of our largest 
metropolitan hospitals. The fact of Professor Chelius's work having been translated into seven languages is 
.«ufficient proof of the estimation in which it is held by our continental brethren, and the English Edition, 
now in course of publication, loses none of the value of the original from the treatment received at the hands 
jof its translator. The notes and additions of Professor South are numerous, and contain the opinions result- 
ing from his vast experience, and from that of his colleague."— The Medical Times. 

" Jt ^ably maintains the character formerly given, of being the 'most learned and complete systematic 
treatise now extant. The descriptions of surgical diseases, and indeed the whole of the pathological depari- 
menl, are most valuable."— TAe Edinburgh Medical and Surgical Journal. 

Persons wishing this work sent to them by mail, in parts, can remit Ten Dollars, for 
which a set will be sent by the publishers, free of postage, together with a copy of "The 
Medical News and Library" for one year. 



LEA & BLANCHARD'S PUBLICATIONS. 



7 



GHELIUS'S SHRfiERY, DONTINnED. 

The publishers annex a very condensed summary of the contents of Chelius's Surgery, showing 
the cojnplete and systematic manner in which the whole subject is divided and treated. 



I. Division. — Of Inflammation. 

1. Of inflammation in general. 

2. Of some peculiar kinds of inflammation^ 

a. Of erysipelas ; b. Of burns ; c. Of frost- 
bite ; d. Of boils ; e. Of carbuncle. 

3. Of inflammation in some special organs. 

a. Of inflammation of the tonsils ; 6. Of the 
parotid gland ; c. Of the breasts ; d. Of 
the urethra ; e. Of the testicle ; /. Of the 
muscles of the loins; g. Of the nail 
joints ; h. Of the joints, viz. 

a. Of the synovial membrane ; b. Of the car- 
tilages ; c. Of the joint-ends of the bones, 
viz., aa. in the hip-joint; 66. in the 
shoulder-joint ; cc. in the knee-joint ; 
and so on. 

n. Division.— Diseases which consist in a dis- 
turbance of physical connexion. 

I. Fresh solutions of continuity. 

A. Wounds ; b. Fractures. 

II. Old solutions, 

A. Which do not suppurate, viz. 

a. False joints ; 6. Hare-lip ; c. Cleft in 
the soft palate ; d. Old rupture of 
the female perineum. 

B. Which do suppurate, viz. 

i. Ulcers. 

1. In general. 

2. In particular. 

a. Atonic; 6. Scorbutic ; c. Scrofulous ; 
d. Gouty ; e. Impetiginous ;/. Vene- 
real ; g. Bony ulcers or caries. 

ii. Fistulas. 

a. Salivary fistula ; 6. Biliary fistula ; c. Faecal 
fistula and artificial anus ; d. Anal fistula ; 
e. Urinary fistula. 
HI. Solutions of continuity by changed position of 
parts. 

1. Dislocations ; 2. Ruptures ; 3. Prolapses ; 
4. Distortions. 
IV. Solutions of continuity by unnatural distention. 

1. In the arteries, aneurisms ; 2. In the veins, 
varices ; 3. In the capillary-vascular sys- 
tem, teleangiectasis. 

ni. Division.— Diseases dependent on the unna- 
tural adhesion of parts. 

1. Anchylosis ofthe joint-ends of bones ; 2. Grow- 
ing together and narrowing of the aperture 
of the nostrils ; 3. Unnatural adhesion ofthe 
tongue ; 4. Adhesion of the gums to the 
cheeks; 6. Narrowing ofthe cesophagus ; 6. 
Closing and narrowing of the rectum ; 7. 
Growing together and narrowing of the pre- 
puce ; 8. Narrowing and closing of the ure- 
thra; 9. Closing and narrowing of the vagina 
and of the mouth of the womb. 



IV. Division. — Foreign bodies. 

1. Foreign bodies introduced externally into our 

organism. 

» a. Into the nose ; 6. Into the mouth ; c. Into 
the gullet and intestinal canal ; d. Into 
the wind-pipe. 

2. Foreign bodies formed in our organism by tJie 

retention of natural products. 

A. Retentions in their proper cavities and 

receptacles. 

a. Ranula; 6. Retention of urine; c. 
Retention of the foetus in the womb 
or in the cavity ofthe belly, (Cesa- 
rean operation, section of the pubic 
symphysis, section of the belly.) 

B. Extravasation external to the proper cavi- 

ties or receptacles. 

a. Blood swellings on the heads of new- 
born children; 6. Haematocele; e. 
Collections of blood in joints. 

3. Foreign bodies resulting from the accumulation 

of unnatural secreted fluids, 
a. Lymphatic swellings ; 6. Dropsy of joints ; 
c. Dropsy of the bursas mucosae ; d. Wa- 
ter in the head, spina bifida ; e. Water 
in the chest and empyema; /. Dropsy 
of the pericardium; g-. Dropsy of the 
belly ; h. Dropsy of the ovary ; i. Hy- 
drocele. 

4. Foreign bodies produced from the concretion of 

secreted fluids. 
Y. Division. — Diseases which consist in the de- 
generation of organic parts, or in the produc- 
tion of new structures. 
1. Enlargement ofthe tongue; 2. Bronchocele ; 
3. Enlarged clitoris; 4. Warts; 5. Bunions; 
6. Horny growths ; 7. Bony growths ; 8. Fun- 
gus of the dura mater; 9. Fatty swellings,' 
10. Encysted swellings; 11. Cartilaginous 
bodies in joints; 12. Sarcoma; 13. Medul- 
lary fungus ; 14. Polypus; 15. Cancer. 

VI. Division. — Loss of organic parts. 

1 . Organic replacement of already lost parts, es- 

pecially of the face, according to the Taglia- 
cotian and Indian methods. 

2. Mechanical replacement: Application of arti- 

ficial limbs, and so on. 
VII. Division. — Superfluity of organic parts. 
VIII. Division. — Display of the elementary ma- 
nagement of surgical operations. 
General surgical operations : Bleeding, cupping, 
application of issues, introduction ofsetons, 
amputations, resections, and so on. 
^nd One Hundred and Scv€%ily-Uve Pages 
of Index, 



DRUITT'S SOReERY. New Edition— Wow Ready, 1847. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. 

By ROBERT DRUITT, Surgeon. 

THIRD AMERICAN FROM THE THIRD LONDON EDITION 
Illustrated with one hundred and fifty -three wood engravings. 
WITH NOTES AND COMMENTS, 
BY JOSHUA B. FLINT, M.D , M. M., S. S., &c. &c. 
In One very neat Octavo Volume of about Five Hundred and Fifty Pages. 
In presenting this work to the American profession for the third time, but littfe need be said to solicit for 
it a conlinuaiion of the favor with which it has been received. The merits which have procured it this 
favor, its clearness, conciseness, and its excellent arrangement, will continue to render it the favorite text- 
book ofthe student who wishes in a moderate space a compend of the principles and practice of Surgery. 

"This work merits our warmest commendations, and we 8tron;g:ly recommend it to young surgeons as aa 
admirable digest of the principles and practice of modern Surgery."— Merftcaf Gazette. 



8 



LEA & BLANCHARD'S PUBLICATIONS. 



now READ7. 

ROYLE'S MATERIA lEDICA. 

MATERIA MEDICA AND THERAPEUTICS; 

INCLUDING THE PREPARATIONS OF THE PHARMACOPCEIAS OF LONDON, 
EDINBURGH, DUBLIN, AND OF THE UNITED STATES. 

WITH MANY NEW MEDICINES. 

BY J. FORBES ROYLE, M.D., F.R.S., 

Late of the Medical Staff in the Bengal Army, Professor of Materia Medica and Therapeutics, King's Col- 
lege London, &c. &c. » 

EDITED BY JOSEPH CARSON, M.D., 

Professor of Materia Medica in the Philadelphia College of Pharmacy, &c. &e. 
WITH NINETY-EIGHT ILLUSTRATIONS. 
See Specimen of the Cuts, but not of the Paper or Working-, on next JPag-e, 
In one large octavo volume of about 700 pages. 
Being one of the most beautiful Medical works published in this Country. 

The want has been felt and expressed for some time, of a text-book on Materia Medica, which 
should occupy a place between the encyclopaedic works, such as Pereira, and the smaller treatises 
which present but a meagre outline of the science. It has been the aim of the author of the 
present \l'ork to fill this vacancy, and by the use of method and condensation, he has been enabled 
to present a volume to the student, which will be found to contain what is necessary in a complete 
and thorough text-book of the science, encumbered with few unnecessary details. The editor. 
Dr. Carson, has added whatever was wanted to adapt it to the Pharmacopoeia of the United States, 
and it is confidently recommended to the student and practitioner of medicine, as one of the best 
text-books on the subject, now before the profession. — Great care has been taken in its mechanical 
execution. 

In regard to the yet more essential constituent, the literary portion of the work, no one who is 
acquainted with the former productions of Dr. Royle, will doubt that the author has discharged his 
duties with the same skill as the artist. The work is, indeed, a most valuable one, and will fill up 
an important gap that existed between Dr. Pereira's most learned and complete system of materia 
medica, and the class of productions at the other extreme, which are necessarily imperfect from 
their small extent. — British and Foreign Medical Review. 

Of the various works that have from time to time appeared on materia medica on the plan of the 
one before us, there is none more deserving of commendation. From the examination which we 
have given, accuracy and perspicuity seem to characterize it throughout, as a text book of refer- 
ence to the student of medicine, and especially of pharmacy in its application to medicine, none 
could be better. 

We think that every one who can afford it should possess this excellent work, the value of which 
has been greatly enhanced by the additions of Dr. Carson, than whom no one is more competent 
to estimate it correctly, and to make such additions as may adapt it for American service. — The 
Medical Examiner. 



BAETLETT ON FEVER—New and much improved edition, now ready, 
THE HISTORY, DIAGNOSIS AND TREATMENT 

OF THE 

PEYERS OP THE UNITED STATES. 

BY ELISHA BARTLETT, M.D., 

Profes?or of the Theory and Practice of Medicine in the Medical Department of Transylvania University. Sec, 
In One Octavo Volume of Five Hundred and Fifty Pages, beautifully printed and strongly bound. 
This is rather a new work, than a second edition of Dr. Bartlett's well known treatise on Fevers. 
Besides numerous improvements in the portion devoted to Typhoid and Typhus Fevers, the whole 
of that descriptive of Periodical and Yellow Fevers, amounting to about half the volume, is addi- 
tional. The work is now what it purports to be, a systematic, complete and methodical treatise on 
the Fevers of the United States. 



NOW READY. 

A MANUAL OF TOXICOLOGY. 

BY ALFRED S. TAYLOR. 

EDITED BY R. E. GRIFFITH, M.D., &c 
^ M one octavo volume, to match the *^ Medical Jurisprudence'* of the same author. 



SPECIMEN OF CUTS IN 

E 0 YLE'S 

MATERIA MEDICA AND THEEAPEUTICS 



10 



LEA & BLANCHARD'S PUBLICATIONS. 



CHURCHILL'S MIDWIFERY. 



ON THE THEORY AND PRACTICE OF MIDWIFERY. 

BY FLEETWOOD CHURCHILL, M. D., M.R.LA., 

Licentiate of the College of Physicians in Ireland : Physician to the VVestern Lying-in-Hospital ; Lecturer oa 
Midwifery, &c., in the Richmond Hospital Medical School, &c. &.c. 

WITH NOTES AND ADDITIONS, 

BY ROBERT HUSTON, M.D., 
Professor of Materia Medica and General Therapeutics, and formerly of Obstetrics and the Disease of Wo- 
men and Children in the Jefferson Medical College of Philadelphia; President of the Philadelphia 
Medical Society, &c. &c. 
'SECOND AMERICAN EDITION. 
WITH ONE HUNDRED AND TWENTY-EIGHT ItlLUSTRATIONS, 

JSngraved by Gilbert from Drawings by Bagg and others. 

In one beautiful octavo volume. 
In this age of books, when much is written in every department of the science of medicine, it is a matter of 
no small moment to the student, which of the many he shall choose for his study in pupilage, and guide in 
practice. In no department is the choice more difficult than in that of midwifery ; many excellent and truly 
valuable treatises in this department of medicine have, within a few years past, been written ; of this character 
are those of Dewees. Velpeau. Meigs and Rigby, with due respect to the authors of the works just cited, we are 
compelled to admit, that to Mr. Churchill has been reserved the honor of presenting to the prof"ession one more 
particularly adapted to the want and use of students, a work rich in statistics— clear in practice — and free ia 
style — possessing no small claims to our confidence. — The New York Journal of Medicine. 

WILLIAMS' PATHOLOGY. 

NEW AND IMPROVED EDITION, BROUGHT UP TO 1S43, NEARLY READY. 



PRINCIPLES OF MEDICINE, 

COMPRISI?f& 

GENERAL PATHOLOQY AND THERAPEUTICS, 

A?fD A PEXERAT, VIEW OT 

ETIOLOGY, NOSOLOGY, SEMEIOLOGY, DIAGNOSIS AND PROGNOSIS. 
BY CHARLES J. B. WILLIAMS, M.D., F.R.S., 

Fel ow of the Royal College of Physicians &c. 
Second American, from the Second L,ondon JEdition, 
WITH N0T1::S AND ADDITIONS, BY MEREDITH CLYMER, M. D., &c. 

hi one volume, octavo. 

P E R E I R A'S MATERIA M E D I C A . 

Witb nearly Tliree Hundred £ngraTing§ on Wood. 
A NEW EDITION, LATELY PUBLISHED. 

THE ELEMENTS OF 

MATERIA MEDICA AND THERAPEUTICS. 

COTMPREHENBIJfG 

THE NATUR/VL HISTORY, PREPARATION, PROPERTIES, COMPO- 
SITION, EFFECTS AND USES OF MEDICINES. 
BY JONATHAN PEREIRA, M.D., F.R.S. and L.S. 

Member of ihe Society of Pharmacy of Paris ; Examiner in Materia Medica and Pharmacy of the University 
of London; Lecturer on Materia Medica at the London Hospital. Szc &c. 
Second American, from the last London Edition, enlarged and improved. 

WITH NOTES AND ADDITIONS BY JOSEPH CARSON, M.D. 

In two volumes, octavo, containing Fifteen Hundred very large pages, illustrated by Two Hvmdred and 

Seventy-five Wood-cuts 

This encyclopa^dia of materia medica. for such it may justly be entitled, gives the fullest and most ample ex- 
position of materia medica and its associate branches of any work hitherto published in the English language. 
It abounds in research and erudition: its statements of facts are clear and methodically arranged, while its 
therapeutical explanations are philosophical, and in accordance with sound clinical experience. It is equally 
adapted as a text-book for students, or a work of reference for the advanced practitioner, and no one can 
consult its pages without profit. The editor has performed his task with much ability and judgment. In the 
first American edition, he adopted the Phanmacopoeia of the United States, and the formulae set forth in that 
it^ndard authority; in the present he has introduced an account of substances that have recently attracted at- 
tention by their therapeutic employment, together with the mode of forming the characters and uses of new 
pharmaceutic preparations, and the details of more elaborate and particular chemical investigations, with 
respect to the nature of previously known and already described elementary principles— all the important 
indigenous medicines of ihe United States heretofore known, are also described. The work, however, is too 
well known to need any further remark. W'e have no doubt it will have a circulation commensurate with its 
extraordinary merits.— T^e i\'isi^) York Journal of Medicine. 

•' \n Encyclopaedia of knowledge in that department of medical science— by the common consent of the pro- 
fession the most elaborate and scientific Treatise 'oa Materia Medica in our tangaage."— Western Journal 
Medicine and Surgery 



LEA & BLANCHARD'S PUBLICATIONS. 



11 



WILSON'S ANATOMY. New Edition— Now Ready, 1847. 

A SYSTEM OF HUMAN ANATOMY, 
GENERAL AND SPECIAL. 

BY ERASMUS WILSON, M.D., 

Lecturer on Anatomy, London. 
THIRD AMERICAN FROM THE LAST LONDON EDITION. 

EDITED BY P. B. GODDARD, A. M. , M.D., 

Professor of Anatomy in the Franklin iVTedical College of Philadelphia. 
WITH TWO HUNDRED AND THIRTY-FIVE ILLUSTRATIONS BY GILBERT. 
Jn one beautiful octavo volume of over SIX HVJyDREn Large Pages, 

Strongly Bound and sold at a low price. 

Since the publication of the second American edition of this work, the author has issued a new 
edition in London, in which he has carefully brought up his work to a level with the most advanced 
science of the day. All the elementary chapters have been re-written, and such alterations made 
through the body of the work, by the introduction of all new facts of interest, illustrated by appro- 
priate engravings, as much increase its value. The present edition is a careful and exact reprint 
of the English volume, with the addition of such other illustrations as were deemed necessary to a 
more complete elucidation of the text ; and the insertion of such of the notes appended to the last 
American edition as had not been adopted by the author and embodied in his text ; together with 
such additional information as appeared calculated to enhance the value of the work. It may also 
be stated that the utmost care has been taken in the revision of the letter-press, and in obtaining 
clear and distinct impressions of the accompanying cuts. 

It will thus be seen, that every effort has been used to render this text-book worthy of a con- 
tinuance of the great favor with which it has been everywhen. received. Professors desirous of 
adopting it for their classes may rely on being always able to procure editions brought up to the 
day. 

This book is well known for the beauty and accuracy of its mechanical execution. The present 
edition is an improvement over the last, both in'the number and clearness of its embellishments ; 
it is bound in the best manner in strong sheep, and is sold at a price which renders it accessible 
to all. 

CONDIE ON CHILDREN.— New Edition, 1847. 
A PRACTICAlT^BEATISE ON 
THE DISEASES OF CHILDREN. 

BY D. FRANCIS CONDIE, M. D , 

Fellow of the College of Physicians, Member of t?ie American Philosophical Society, &c. 
In one large octavo volume. 
The publishers would particularly call the attention of the profession to an examination of this book. 
In the preparation of a new edition of the present treatise, every part of the work has been subjected to a 
careful revision; several portions have been entirely rewritten; while, throughout, numerous additions 
have been made, eomprising all the more important facts, in reference to the nature, diagnosis, and treat- 
ment of the diseases of infancy and childhood, that have been developed since the appearance of the first 
edition. It is with some confidence that the author presents this edition as embracing a full and connected 
view of the actual state of the pathology and therapeutics of those affections which most usually occur be- 
tween birth and puberty. 
This work is being introduced, as a text-book, very extensively throughout the Union. 



CHURCHILL ON FEMALES. New Edition, 1847.— Now Ready. 

THE DISEASES~OF FEMALES, 

INCLUDING THOSE OF 

PREGNANCY AND CHILDBED. 

BY FLEETWOOD CHURCHILL, M D., 

Author of "Theory and Practice of Midwifery," &c. &c. 
FOURTH AMERICAN, FROM THE SECOND LONDON EDITION, WITH ILLUSTRATIONS, 
EDITED, WITH NOTES, 
BY ROBERT M. H U S T O N , M . D . , & c , &.c . 
In one volume, 8vo. 

The rapid sale of three editions of this valuable work, stamp it so emphatically with the s^pprobation of the, 
profession of this country, that the publishers in presenting a fourth deem it merely necessary to observe, 
that every care has been taken, by the editor, to supply any deficiencies which may have existed in former, 
impressions, and to bring the work fully up to the date of publication. 



12 



LEA & BLANCHARD'S PUBLICATIONS. 



LIBRARY OF OPHTHALMIC MEDICINE AND SURGERY. 
Brought up to 1847. 

A TREATISE ON THE"DISEASES OF THE EYE. 

BY W. LAWRENCE, F.R.S., 
Surgeon Extraordinary to the Queen, Surgeon to St. Bartholomew's Hospital, &c. &c. 
^ ANEW EDITION, 

With many Modifications and Additions, and the Introduction of nearly two hundred Blustrations, 

BY ISAAC HAYS, M. D., 

Surgeon to Wills' Hospital, Physician to the Philadelphia Orphan Asylum, &c. &c. 

In one very large octavo yolume of near 900 pages, with twelve plates and numerous wood-cuts through 

the text. 

This is among the largest and most complete works on this interesting and difficult branch of Medica 
Science. 

The early call for a new edition of this work, confirms the opinion expressed by tlie editor of its great 
value, and has stimulated him to renewed exertions to increase its usefulness to practitioners, by incorporat-'" 
ing in it the recent improvements in Ophthalmic Practice. In availing himself, as he has freely done, of 
the observations and discoveries of his fellow-laborers in the same field, the editor has endeavored to do so 
with entire fairness, always awarding to others what justly belongs to them. Among the additions which 
have been made, may be noticed,— the descriptions of several affections not treated of in the original, — an 
account of the catoptric examination of the eye, and of its employment as a means of diagnosis.— one hun- 
dred and seventy-six illusirations, some of them from original drawings,— and a very full index. There have 
also been introduced in the several chapters on the more important diseases, the results of the editor's ex- 
perience in regard to their treatment, derived from more than a quarter of a century's devotion to the subject, 
during all of which period he has been attached to some public institution for the treatment of diseases of the 
eye. 

" We think there are few medical works which could be so generally acceptable as this one will be to the 
profession on this side of the Atlantic. The want of a scientific and comprehensive treatise on Diseases 
of the Eye, has been much deplored. That want is now well supplied. The reputation of Mr. Lawrence 
as an Oculist has been long since fully established; his great merit consists in the clearness of his style 
and the very practical tenor of his work. The value of the present beautiful edition is greatly enhanced, 
by the important additions made by the editor. Dr. Hays has, for nearly a quarter of a century, been con- 
nected with public institutions for the treatment of Diseases of the Eye, and few men have made better im- 
provement than he has, of such extensive opportunities of acquiring a thorough knowledge of the subject. 
The wood-cuts are executed with great accuracy and beauty, and no man, who pretends to treat diseases 
of the eye, should be without this work."— Xancei. 



JONES ON THE EYE. Now Ready. 

THE PRINCIPLES AND PRACTICE 
OF OPHTHALMIC MEDICINE AND SURGERY. 

By T. WHARTON JONES, F.R.S., &c. &c. 

WITH ONE HUNDRED AND TEN IliliUSTRATIONS. 

.iood8iifr| EDITED BY ISAAC HAYS; M.D., &c. \'| 

In One very neat Volume^ large royal \2mo.^ with Four Plates^ plain or colored, and Ninety- 
eight well executed Wood-cuts. 

This volume will be found to occupy a place hitherto unfilled in this department of medical science. 
The aim of the author has been to produce a work which should, in a moderate compass, be suffi- 
cient to serve both as a convenient text-book for students and as a book of reference for practitioners, 
suitable for those who do not desire to possess the larger and encyclopaedic treatises, such as 
Lawrence's. Thus, by great attention to conciseness of expression, a strict adherence to arrange- 
ment, and the aid of numerous pictorial illustrations, he has been enabled to embody in it the prin- 
ciples of ophthalmic medicine, and to point out their practical application more fully than has 
been done in any other publication of the same size. The execution of the work will be found 
to correspond with its merit. The illustrations have been engraved and printed with care, and the 
whole is confidently presented as in every way worthy the attention of the profession. 

" We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the 
promise of the preface, and sustains, in every point, the already high reputation of the author as an ophthal- 
mic surgeon, as well as a physiologist and pathologist. The book is evidently the result of much labor and 
research, and has been written with the greatest care and attention ; it possesses that best quality which a 
general work, like a system, or manual, can show, viz:— the quality of having all the materials whenceso- 
ever derived, so thoroughly wrought up, and digested in the author's mind, as to come forth with the freshness 
and impressiveness of an original production. We regret that we have received the book at so late a period 
as precludes our giving more than a mere notice of it, as although essentially and necessarily a compilation, 
it contains many things which we should be glad to reproduce in our pages, whether in the shapt; of new 
pathological views, of old errors corrected, or of sound principles of practice in doubtful cases clearly laid 
down. But we dare say most of our readers will shortly have an opportunity of seeing these in their original 
locality, as we entertain little doubt that this book will become what its author hoped it might become, a 
manual for daily reference and consultation by the student and the general practitioner. The work is 
marked by that correctness, clearness and precision of style which distinguish all the productions of the 
learned author."— T/ie British and Foreign Medical Review. 



LEA & BLANCHARD'S PUBLICATIONS. 



13 



NEW AND COMPLETE MEDICAL BOTANT. 

NOW READY. 

medicaFbotany, 

OR, A DESCRIPTION OF ALL THE MORE IMPORTANT PLANTS USED IN 
MEDICINE, AND OF THEIR PROPERTIES, USES AND 
MODES OF ADMINIS I RATION. 

BY R. EGLESFELD GRIFFITH, M. D. &c. &c. 

In one large octavo volume. ^ 

With about three hundred and fifty Illustrations on Wood. 
{Specimens of the Cuts are annexed, but not so well printed as in the work, nor on as good paper. 

This work is intended to supply a want long felt in this country, of sonie treatise present- 
ing correct systematic descriptions of medicinal plants, accompanied by representations of 
the most important of them, and furnished at a price so moderate as to render it generally 
accessible and useful. In the arrangement, the author has treated more fully of those 
plants which are known to be of the greatest importance; and more especially of such as 
are of native origin; while others, rarely used, are briefly noticed, or mentioned only by 
name. In all cases, the technical descriptions are drawn up in accordance with the existing 
state of botanical knowledge, and in order that these may be fully appreciated, even by those 
not proficients in the science, an Introduction has been prepared, containing a concise view 
of Vegetable Physiology, and the Anatomy and Chemistry of Plants. Besides this, a very 
copious Glossary of botanical terms has been appended, together with a most complete 
Index, giving not only the scientific but also the common names of the species noticed ia 
it. It will thus be seen that the work presents a view not only of the properties and medical 
virtues of the various species of the vegetable world, but also of their organization, compo- 
sition and classification. 

To the student, who is really anxious to study Botany for those great purposes which ren- 
der it so necessary for the advancement of Medical Science, and who has been obliged to 
rest satisfied with such imperfect knowledge as can be obtained from the diflTerent treatises 
on the Materia Medica, the present work will be of great utility as a text-book and guide in 
his researches, as it presents in a condensed form, all that is at present known respecting 
those vegetable substances which are employed to alleviate suffering and to minister to the 
wants of man. It will also be found extremely convenient to practitioners through the 
country, who are anxious to obtain a knowledge of the medicinal plants occurring in their 
vicinity, and who are unwilling to procure the scarce and high-priced works which are at 
present the only ones accessible on this important branch of medical knowledge. 

Great care has been taken to render the mechanical execution satisfactory. 

NOW PREPARING, 
AND TO BE READY AT AN EARLY DAY, 

AN ANALYTICAL COBIPEND OF THE VARIOUS BRANCHES OF 

PBAOTicAL mmum, mmi, mmmi, 

MIDWIFERY, DISEASES OF WOMEN AND CHILDREN, 
•Wuteria •Wedica and Thertipeuiics^ Physiology ^ 

BY JOHN NEILL, M D., 

Demonstrator of Anatomy in the University of Pennsylvania, and ' 
F. GURNEY SMITH, M.D., 
Lecturer on Physiology in the Philadelphia Association for Medical Instruction. 

To make one large royal Duodecimo volume, with numerous Illustrations on Wood. 
It is the intention of the publishers to page this work in such a way, that it can be done up in 
Beparate divisions, and in paper to go by mail; no one division will cost over 50 cents, thus pre- 
senting separate MANUALS on the various branches of medicine, and at a very low price. 



NEARLY READY. 

BURROWS ON DISORDERS OF CEREBRAL CIRCULATION, 

AND ON THE CONNECTION BETWEEN AFFECTIONS OF THE BRAIN AND 
DISEASES OF THE HEART. 
In one neat octavo volume, with six colored plates. 



SPECIMEN OF TlIB HIUSTEITIONS IN 

GRIFFITH'S MEDICAL BOTANY. 




LEA & BLANCHARD'S PUBLICATIONS. 



15 



THE GREAT MEDICAL LIBHARY. 
THE CYCLOP/EDIA OF PRACTICAL MEDICINE ; 

COMPRISING TREATISES ON THE 

• ' NATURE AND TREATMENT OF DISEASES, 

MATERIA MEDICA AND THERAPEUTICS, 

DISEASES OF WOMEN AND CHILDREN, 
MEDICAL JURISPRUDENCE, &c. &c. 

EDITED BY 

JOHN FORBES, M. D., F.R. S., 
ALEXANDER TWEEDIE, M.D., F.R.S., 

AND 

JOHN C0N6LLY, M.D. 

REVISED, WITH ADDITIONS, 

By ROBLEY DDNGLISON, M. D. 

THIS WORK IS NOW COMPLETE, AND FORMS 

FOUR LARGE SUPER-ROYAL, OCTAVO VOLUMES. 

CONTAINING THIRTY-TWO HUNDRED AND FIFTY-FOUR 

UNUSUALLY LARGE PAGES IN DOUBLE COLUMNS, 

PRINTED ON GOOD PAPER, WITH A NEW AND CLEAR TYPE. 
THE WHOLE WELL AND STRONGLY BOUND, 
WITH RAISED BANDS AND DOUBLE TITLES. 
Or, to he had in twenty-four parts, at Fifty Cents each. 

For a list of Articles and Authors, together with opinions of the press, see Supplement to the No- 
vember number of the Medical News and Library for 1845. 

This work having been completed and placed before the profession, has 
been steadily advancing in favor with all classes of physicians. The nu- 
merous advantages which it combines, beyond those of any other work ; the 
weight which each article carries with it, as being the production of some 
physician of acknowledged reputation who has devoted himself especially 
to the subject confided to him; the great diversity of topics treated of ; the 
compendiousness with which everything of importance is digested into a 
comparatively small space ; the manner in which it has been brought up 
to the day, everything necessary to the American practitioner having been 
added by Dr. Dunglison ; the neatness of its mechanical execution; and 
the extremely low price at which it is afforded, combine to render it one of 
the most attractive works now before the profession. As a book for con- 
stant and reliable reference, it presents advantages which are shared by no 
other work of the kind. To country practitioners, especially, it is abso- 
lutely invaluable, comprising in a moderate space, and trifling cost, the 
matter for which they would have to accumulate libraries, when removed 
from public collections. The steady and increasing demand with which 
it has been favored since its completion, shows that its merits have been 
appreciated, and that it is now universally considered as the 

LIBRARY FOR CONSULTATION AND REFERENCE. 



A mAGnmoin^ Aim chsap wohk. 



& HORNER'S ANATOMICAL ATLAS. 

Just Published, Price Five Dollars in Parts. 



AN 

ANATOMICAL ATLAS 
ILLnSTKATI¥E OF THE STEUGTHRE OF THE HUMAN mW- 

BY HENRY H. SMITH, M.D., i Ai/i 

Fellow of the College of Physicians, ^e. 
UNDER THE SUPERVISION OF 

WILLIAM E. HORNER, M.D., 

Professor of Anatomy in the University of PennsylvaauOm 

In One la!rge Volume, Imperial Octavo. 

This work is but just completed, having been delayed over the time intended by the great difficulty in giving 
to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows: 
Part I. The Bones and Ligaments, with one hundred and thirty engravings. 
Part II. The Muscular and Dermoid Systems, with ninety-one engravings. 

Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. 

Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. 

Part V. The Nervous System and the Senses, with one hundred and twenty-six engravings. 
Forming altogether a complete System of Anatomical Plates, of nearly 

SIX HUNDRED AND FIFTY FIGURES, 
executed in the best style of art, and making one large imperial octavo volume. Tliose who do not want it in 
parts can have the work bound in extra cloth or sheep at an extra cost. 

Tliis work possesses novelty both in the design and the execution. It is the first attempt to apply engraving 
on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the 
publishers to flatter themselves with the hope of the perfect success of their undertaking. The plan of the 
work is at once novel and convenient. Each page is perfect in itself, the references being immediately under 
the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference 
backwards and Ibrwards. The cuts are selected from the best and most accurate sources ; and, where neces- 
sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn 
sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in tlie investi- 
gation of th* minute structure of the tissues. 

In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they 
now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific 
and artistical point of view, while, at the same time, its very low price places it within the reach of all. 

It is particularly adapted to supply the place of skeletotu or subjects, as the profession will see by examining the list 
of plates 



SMITH 



" These figures are well selected, and present a complete and accurate representation of that wonderful fabric, 
the human body. The plan of this Atlas, which renders it so peculiarfy convenient for the student, and its 
superb artistical execution, have been already pointed out. We must congratulate the student upon the 
completion of this atlas, as it is the most convenient work of the kind that has yet appeared; and, we must 
add, the very beautiful manner in which it is 'got up' is so creditable to the country as to be flattering to our 
national pride." — American Medical Journal. 

"This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, 
but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We 
strongly recommend to our friends, both urban and suburban, the purchase of this excellent work, for which 
both editor and publisher deserve trie thanks of the profession." — Medical Examiner. 

"We would strongly recommend it, not only to the student, but also to the working practitioner, who, 
although grown rusty in the toils of his harness still has the desire, and often the necessity, of refreshing his 
knowledge in this fundamental part of the science of medicine." — hhw York Journal of Mediciyie and Surg. 

" The plan of this Atlas is admirable, and its execution superior to any thing of the kind belbre published m 
this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be 
conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy 
means of recalling the details learned in the dissecting room, and which are soon forgotten." — American Mtdv' 
etil Journal. 

" It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, 
Burgeons and medical students." — Boston Med. and Surg. Journal. 

It has been the aim of the author of the Atlas to comprise in it tne valuable points of all previous works, to 
embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate 
price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other field 
of practice." — Wesurn Journal of Med. and Surgery. 

"These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the 
earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, 
and cordially recommend the work to all engaged in the study of anatomy." — New York Journal of Medidus 
and Surgery. 

"A more elegant work than the one before us could not easily be placed by a physician upon the table ol 
his student.^ — Western Journal of Medicine and Surgery. 

"We were much pleased with Part I, btu the Second Part gratifies us still more, both as regards the attract- 
ive nature of the subject, (The Dermoid and Muscular Systems.) and the beautiful artistical execution of the 
Jlustraiions. We have here delineated the most accurate microscopic views of some of the tissues, as, foi 
inftance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous ant 
perspiratory organs of the skin, the per.=piratory glands and hairs of the skin, and the hair and nails. Thes 
.'"oUovvs tlie general anatomy of the muscles, and, lastly, their separate delineations. We would recommend 
this Anatomical Atlas to our readers in tlie very strongest te^ms." — New York Journal of Medicine and Sur* 
gery, . 



LEA & BLANCHARD'S PUBLICATIONS. 



17 



NEW EDITION. 

SPECIAL anatomy" AND HISTOLOGY. 

BY WILLIAM E. HORNER, M.D., 

PBOFESSOK OF ASTATOMT IIT THE XTXIVERSITr OF PENNSYLVANIA, &C., &C. 

Seventh edition. 

With many improvements and additions. In two octavo volumes, with illustrations on 

wood. 

This standard work has been so long before the profession, and has been so extensively 
used, that, in announcing the new edition, it is only necessary to state, that it has under- 
gone a most careful revision ; the author has introduced many illustrations relating to Mi- 
croscopical Anatomy, and has added a large amount of text on those various points of 
investigation that are rapidly advancing and attracting so much attention. This new edition 
has been arranged to refer conveniently to the illustrations in Smith and Horner's Anato- 
mical Atlas. ' 

"The name of Professor Horner is a sufficient voucher for the fidelity and accuracy of 
any work on anatomy, but if any further evidence could be required of the value of the pre- 
sent publication, it is aiforded by the fact of its having reached a seventh edition. It is 
altogether unnecessary now to inquire into the particular merits of a work which has been 
so long before the profession, and is so well known as the present one, but in announcing a 
new edition, it is proper to state that it has undergone several modifications, and has been 
much extended, so as to place it on a level with the existing advanced stale of anatomy. — 
The histological portion has been remodelled and rewritten since the last edition; numerous 
wood cuts have been introduced, and specific references are made throughout the work to 
the beautiful figures in the Anatomical Atlas, by Dr. H. H. Smith." — The American Medical 
Journal, for January , 1847. 



HORNER' S^ISSSCTOR. 

THE UNITED STATES DISSECTOR, 

■ BEING A NEW EDITION, WITH EXTENSIVE MODIFICATIONS, 
AND ALMOST REWRITTEN, OF 

'^MOUJ^mw'S JPR^lCTlCJlIj ^JWMTO^W-^V^ 

IN ONE VERY NEAT VOLUME, ROYAL 12mo. 
With many Illustrations on Wood. 

The numerous alterations and additions which this work has undergone, the improve- 
ments which have been made in it, and the numerous wood-cuts which have been intro- 
duced, render it almost a new work. 

It is the standard work for the Students in the University of Pennsylvania. 

Some such guide-book as the above is indispensable to the student in the dissecting room, 
and this, prepared by one of the most accurate of our anatomists, may claim to combine as 
many advantages as any other extant. It has been so favorably received that the publish- 
ers have issued the fourth edition, which comes forth embellished by various wood cuts. — 
The copy for which we are indebted to the publishers, although received by us a fortnight 
since, gives proof in its appearance that it has already seen service at the dissecting table, 
■where students have found it a valuable guide. — The Western Journal of Medicine and Sur- 
gery. 



HOPE ON THE HEART. NEWJDITION, JUST PUBLISHED. 

A TREATISE ON THE DISEASES 

OF THE MEAilT AMI> GI^EAT YE^SEIiS, 

AND ON THE AFFECTIONS WHICH MAY BE MISTAKEN FOR THEM. 
Comprising the author's view of the Physiology of the Heart's Action and Sounds as demonstrated by his ex- 
periments on the Motions and Sounds in 1830, and on the Sounds in 1834— 5. 
BY J. HOPE, M. D., F. R. S,, &c. &c. 
Second American from the third London edition. With Notes and a Detail of Recent Experiments. 
BY C. W. PENNOCK, M.D,, &c. 
In one octavo volume of nearly six hundred pages with thographic plates. 



38 



LEA & BLANCHARD'S PUBLICATIONS. 



WORKS BY PROFESSOR W. P. DEWEES. 

NEW EDITIONS. 

. , DEWEES'S MIDWIFERY. 

' " a comprehensive system of midwifery. 

CHIEFLY DESIGNED TO FACILITATE THE INQUIRIES OF THOSE WHO MAY BE PUR- 
SUING THIS BRANCH OF STUDY. 
ILLUSTRATED BY OCCASIONAL CASES AND MANY ENGRAVINGS. 
Eleventh Edition, with the Author^s last Improvements and Corrections, 

BY WILLIAM P. DEWEES, M.D., 

LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 

In one volume, octavo. 

' That this work, notwithstanding the length of time it has been before the profession, and the numerous treat- 
ises that have appeared since it was written, should have still maintained its ground, and passed to edition after 
edition, is sufficient proof that in it the practical talents of the author were fully placed before the profes- 
sion. Of the book itself it would be superfluous to speak, having been so long and so favorably known through- 
out the country as to have become identified with American Obstetrical Science. 



DEWEES qN_ FEMALES. 

A TREATISE ON THE DISEASES OF FEMALES. 

BY WILLIAM P. DEWEES, M.D., &c., 

LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. 

NINTH EDITION, 
With the Author's last Improvements and Corrections. 

In one octavo volume, with plates. 



DEWEES ON CHILDREN. 

A TREATISE ON THE 

PHYSICAL AND MEDICAL TREATMENT OF CHILDREN, 

BY WILLIAM P. DEWEES, M.D., 

LATE PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA, ETC. ETC. 

NINTH EDITION. 

In one volume octavo. 

This edition embodies the notes and additions prepared by Dr. Dewees before his death, and will be found 
much improved. 

The objects of this work are, 1st, to teach those who have the charge of children, either as parent or guardian, 
the most approved methods of securing and improving their physical powers. This is attempted by pointing 
oui the duties which the parent or the guardian owes for this purpose, to this interesting but helpless class of 
beings, and the manner by which their duties shall be fulfilled. And 2d, to render available a long experience 
to those objects of our affection when they become diseased. In attempting this, the author has avoided as 
much as possible, "technicality," and has given, if he does not flatter himself too much to each disease of 
which he treats, its appropriate and designating characters, with a fidelity that will prevent any two being 
confounded together, with the best mode of treating them, that either his own experience or that of others has 
suggested. 

Physicians cannot too strongly recommend the use of this book in all families. 



ASHWELL ON THE DISEASES OF FEMALES. 

A PRACTICAL TREATISE ON THE 

DISEASES PECULIAR TO WOMEN. 

ILLUSTRATED BY CASES 
DERIVED FROM HOSPITAL AND PRIVATE PRACTICE. 

By SAMUEL ASHWELL, M.D., 

Member of the Royal College of Physicians ; Obstetric Physician and Lecturer to Guy's Hospital, &c. 

Edited by PAUL BECK GODDARD, M. D. 

The whole complete in one large octavo volume. 
" The most able, and certainly the most standard and practical work on female diseases that we 
have yet seen." — Medico-Chirurgical Review. 



LEA & BLANCHARD'S PUBLICATIONS. 



19 



WATSON'S PRACTICE OF PHYSIC. 

NEW EDITION, BROUGHT UP TO SEPTEMBER 1847. 



LECTURES ON THE 

PRINCIPLES AND PRACTICE OF PHYSIC 

DELIVERED AT KING'S COLLEGE, LONDON, 

By THOMAS WATSON, M.D., &c. &c. 
Third American, from the Last London Edition. 

REVISED, WITH ADDITIONS, 
BY D. FRANCIS CONDIE, M. D., 
Author of a work on the "Diseases of Children," &c. 

In One Octavo Volume 
Of nearly ELEVEN HUNDRED Lahge Pages, strongly bound with raised bands. 
The rapid sale of two large ediiions ot this work is an evidence of its merits, and of its general favor with the 
American practitioner. To commend it still more sironEfly to the profession, the publishers have gone to a 
great expense in preparing this edition with larger type, fiaer paper, and stronger binding with raised bands. 
It is edited with reference particularly to American practice, by Dr. Condie; and with these numerous im- 
provements, the price is still kept so low as to be within the reach of all, and to render it among the cheapest 
works offered Jo the profession. It has been received with the utmost favor by the medical press, both of this 
country and of England, a few of the notices of which, together with a letter from Professor Chapman, are 
submitted. 

Philadelphia, September 27th, 1844. 
Watson's Practice of Physic, in my opinion, is among the most comprehen- 
sive works on the subject extant, replete with curious and important matter, and 
written with great perspicuity and felicity of manner. As calculated to do much 
good, I cordially recommend it to that portion of the profession in this country 
who may be influenced by my judgment. 

N. CHAPMAN, M.D., 

Professor of the Practice and Theory of Medicine in the University of Pennsylvania. 

" We know of no work better calculated for being placed in the hands of the student, and for a text-book, and 
as such we are sure it will be very extensively adopted. On every important point the author seems to have 
posted up his knowledge to the day." — American MedicalJournal. 

One of the most practically useful books that ever was presented to the student— indeed a more admirable 
summary of general and special pathology, and of the application of therapeutics to diseases, we are free to 
say has not appeared for very many years. The lecturer proceeds through the whole classification of human 
ills, acapite ad calcem, showing at every step an extensive knowledge of his subject, with the ability of commu- 
nicating his precise ideas in a style remarkable for its clearness and simplicity."— iV. Y. Journal of Medi' 
cine and Surgery. 

" We are free to state that a careful examination of this volume has satisfied us that it merits all the com- 
mendation bestowed on it in this country and at home. It is a work adapted to the wants of young practi- 
tioners, combining as it does, sound principles and substantial practice. It is not too much to say that it is a 
representative of the actual state of medicine as taught and practised by the most eminent physicians of the 
present day, and as such we would advise every one about embarking in the practice of physic to provide him- 
self with a copy of it."— Western Journal of Medicine and Surgery. 



VdCEUS PATHOLOGICAL ANATOMY. 

THE 

PATHOLOGICAL ANATOMY OF THE HUMAN BODY. 

By JULIUS VOGEL, M.D., &c. 

TRANSLATED FROM THE GERMAN, WITH ADDITIONS, 
By GEORGE E. DAY, M.D., &c. 
KllustratetJ hs uptoavtrs of (?^ne 74uix"tirc"0 3^UUx anti €olore"0 ISnflrabftiflSf. 

In One neat Octavo Volume. 

Incur last number we gave a pretty full analysis of the original of this very valuable work, to which we 
must refer the reader. We have only to add here our opinion that the translator has performed his task in an 
excellent manner, and has enriched the work wuh many valuable additions.— TAe British and Foreign Medical 
Review. 

It is decidedly the best work on the sultject of which it treats in the English language, and Dr. Day, whose 
translation is well executed, has enhanced its value by a judicious selection of the most important figures from 
the atlas, which are neatly engraved.— TAe London Medical Gazette. 



20 ^ 



LEA. & BLANCHARD'S PUBLICATIONS. 



A NEW EDITION OF THE GREAT 

V MEDIO AL_LEZICSOn. 

A Dictionary of 

MEDICAL SCIENCE, 

CONTAINING A CONCISE ACCOUNT OF THE VARIOUS SUBJECTS AND TERMS; WITH THE 
FRENCH AND OTHER SYNONVMES; NOTICES OF CLIMATES AND OF CELE- 
BRATED MINERAL WATERS; FORMULAS FOR VARIOUS OFFICINAL 
AND EMPIRICAL PREPARATIONS, &c. 

BY ROBLEY DUNGLISON, M. D., 

PKOFESSOR OF THE INSTITUTES OF MEDICINE, ETC. IN JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. 

Sixth edition, revised and greatly enlarged. In one royal octavo volume of over 800 very large pages, 

double columns. Strongly bound in the best leather, raised bands. 
" The most complete medical dictionary in the English language."— Western Lancet. 

" We think that 'the author's anxious wish to render the work a satisfactory and desirable— if not indispen- 
sable — Lexicon, m which the student may search without disappointment for every term that has been 
legitimated in the nomenclature of the science,' has been fully accomplished. Such a work is much needed 
by all medical students and young physicians, and will doubtless continue in extensive demand. It is a 
lasting monument of the industry and literary attainments of the author, who has long occupied the highest 
rank among the medical teachers of America."— T/ie New Orleans Medical and Surgical Journal. 

"The simple announcement of the fact that Dr. Dunglison's Dictionary has reached a sixth edition, is almost 
as high praise as could be bestowed upon it by an elaborate notice. It is one of those srandard works that have 
been ' weighed in the balance and (not) been found wanting ' It has stood the test of experience, and the fre- 
quent calls for new editions, prove conclusively that it is held by the profession and by students in the highest 
estimation. The present edition is not a mere reprint of former ones; the author has for some time been 
laboriously engaged in revising and making such alterations and additions as are required by the rapid pro- 
gress of our sc ience, and the introduction of new terms into our vocabulary. In proof of this it is slated ' that 
the present edition comprises nearly two thousand five hundred subjects and terms not contained in the last. 
Many of these had been introduced into medical terminology in consequence of the progress of the science, 
and others had escaped notice in previous revisions.' We think that the earnest wish of the author has been 
accomplished ; and that he has succeeded in rendering the work ' a satisfactory and desirable— if not indis- 
pensable— Lexicon, in which the student may search, without disappointment, for every term that has been 
legitimated in the nomenclature of the science.' This desideratum he has been enabled to attempt in suc- 
cessive editions, by reason of the work not being stereotyped ; and the present edition certainly offers stronger 
claims to the attention of the practitioner and student, than any of iis predecessors. The work is got up in 
the usual good taste of the publishers, and we recommend it in full confidence to all who have not yet supplied 
themselves with so indispensable an addition to their libraries." — The New York Journal of Medicine. 



A NEW EDITION OF DUNGLISON'S HUMAN PHYSIOLOGY. 



HUMAN PHYSIOLOaY, 

WITH THREE HUNDRED AND SEVENTY ILLUSTRATIONS. 
BY ROBLEY DUNGLISON, M.D., 

PEOFESSOE OF THE INSTITUTES OF MEDICINE IN THE JEFFERSON MEDIC AL COLLEGE, PHILADELPHIA, ETC., ETC. 

Sixth edition, greatly improved. — In two large octavo volumes, containing nearly 1350 pages. 
"It is but necessary for the Author to say, that all the cares that were bestowed on the preparation of the 
fifth edition have been extended to the sixth, and even to a greater amount. Nothing of importance that has 
been recorded since its publication, has, he believes, escaped his attention. Upwards of seventy illustrations 
have been added ; and many of the former cuts have been replaced by others. The work, he trusts, will be 
found entirely on a level with the existing advanced state of physiological science." 

In mechanical and artistical execution, this edition is far in advance of any former one. 
The illustrations have been subjected to a thorough revision, many have been rejected and 
their places supplied with superior ones, while numerous new wood-cuts have been added 
wherever perspicuity or novelty seemed to require them. 

, "Those who have been accustomed to consult the former editions of this work, know with how much 
care and accuracy every fact and opinion of weight, on the various subjects embraced in a treatise on 
Physiology, are collected and arranged, so as to present the latest and best account of the science To such 
we need hardly say, that, in this respect, the present edition is not less distinguished than those which have 
preceded it. In the two years and a half which have elapsed since the last or fifth edition appeared, nothing 
of consequence that has been recorded seems to have been omitted. Upwards of seventy illustrations have 
been added, and many of the former cuts have been replaced by others of better execution. These mostly 
represent the minute structures as seen through the microscope, and are necessary for a proper comprehensioa 
of the modern discoveries in this department " — The Medical Examiner. 

The " Human Physiology" of Professor Dunglison has long since taken rank as one of the medical classics 
in our language. Edition after edition has been issued, eacli more perfect than the la>t, till now we have the 
sixth, with upwards of seventy new illustrations. To say that it is by far the best text-book of physiology ever 
published in this country, is but echoing the general voice of the profession. It is simple and concise in style, 
clear in illustration, and altogether on a level with the existing advanced state of physiological science. The 
additions to the present edition are extremely numerous and valuable; scarcely a fact worth naming which 
has a bearing upon the subject seems to have been omitted. All tlie recent writers on physiology, both in the 
French, German and English languages, have been consulted and freely used, and the facts lately revealed 
through the agency of organic chemistry and the microscope have received a due share of attention. As it is, 
we cordially recommend tlie work as in the highest degree indispensable both to students and practitioners 
of medicine. — New York Journal of Medicine. 

The most full and complete system of physiology in our language.— Western Lancet. 



LEA & BLANCHARD'S PUBLICATIONS. 



21 



DUNGLISON'S THERAPEUTICS. 

NEW AND MUCH IMPROVED EDITION. 

eE^ERAL THERiiPEOTICS m MATERIA MEMQk. 

With One Hundred and Twenty Illustrations. 

ADAPTED FOR, A MEDICAL TEXT-BOOK. 

BY ROBLEY DUNGLISON, M.D., 

Professor of Institutes of Medicine, &c. in Jefferson Medical College; Late Professor of Materia Medica, &c. 
in the Universities of Virginia and Maryland, and in Jefferson Medical College. 

Third Edition, Revised and Improved, in two octavo volumes, well bound. 

In this edition much improvement will be found over the former ones The author has subjected it to a tho- 
rough revision, and has endeavored to so modify the work as to make it a more complete and exact exponent 
of the present state of knowledge on the important subjects of which it treats. The favor with which the former 
editions were received, demanded that the present should be rendered still more worthy of the patronage of tlie 
profession, and this alteration will be found not only in the matter of the volumes, but also in the numerous 
illustrations introduced, and the genei-al improvement in the appearance of the work. 

•'This is a revised and improved edition of ihe author's celebrated book, entitled ' General Therapeutics;' an 
account of the different articles of the Materia Medica having been incorporated with it. The work has, in 
fact, been entirely remodelled, so that it is now the most complete and satisfactory exponent of the existing state 
of Therapeutical Science, within the moderate limitsof a text-book, of any hitherto published. What gives the 
work a superior value, in our judgment, is the happy blending of Therapeutics and Materia Medica as they are, 
or ought to be taught in all our medical schools; going no farther into the nature and commercial history of 
drugs, than is indispensable for the medical student. This gives to the treatise a clinical and practical charac- 
ter, calculated to benefit in the highest degree, both students and practitioners. We shall adopt it as a text- 
book for our classes, while pursuing this branch of medicine, and shall be happy to learn that it has been 
adopted as such, in all of our medical institutions."— T/ie N. Y. Journal of Medicine. 

"Our junior brethren in America will find in these volumes of Professor Dunglison, a 'THESAUEtrs Medica.- 
MiNUM,' more valuable than a large purse of goXA.''''— London Medico-Chirurgical Review. 

DUNGLISON ON NEW REMEDIES. 

NEW EDITION, BROUGHT UP TO OCTOBER 18-46. 

MEW REMEDIES. 

BY ROBLEY DUNGLISON, M.D., &c. &c. 

Fifth edition, with extensive additions. ^In one neat octavo volume. 

The numerous valuable therapeutical agents which have of late years been introduced into the Materia 
Medica, render it a difficult matter for the practitioner to keep up with the advancement of the science, espe- 
cially as the descriptions of them are difficult of access, being scattered so widely through transactions of 
learned societies, journals, monographs, &c. &c. To obviate this difficulty, and to place within reach of the 
profession this important information in a compendious form, is the otyect of the present volume, and the num- 
ber of ediiions through which it has passed show that its utility has not been underrated. 

The author has taken particular care that this edition shall be completely brought up to the present day. — 
The therapeutical agents added, which maybe regarded as newly introduced into the Materia Medica, to- 
gether with old agents brought forward with novel applications, and which may therefore be esteemed as 
•'New Remedies," are the following :— Benzoic Acid, Chromic Acid, Gallic Acid. Nitric Acid, Phosphate of 
Ammonia, Binelli Water, Brocchieri Water, Atropia Beerberia, Chloride of Carbon (Chloroform), Digitalia, 
Electro-Magnetism, Ergotin, Ox-gall, Glycerin, Hajmospasy, Ha3mo.«tasis, Hagenia Abyssinica. Honey Bee, 
Protochloride of Mercury and Quinia, Iodoform. Carbonate of liithia. Sulphate of Manganese, Matico, Double 
Iodide of Mercury and Morphia, lodhydrate of Morphia, Iodide of lodhydrale of Morphia, Muriate of Mor- 
phia and Codeia, Naphthalin, Piscidia Erythrina. Chloride of Lead. Nitrate of Potassa. Arseniateof Quinia, 
Iodide of Quinia, Iodide of Cinchonia. Iodide of lodhydrate of Quinia, I^actate of Quinia, Pyroacetic Acid, 
(Naphtha, Acetone) Hyposulphate of Soda. Plio-sphate of Soda, Iodide of lodhydrate of Strychnia, Double Iodide 
of Zinc and Strychnia, Double Iodide of Zinc and Morphia, and Valerianate of Zinc. 

; " A work like this is obviously not suitable for either critical or analytical review. It is. so far as it goes, a 
dispensatory, in which an account is given of the chemical and physical properties of all the articles recently 
added to the Materia Medica and their preparations, with a notice of the diseases for which they are prescribed, 
the doses, mode of administration. &c." — The Medical Examiner. 



THE lEOiCIlL SIlBEiT, 

OR AIDS TO THE STUDY OF MEDICINE. 

A REVISED AND MODIFIED EDITION. 

BY ROBLEY DUNGLISON, M. D. 

In one neat \2mo. volume. 



HUMAN HEALTH: 

OR, THE INFLUENCE OF ATMOSPHERE AND LOCALITY. CHANGE OF AIR ^VND CLIMATE, 
SEASONS, FOOD. CLOTHING, BATHING AND MINERAL !<PRINGS, EXERCISE, 
SLEEP, CORPOREAL AND INTELLECTUAL PURSUITS, &c. &c., 
OJV HEALTHY MAN: CONSTITUTING 

ELEMENTS OF HYGIENE. 

BY ROBLEY DUNGLISON, M.D. 

A New Edition with many Modifications and Additions. In one Volume, 8vo, 



LEA & BLANCHARD'S PUBLICATIONS. 



AMERICAN PRACTICE OF MEDICINE. 

BY PROFESSOR DUNGLISON. 
THIRD EDITION, MUCH IMPROVED, NOW READY, BROUGHT UP TO 1S48. 

THE PRACTICE'oF MEDICINE; 

A TREATISE ON 

SPECIAL PATHOLOGY AND' THERAPEUTICS. 

THIRD EDITION. * 

By ROBLEY DUNGLISON, M. D. 

Professor of the Institutes of Medicine in the Jefferson Medical College; Lecturer on Clinical Medicine, 

In Two large Octavo Volumes of over Fourteen Hundred Pages. 

Since the publication of the second edition of this work, short as the interval has been, so much 
activity has prevailed in the advancement of medical knowledge, that a thorough revision of it 
became necessary. Several pathological affections, too, had been omitted, which are now insert- 
ed. The greatly enlarged dimensions of the work will suflBciently exhibit the amount of additions, 
which might escape superficial observation. 

In preparing the present edition, the author has carefully scanned the various monographs on 
pathology and therapeutics, which have appeared alone or in different cyclopsediac and other works, 
transactions of learned societies, and journals. He has also availed himself of the valuable matter 
contained in recent treatises having a similar scope with his own, of which he may specify more 
particularly those of Canstatt, Fuchs, and Wunderlich of Germany; Valliex and Grisolle of France; 
and Dickson of this country. The Pathological Anatomy of Vogel, and the Animal Chemistry of 
Simon, have also yielded him valuable assistance. Nothing of importance that has been recorded 
since the publication of the last edition has, he believes, escaped his attention; and altogether he 
trusts that the present edition will be regarded as an adequate exponent of the existing condition 
of knowledge on the important departments of which it treats. 

Notwithstanding the numerous and attractive works which have of late been issued on the Practice of 
Physic, these volumes keep their place as a standard text-book for the student, and manual of reference for 
the practitioner. The care with which the author embodies everything of value from all sources, the industry 
with which all discoveries of interest or importance are summed up in succeeding editions, the excellent 
order and system which is everywhere manifested, and the clear and intelligible style in whichhis thoughts 
are presented, render his works universal favorites with the profession. 

"In the volumes before us, Dr. Dunglisou has proved that his acquaintance with the present facts and 
doctrines, wheresoever originating, is most extensive and intimate, and the judgment, skill, and impartiality 
with which the materials of the work have been collected, weighed, arranged, and exposed, are strikingly 
manifested in every chapter. Great care is everywhere taken to indicate the source of information, and 
under the head of treatment, formulee of the most appropriate remedies are every where introduced. In con- 
clusion, we congratulate the students and junior practitioners of America on possessing in the present 
volumes a work of standard merit, to which they may confidently refer in their doubts and difficulties." — 
Brit, and For. Med. Rev. 

" Since the foregoing observations were written, we have received a second edition of Dunglison's work, 
a sufficient indication of the high character it has already attained in America, and justly attained."— Jbi<i. 

"In the short space of two years, a second edition of Dr. Dunglison's Treatise on Special Pathology and 
Therapeutics has been called for. and is now before the public in the neat and tasteful dress in which Lea 
& Blanchard issue all their valuable publications. We do not notice the fact for the purpose of passing any 
studied eulogy upon this work, which is now too well known to the profession to need the commendation of 
the press. 

" A cursory examination will satisfy any one, that great labor has been bestowed upon these volumes, 
and on a careful perusal it will be seen that they exhibit the present state of our knowledge relative to 
special pathology and therapeutics. The work is justly a great favorite with students of medicine, whose 
exigencies the learned author seems especially to have consulted in its preparation." — Western Jour, of 
Med. and Surg. 

" This is a work which must at once demand a respectful consideration from the profession, emanating as 
it does from one of the most learned and indefatigable physicians of our country. 

"This arrangement will recommend itself to the favorable consideration of all, for simplicity and com- 
prehensiveness. We have no space to go into details, and, therefore, conclude by saying, that although 
isolated defects might be pointed out, yet as a whole, we cheerfully recommend it to the profession, as 
embracing much important matter which cannot easily be obtained from any other source."— Western La?icet, 



WIIiSOIT ON THE SKIU. 

NEW AND IMPROVED EDITION, (1847.) 

ON DISEASES~OF THE SKIN. 

BY ERASMUS Vl^ILSON, F. R. S., 

AUTHOR OF ''a SYSTEM OF HUMAN ANATOMY," ETC. 

SECOND AMERICAN, FROM THE SECOND LONDON EDITION. 
In one neat octavo volume, extra doth, of Four Hundred and Forty Pages, with Eight Steel Plates, 
accurately and beautifully colored. 
Copies may be had with or without the plates, or the plates may be had separate, neatly and strongly 
done up. 

The increase of this work by nearly a hundred pages shows that this edition is much improved, and brought 
up to the date of publication. 



LEA & BLANCHARD'S PUBLICATIONS. 



23 



BRODIE'S SURGICAL WORKS. 



SELECT SUEBICAL WORKS OF SIR BENJ'N BEODIE, BART., V.P.R.S. 

CONTAINING HIS 

CLINICAL LECTURES ON SURGERY, 
LECTURES ON THE DISEASES OF THE URINARY ORGANS, 

AND 

OBSERVATIONS ON THE DISEASES OF THE JOINTS. 

The whole in one neat octavo volume, strongly hound, 
ALSO, 

I^acli of tlie above works to Tie liad separately, done up in cloth. 



MULLER'S PHYSICS AND METEOROLOGY— Nearly Ready. 



PRINCIPLES OF PHYSICS AND METEOROLOGY- 
BY J. MULLER, 

PROFESSOR OF PHYSICS AT THE UNIVERSITY OF FREIBURG. 

Illustrated with nearly Five Hundred and Fifty Engravings on Wood, and Two Colored Plates. 

In One Octavo Volume. 
"The Physics of Muller is a work superb, complete, unique ; the greatest want known to English Science 
could not have been better supplied. The work is of surpassing interest. The value of this contribution to 
the scientific records of this country may be duly estimated by the fact, that the cost of the original drawings 
and engravings alone has exceeded the sum of £2000."- Lancet. March 1647. 



SOLLY ON THE BRAIN— Nearly Ready. 
THE HUMAN BRAIN: ITS STRUCTURE, FHYSIOLO&Y, AND DISEASES. 

WITH 

A DESCRIPTION OF THE TYPICAL FORMS OF BRAIN IN THE ANIMAL KINGDOM. 
BY SAMUEL SOLLY, F.R.S., 

Senior Assistant-Surgeon to St. Thomas' liospiial; and Lecturer on Clinical Surgery, &c. 
SECOND EDITION, GREATLY ENLARGED. 
0?ie Octavo Volume, with 120 Cuts. 

MILLER'S SURGICAL WORKS. 



THE PRINCIPLES OF SURGERY. 

BY JAMES MILLER, F.R.S.E., F.R.C.S.E., 

Professor of Surgery in the University of Edinburg, &c. 
In one neat octavo volume, to match the Author'>s volume on " Practice.^* 
" We feel no hesitation in expressing our opinion that it presents the philosophy of the science 
more fully and clearly than any other work in the language with which we are acquainted." — Phi- 
ladelphia Medical Examiner. 



LATELY PUBLISHED. 

THE PRACTICE OF SURGERY. 

BY JAMES MILLER, 

Professor of Surgery in the University of Edinburg. 
In one neat octavo volume. 
This work is printed and bound to match the " Principles of Surgery," by Professor Miller, lately 
issued by L. & B. Either volume may be had separately. 
This work, with the preceding one, forms a complete text-book of surgery, and has been under- 
taken by the author at the request of his pupils. Although as we are modestly informed in the 
preface, it is not put forth in rivalry of the excellent works on practical surgery which already exist, 
we think we may take upon ourselves to say ,that it will form a very successful and formidable 
rival to most of them. While it does not offer the same attractive illustrations, with which some of 
our recent text-books have been embellished, and while it will not, as indeed is not its design, set 
aside the more complete and elaborate works of reference which the profession is in possession of, 
we have no hesitation in stating that the two volumes form, together, a more complete text-book 
of surgery than any one that has been heretofore offered to the student." — The Northern Journal 
of Medicine. 



24 



LEA & BLANCHARD'S PUBLICATIONS. 



CARPENTIIR'S N£W WOBK. 



A MANUAL, OR ELEMENTS OF PHYSIOLOGY, 

jjircjLunijya phy'siol.ogicjiIj .iJVjiTOMir^ 

FOR THE USE OF THE MEDICAL STUDENT. 

BY WILLIAM B. CARPENTER, M.D., F. R. S , 

rULLERIAN PROFESSOR OF PHYSIOLOGY IN THE ROYAL INSTITUTION OF GREAT BRITAIN, ETC. 

With one hundred and eighty illustrations. In one octavo volume of 566 pages. Elegantly printed to match 

his " Principles of Human Physiology." 
This work, though but a very short time published, has attracted much attention from all engaged in teach- 
ing the science of medicine, and has been adopted as a lext-book by many schools throughout the country. — 
The clearness and coiiciseness vriih w^hich all the latest investigations are enunciated render it peculiarly 
well suited for those commencing the study of medicine. It is profusely illustrated with beautiful wood en- 
gravings, and is confidently presented as simong the best elementary text-books on Physiology in the lan- 
guage. 



NEW AND MUCH IMPROVED EDITION. NOW READY. 

CARPENTER'S HUMAN PHYSIOLOGY. 

BROUGHT UP TO SEPTEMBER, 1847. 

PRINCIPLES OF HUMAN PHYSIOLOGY, 

WITH THEIR CHIEF APPLICATIONS TO 

PATHOLOGY, HYGIENE, AND FO.RENSIC MEDICINE. 
BY WILLIAM B. CARPENTER, M.D., F.R. S., &c. 

Third American, from a New and Revised London Edition. 

WITH NOTES AND ADDITIONS, 

BY MEREDITH CLYMER, M. D., &c. 

WHth Three Hundred and Seventeen Wood-cut and other Illuatrationa, 

In one octavo volume, of over 750 closely and beautifully printed pages. 

The character of the present work is too well known and established to need any commendation. Within 
a period of four years, it has passed through three editions both in this country and Great Britain. It will be 
seen, that the present edition has been essentially modified and improved; and, besides attentive revision, has 
undergone material alteration in the arrangement. 

Many of the iSotes of the American Editor to former editions have been incorporated by the Author in the 
text of the present: others remain; whilst such additions have been made, as the progress of tlie science 
required. 

Besides the additions of the Author, the Editor has been enabled to add numerous illustrations; which, 
accompanied by copious references, will, he trusts, be found to enhance the value of this edition, and to 
peculiarly adapt it to the Student of Physiology. There are one hundred and fifteen more wood-cuts in this 
inau in the third English edition, and one hundred and one more than in the last Ajuerican. 



* SUPPLEMENT TO THE ENCYCLOPiEDIA AMERICANA, TP TO THE TEAR 1847. 

ENCYCLOPEDIA AMERICANA-Supplementary Vol. 

A POPULAR DICTIONARY 
OF ARTS, SCIENCES, LI'I EEITURR, HISTORY, POLITICS AND 

BIOGRAPHY. 

VOL. XIV. 

Edited BY HENRY VETHAKE, LL.D., 

Vice-Provost and Professor of Mathematics in the University of Pennsylvania, Author of "A Treatise on Poli- 
tical Economy." 

In One large Octavo Volume of over Six Hundred and Fifty double columned pages. 

The numerous subscribers who havg been waiting the completion of this volume can now perfect 
their sets, and all who want 'a Register of the Events of the last Fifteen Years, for the Whole 
World, particularly embracing interesting scientific investigations and discoveries, can obtain this 
volume separately, price Two Dollars uncut in cloth, or Two Dollars and Fifty Cents in leather, 
to match the styles in which the publishers have been selling sets. 

Subscribers in the large cities can be supplied on application at any of the principal bookstores; 
and persons residing in the country can have their sets matched by sending a volume in charge of 
friends visiting the city. 

Complete sets furnished at very low prices in various bindings. 

"The Couversations Lexicon (Encyclopaedia Americana) has become a householcl book in all the intelli- 
gent families in America, and is undoubtedly the best depository of biographical, historical, geographical and 
political information of that kind which discriminating readers require. There is in the present volume much 
matter purely scientific, which was ail the more acceptable to us that it was unexpected."— SiKman's JournoL 



* 

LEA & BLANCHARD'S PUBLICATIONS. 



25 



FOWNES' CHEMISTRY FOR STUDENTS. 

NEW AND IMPROVED EDITION, 1847. 

ELEMENTARY CHEMISTRY. 

THEORETICAL AND PRACTICAL. ' 
BY GEORGE FOWNES, Ph. D., 

Chemical Lecturer in the Middlesex Hospital Medical School, &c. &c. 
With Xumerous Illustrations. Second American Edition. Edited, with Additions, 

BY ROBERT BRIDGES, M.D., 

Professor of General and Pharmaceutical Chemistry in the Philadelphia College of Pharmacy, &c. &c. 
In one large duodecimo volume, sheep or extra cloth. 
Though this work has been so recently published, it has already been adopted as a text-book by many of the 
Medical Institutions throughout the country. As a work for the fir.«t class student, and as an introduction to 
the larger systems of Chemistry, such as Graham's, there has been but one opinion expressed concerning it, 
and it may now be considered as 

THE TEXT'BOOK FOU THE CHEMICAL STVHEJTT, 

" An admirable exposition of the present stale of chemical science, simply and clearly written, and display- 
ing a thorough practical knowledge of its details, as well as a profound acquaintance with its principles. The 
illustrations, and the whole getting-up of the book, merit our highest praise."— jBW^/s/i and Foreign Med. Rev. 

"Remarkable for its clearness, and the most concise and perspicuous work of the kind we have seen, admi- 
rably calculated to prepare the student for the more elaborate treatises." — Pharmaceutical Journal. 

This workof Fownes, while not enlarging on the subject as much as Graham, is far more lucid and expanded, 
than the usual small introductory works. Persons using it may rely upon its being kept up to the day by fre- 
quent revisions. 

NEW EDITION OF GRAHAM'S CHEMISTRY, PREPARING. 

THE ELEMENTS~OF CHEMISTRY. 

INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS. 
Witli Numerous Illustrations. 

Bx THOMAS GRAHAM, F. R. S. L. and E. D., 
Professor of Chemistry in University College, London, &c. &c. 
SECOND AMERICAN. FROM THE SECOND ENGLISH EDITION. 
WITH NOTES AND ADDITIONS BY ROBERT BRIDGES, M. D., &c. &c. 
In one volume octavo. 



SIMON'S CHEIVnSTRY OF MAN. 

ANIMAL CHBMISTRir, 

WITH REFERENCE TO THE PHYSIOLOGY AND PATHOLOGY OF MAN. 
BY DR. J. FRANZ SIMON. 

TRANSLATED AND EDITED BY 

GEORGE E. DAY, M. A. & L. M. Cantab., &c. 

With plates. In one octavo volume, of over seven hundred pages, sheep, or in two parts, hoards. 

This important work is now complete and may be had in one large octavo volume. Those who obtained the 
first part can procure the second separate. 

"No treatise on physiological chemistry approaches, in fulness and accuracy of detail, the work which 
stands at the head of this article. It is the production of a man of true German assiduity, who has added to his 
own researches the results of the labors of nearly every other inquirer in this interesting branch of science — 
The death of such a laborer, which is mentioned in the preface to the work as having occurred prematurely in 
1842, is indeed a calamity to science. He had hardly reached the middle term of life, and yet had made himself 
known all over Europe, and in our country, where his name has been familiar for several years as among the 

most successful of the cultivators of the Chemistry of Man It is a vast repository of facts to which the 

teacher and student may refer with equal satisfaction."— TAe Western Journal of Medicine and Surgery. 

" The merits of the work are so universally known and acknowledged, as to need no further commendatioa 
at our hands,"— iV. Y. Journal of Medicine and Surgery. 

THE CHEMISTRY OF THE FOUR SEASONS™ A NEW WORK. 

THE CHEMISTRY OF THE FOUR SEASONS, 

SPRING, SUMMER, AUTUMN AND WINTER. 

AN ESSAY PRINCIPALLY CONCERNING NATURAL PHENOMENA ADMITTING OF ILLUS- 
TRATION BY CHEMICAL SCIENCE. AND ILLUSTRATING PASSAGES OF SCRIPTURE. 

BY THOMAS GRIFFITHS, 

Professor of Chemistry in the Medical College of St. Bartholomew's Hospital, &c. 
In One very neat Volume., royal 12mo., of Four Hundred and Fifty large Pages, extra clotTi, illus- 
trated udth numerous Wood-cuts. 

ANSTED'S AWCIEWT WORL.I> Just Issued. 

THE ANCIENT WORLD; OR, PICTHRESQUE SKETCHES OF CREATION. 

BY T. D. ANSTED, M.A., F.R.S., F.G.S., &c. 

PROFESSOR OF GEOLOGY IN KING''S COLLEGE, LONDON. 

In One very neat volume, fine extra cloth, with about One Hundred and Fifty Illustrations. 
The object of this work is to present to the general reader the chief results of Geological investigation in 
a simple and comprehensive manner. The author has avoided all minute details of geological formations 
and particular observations, and has endeavored as far as possible to present striking views of the wonderful 
results of the science, divested of its mere technicalities. The work is printed in a handsome manner, with 
numerous illustrations, and forms a neat volume for the cenlre-table. 



26 



LEA & BLANCHARD'S PUBLICATIONS. 



LECTURES ON THE OPERATIONS OF SURGERY, 

AND ON ' 

DISEASES AND ACCIDENTS REQUIRING OPERATIONS, 

DELIVERED AT UNIVERSITY COLLEGE, LONDON. 
BY ROBERT LISTON, Esq., F. R. S., &c. 

EDITED, WITH NUMEKOUS ALTEKATIONS AND ADDITIONS, 

BY T. D. MUTTER, M.D., 

Professor of Surgery in the Jefferson Medical College, Philadelphia. 

In One L<airge and Beautifully Printed Octavo Volume. 

WITH TWO HUNDRED AND SIXTEEN ILLUSTRATIONS ON WOOD. 

More than one-third of this volume is by Professor Mutter, embodying elaborate treatises on 
plastic Operations, Staphyloraphy, Club-Foot, Diseases of the Eye, Deformities from Burns, &c. &c. 



A STSTIM OP PRAOTIGAL STJR^EP.?. 

BY WILLIAM FERGUSSON, F. R. S. E. 

SECOND AMERICAN EDITION, REVISED AND IMPROVED. 
With Two Hundred and Fifty-two Illustrations from Drawings by Bagg, Engraved by Gilbert , 
With Notes and Additional Illustrations, 
BY GEORGE W. NORRIS,M. D.,&c. 
In one beautiful octavo volume of six hundred and forty large pages. 



THE PRINCIPLES AND PRACTICE OF 

OBSTETRIC MEDICINE AND SURGERY, 

IN REFERENCE TO THE PROCESS OP PARTBRITIOS. 

ILLUSTRATED BY 

One hundred and forty-eight Iiarg-e Figures on 55 Liitho graphic JPlates, 

BY FRANCIS H. RAMSBOTHAM, M.D., &c. 

A NEW EDITION, FROM THE ENLARGED AND REVISED LONDON EDITION. 
In one large i7nperial octavo volume, well bound. 

Philadelphia, August 6th, 1845. 

Messrs. Lea. & Bla.nchard. 

Gentlemen :— I have looked over ihe proofs of Ramsbotham on Human Parturition, with its important im- 
provements, from the new London edition. 

This Work needs no commendation from me, receiving, as it does, the unanimous recommendation of the 
British periodical press, as the standard work on Midwifery; "chaste in language, classical in composition, 
happy in point of arrangement, and abounding in most interesting illustrations." 

To the American public, therefore, it is most valuable— from its intrinsic undoubted excellence, and as being 
the best authorized exponent of British Midwifery. Its circulation will, I trust, be extensive throughout our 
country. 

There is, however, a portion of Obstetric Science to which sufficient attention, it appears to me, has not been 
paid. Through you, I have promised to the public a work on this subject, and although the continued occupa- 
tion of my time and thoughts in the duties of a teacher and practitioner have as yet prevented the fulfilment of 
the promise, the day, I trust, is not distant, when, under the hope of being useful, I shall prepare an account of 
the Mechanism of Labor, illustrated by suitable engravings, which may be regarded as an addendum to th© 
standard works of Ramsbotham, and our own Dewees. 

Very respectfully, yours, 

HUGH L. HODGE, M.D., 
Professor of Obstetrics, Sj-c. dj-c, in the University of Pennsylvania. 

PROFESSOR CHAPMAN'S' WORKS ON PRACTICE. 

A COMPENDIUM OF LECTURES ON THE 

THEORY AND PRACTICE OF MEDICINE. 

DELIVERED BY PROFESSOR CHAPMAN IN THE UNIVERSITY OF PENNSYL- 
VANIA. PREPARED, WITH PERMISSION, FROM DR. CHAPMAN'S MA- 
NUSCRIPTS, AND PUBLISHED WITH HIS APPROBATION, 
By N. D. BENEDICT, M. D. In one very neat octavo volume. 

§^ This work contains the diseases not treated of lu the two following. 



LECTURES ON THE MORE IMPORTANT DISEASES OF THE 

THORACIC AND ABDOMINAL VISCERA. 

Delivered in tiie University of Pennsylvania, by N. Chapmax, M. D., Professor of the Theory 
and Practice of Medicine, &c. In one volume, octavo. 

LECTURES ON THE MORE IMPORTANT 

ERUPTIVE FEVERS, HEMORRHAGES AND DROPSIES, 

AND ON GOUT AND RHEUMATISM, 
Delivered in the University of Pennsylvania by N. Chapmajt, M.D., Professor of the Theory 
and Practice of Medicine, «&;Cj &c. In one neat octavo volume. 



LEA & BLANCHARD'S PUBLICATIONS. 



27 



A NEW MEDICAL DICTIONARY. 
In one Volume, large 12mo., now ready, at a low price. 

A DICTIONARY OF 

THE TERMS USED IN MEDICINE 

AND 

THE COLLATERAL SCIENCES; 
BY RICHARD D. HOBLYN, A. M., Oxon. 

FIRST AMERICAN, FROM THE SECOND LONDON EDITION. 

EEVISED, WITH NUMEROUS ADDITIONS, 

BY ISAAC HAYS, M. D., 
Editor of the American Journal of the Medical Sciences. 

A NEW AN^^COMPLEtF^^ FEVERS. 

FEVERS; 

THEIR DIAGNOSIS, PATHOLOGY AND TREATMENT. 

PREPARED AND EDITED WITH LARGE ADDITIONS, 

FROM THE ESSAYS ON FEVER IN 

TWEEDIE'S LIBRARY OF PRACTICAL MEDICINE, 
BY MEREDITH CLYMER, M. D., 

Professor of the Principles and Practice of Medicine in Franklin Medical College, Philadelphia f 
Consulting Physician to the Philadelphia Hospital ; Fellow of the College of Physicians j ^c. ^c. 
In one octavo volume of 600 piiges. 

THE SURGICAL V/ORKS OF SIR ASTLEY COOPER. 

THE ANATOMY AND SURGICAL TREATMENT OF 

ABE)® MI HAIL MHIEHIIAo 

By SIR ASTLEY COOPER, BART. 

Edited by C. ASTON KEY, Surgeon to Guy's Hospital, &c. 
In one large imperial 8vo. volume, with over 130 Lithographic Figures. 

ON THE STRUCTURE AND DISEASES OF THE TESTIS. 

Illustrated by 120 Figures. From the Second London Edition. 
BY BRANSBY B. COOPER, Esq. 
AND ALSO ON THE ANATOMY OF THE THYMUS GLAND. 
Illustrated hy jifty-seven Figures. 
The two works together in one beautiful imperial octavo volume, illustrated with twenty-nine plates, 

ANATOMY AND DISEASES OF THE BREAST, &c. 

THIS LARGE AND BEAUTIFUL VOLUME CONTAINS THE ANATOMY OF THE BREAST 
THE COMPARATIVE ANATOMY OF THE MAMMARY GLANDS; ILLUSTRA- 
TIONS OF THE DISEASES OF THE BREAST ; 
And Twenty-five Miscellaneous Surgical Papers, now first published in a collected form. 
BY SIR ASTLEY COOPER, Baet., F. R. S., &c. 
The whole in one large imperial octavo volume, illustrated with two hundred and fifty-two figures. 

A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. 

By Sir ASTLEY COOPER, Bart., F. R. S., Sergeant Surgeon to the King, &c. 
A New Edition much enlarged ; 
Edited by BRANSBY COOPER, F. R. S., Surgeon to Guy's Hospital. 
With additional observations from Professor JOHN C. WARREN, of Boston. 
With numerous Engravings on Wood, after designs by Bagg, a Memoir and a splendid Portrait of Sir Astley 

In one octavo volume. 



28 



LEA & BLANCHARD'S PUBLICATIONS. 



OTHER WORKS 

IN" 

VARIOUS DEPARTMES^TS 

OF 

MEDICINE AND SURGERY, 

PUBLISHED 

BY LEA & BLANC HARD. 

AMERICAN JOURNAL OF THE MEDICAL SCIENCES. Edited by Isaac Hays, M. D. 
Published quarterly at §5 00 per annum. 

ANDRAL ON THE BLOOD. Pathological Hematology; an Essay on the Blood in Dis- 
ease. Translated by J. F. Meigs and Alfred Stille. In one octavo volume, cloth. 

ARNOTT'S PHYSICS. The Elements of Physics in plain or non-technical language. A 
New Edition. Edited by Isaac Havs, M. D. In 1 vol. 8vo., sheep, with 176 wood-cuts. 

ABERCROMBIE ON THE STOMACH. Pathological and Practical Researches on Dis- 
eases of the Stomach, Intestinal Canal, &c. Fourth Edition. In 1 vol. 8vo.j sheep. 

ABERCROMBIE ON THE BRAIN. Pathological and Practical Researches on the Dis- 
eases of the Brain and Spinal Cord. A New Edition. In one octavo volume, sheep. 

ALISON'S PxATHOLOGY. Outlines of Pathology and Practice of Medicine. In three 
parts, containing Preliminary Observations, Inflammatory and Febrile Diseases, and 
Chronic or Non-Febrile Diseases. In one neat octavo volume, sheep. 

BENNET'S PRACTICAL TREATISE ON INFLAMMATION, ULCERATION AND 
INDURATION OF THE NECK OF THE UTERUS. In one small i2mo. volume, 
cloth. 

BIRD ON URINARY DEPOSITS. Urinary Deposits, their Diagnosis, Pathology and The- 
rapeutical Indications. In one neat octavo volume, cloth, with numerous wood-cuts. 

BERZELIUS ON THE KIDNEYS AND URINE, in 1 vol. 8vo., cloth. 

BUCKLAND'S GEOLOGY. Geology and Mineralogy, with reference to Natural Theology. 
A Bridgewater Treatise. In two octavo volumes, with numerous maps, plates, &c. 

BUDD ON DISEASES OF THE LIVER. In one octavo volume, sheep, with beautiful 
colored plates and numerous wood cuts. 

BRIDGEWATER TREATISES. The whole complete in 7 vols. 8vo., containing Roget's 
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A TREATISE ON THE DISEASES OF FEMALES, 

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LANDRETH'S JOHNSON'S_GARDENERS' DICTIONARY. 

JUST RSAD7. 

A DICTIONARY OF MODERN GARDENING. 

BY GEORGE WILLIAM JOHNSON, Esa., 
Fellow of the Horticultural Society of India, &c. &c. 
With One Hundred and Eighty Wood-Cuts. 

EDITED, WITH NUMEROUS ADDITIONS, 

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Sold by all Booksellers, JYurserymen and Seedsmen in the United States, 



CONTENTS OF THE 

AMERICAN mmmi of the medical sciences, 

JFor ^^pril, 1847. 

Memoirs and Cases. — Art. I. History of seven cases of Pseudo-membranous Laryngitis, or True Croup. 
By J. F. Meigs, M. D. IL Poisonous Properties of the Sulphate of Quinine. By Wm. O. Baldwin, M. D. IIL 
Removal of the Superior Maxilla for a tumour of the antrum ; Apparent cure. Return of the disease. Second 
operation. Sequel. By J. Marion Sims, M. D. [ With a wood-cut.] IV. Laceration of the Perineum. By John 
P. Mettauer, M. D. V. Report of Cases treated in Cincinnati Commercial Hospital. By John P. Harrison, 
M. D. VI. Surgical Cases. By Geo. C. Blackman, M. D. [With a wood-cut.] VH. Cases of Paralysis 
peculiar to the Insane. By Pliny Earle, M. D. VHI. Contributions to Pathology ; being a Report of Fatal 
Cases taken from the records of the U. S. Naval Hospital. New York. By W. S. W. Ruschenberger, M. D. 
IX. Case of Hydrops Pericardii suddenly formed, with Remarks. By S. Jackson, M. D. X. Case of Tuber- 
cles in the pericardium, vena cava, columnae carneae, pleura, lungs, liver, &c., with Meningitis. By J. D. 
Trask, M. D. XI. On letting Blood from the Jugular in the Diseases of Children. By Charles C. Hildreth, 
M. D. 

Review.— XII. Lectures on Subjects connected with Clinical Medicine ; comprising Diseases of the 
Heart. By P. M. Latham, M. D. 

Bibliographical Notices. — XIII. Green on Diseases of the Air Passages. XIV. Condie on the Diseases of 
Children. Second edition; XV. Royle's Materia Medica and Therapeutics. Edited by Carson. XVI. Vogel's 
Pathological Anatomy of the Human Body. Translated, with additions, by George E. Day. XVII. Trans- 
actions of the College of Physicians of Philadelphia. From September to November, 1S46, inclusive. 
XVIII. Wharton Jones on the Principles and Practice of Ophthalmic Medicine and Surgery. Edited by 
Isaac Hays, M. D. XIX. Wood on the Practice of Medicine. XX. Wernher's Manual of General and 
Special Surgery. XXI. Baumgarten's Surgical Almanac for the years le44 and lfc45. XXII. Wilson's 
System of Human Anatomy, General and Special. Third American from the third London edition. Edited 
by Paul B Goddard, M. D. XXIII. Von Behr's Handbook of Human Anatomy, General, Special and 
Topographical. Translated by John Birkeiu 



f 



LEA & BLANCHARD'S PUBLICATIONS. 



31 



Contents of the Medical Journal Continued. 
QUARTERLY RETROSPECT, 

A SUMMARY OF THE IMPROVEMENTS AND DISCOVERIES IN THE MEDICAL SCIENCES 

Foreign Intelligence— Anatomy and Physiology — 1. Qweieii on Intimate Structure of Bone. 2. Meckel 
on Process of Secretion. 3. Blondlot on the Properties of the Bile. 4. Bainbrigge on Supplementary Spleen, 
death from the patient being placed in the supine position. 5. Robinson on the Nature and Source of the 
contents of the Fcetal Stomach. 6. Prof. Bischoff on the Absorption of Narcotic Poisons by the Lymphatics. 

Materia Medica and Pharmacy.— 7. Battley on Syrap of Iodide and Chloride of Iron. 8. Ricord on Bro- 
mide of Potassium as a substitute for the Iodide. 9. Voillemier on Santonine. 10. Guibourt onihe changes 
of composition which the Tincture of Iodine undergoes in keeping, li. Mellon on the Action of the Acetate 
af Morphia on Children. 

Medical Pathology and Therapeutics and Practical Medicine. — 12. Bennett o^ Anormal Nutrition 
and Diseases of the Blood. 13. Rostan on Acute Spinal Myelitis. 14. Rostan on Curability of Hypertrophy 
of the Heart. 15. Crisp on Rupture of the left Ventricle of the Heart. 16. Francis on Aneurism of the Basi- 
lar Artery. 17. Lombard^s Observations on Sudden deaths, probably dependent on Diseases of the Heart 
and large Blood-vessels. 18. Carson on Obliteration of the Vena Cava Descendens. 19. Thompson on 
Treatment of Chronic Bronchitis and Bronchial Asthma. 20. Muhlbauer''s Microscopic Researches on the 
Absorption of Pus. 21. Briquet on Mercurial Ointment in Variola. 22. Bell on Rupture of Lateral Sinus of 
Dura Mater. 23. Watts on Tubercles in Bones. 24. Gendrin on Hysterical Affections. 25. Cottereau''s 
Remedy for Toothache. 26. Prof Trousseau on Anatomy of Pneumonia in Infants. 27. Volz on Hooping 
Cough an Exanthemata. 28. Crisp on Infantile Pleurisy. 29. Youl on Abscess of the Brain in a Child. 30. 
Trousseau on the Employment of Nux Vomica in the Treatment of St. Vitus' Dance. 

Surgical Pathology and Therapeutics and Operative Surgery. — 31. Prof. Syme on Amputation at 
the Shoulder Joint for Axillary Aneurism. 32. Whipple on Amputation at the Hip Joint. 33. Prof. Ehr- 
mann on Successful Extirpation of a Polypous Tumour of the Larynx. 34. Bellingham on Compression in 
Aneurism. 85. Orr's Case of Tracheotomy. 36. Holmes Coote on Cancer of the Breast in the Male. 37. 
Moore on Gunshot wound of the Lung, where the ball lodged fifty years. 33. On the Employment of Iodide 
of Potassium in the Treatment of Syphilis, 39. Application of ice in the treatment of injuries. 40. Lenoir on. 
Ununited Fracture successfully treated by Acupuncturation. 41. Prof. Syme on Amputation of the Thigh. 
42. Curling''s Case of Fatal Internal Strangulation caused by a cord prolonged from a Diverticulum of the 
Ileum. 43. Gelding Bird and John Hilton on Case of Internal Strangulation of Intestine relieved by Opera- 
tion. 44. Fergusson on Strangalsited Congenital Hernia in an infant seventeen days old, requiring opera- 
tion. 45. GwersanZ, Jr., on Surgical Treatment of Croup. 46. &eog-/ieg-an on Partial Amputation of the Foot. 
47. Report of a Committee of the Surgical Society of Ireland, relative to the use and effects of Sulphuric 
Ether. 

Ophthalmology.— 48. Prof. Jacob on Foreign Bodies in the Eye. 49. Bixon''s Remarkable Case of Injury 
of the Eye. 50. Szokalskion Obscurations of the Cornea in their Histological relations with reference to the 
Practice of Ophthalmic Surgery. 51. Berncastle on Amauro sis from Hydatid Cyst in the Brain. 

Midwifery.— 52. Robiquet on Remarkable case of spontaneous rupture of the Uterus during labour — Re- 
covery. 53. Le Chaptois^ Case of Vaginal Entero-hysterocele reduced by taxis, and maintained in place 
by the introduction of sponges in the Vagina. 54. Kuhne on Riipture of the Uterus— abdominal section — 
recovery. 55. Cza;ezf>sA;i on Wound of the Gravid Uterus — premature delivery— peritonitis— recovery. 56. 
Bennett on Inflammatory Ulceration of the Cervix Uteri during Pregnancy, and on its Influence as a Cause 
of Abortion. 57. Caesarian Operation performed by Mr. Skey, at St. Bartholomew's Hospital, the patient 
being rendered insensible by ether. 58. Pochhammer on Congenital protrusion of the Liver through the 
umbilical ring. 59. Csesarian Section. 60. iJowx on Lacerated Perineum. 61. DepawZ on Asphyxia neona- 
torum. 62. Klencke on Diet in Infancy. 

Medical Jurisprudence and Toxicology.— 63. Taylor on Contested identity determined by the teeth. 
64. Blake on Poisons. 65. Delirium Tremens in an Infant. 66. Hamilton on the Echites Suberecta. 67. 
Bupasquier on Vapours of Phosphorus, Lucifer Matches. 68. Thompson on the mode of testing the presence 
of minute quantities of Alcohol. 69. Invalidity of a Contract made by a Lunatic. 70. Procuring of Abortion. 
71. Lepage''s Case of Poisoning by Arsenic relieved by the use of Magnesia. 72. Sale of Poisonous Sub- 
stances. 

Medical Education.— 73. The Edinburgh Statutes regarding the Degree. 74. Medical Organization in 
Spain, 

Foreign Correspondence.— Letters to the Editor from London. Sulphuric Ether in Surgical Operations 
.at Vienna. 

American Intelligence— Original Communications.— Par^rjwan's Anatomical Anomaly. Tyler''s Ante- 
version of the Womb with adhesion of Os Uteri to body of 4th Lumbar Vertebra, &c. 

Domestic Summary -.Bec^ on Effects of Mercury on the Young Subject. Brainard on Amputation for 
Scrofulous Diseases of the Joints. Baker on Case of Vicarious Menstruation from an Ulcer on the right 
Mamma. Allen on Singular case of laceration of the Broad Ligaments. MLean on Blindness caused by 
the use of Sulphate of Quinine. Harrison''s Speculations on the Cause of Yellow Fever. Herrickon Foreign 
Bodies in the Organs and Tissues of the Body. Swett on Case of Empyema in which the operation for Para- 
centesis Thoracis failed from a cause not generally noticed. WPheeters on Rheumatism, with Hypertrophy 
of both eyes. Draper on the Cause of the Circulation of the Blood. Little on Ischuria Renalis. Hogan on 
Strychnine in Chorea. Beaderick on Excision of the Inferior Maxillary Bone for Osteo-Sarcoma. Cain on 
Imperforate Prepuce. Couper on Medical Schools of the United Slates. Warren on Inhalation of Ether. 
Burwellon Absence of one Kidney. Brainard on Dislocation of the Elbow. Gilman on Presentation of 
the shoulder,— prolapsed Cord,— cord not pulsating, yet child born alive. National Medical Convention. 
Delegates to National Medical Convention. Arrangements for the Meeting of the National Medical Con- 
vention. Resignation of Professor Warren. New Medical Books. 

LSA & BLANOHAHD, Philadelphia. 
THIS TISRMS ATiH 

For the Medical Journal and the Medical News, if paid for in advance, (owing to the time of 
issuing this advertisement, this year, amounts remitted before the first of July will be con- 
sidered in advance,) Five Dollars. 
For the Journal only, when ordered without funds, or when paid for after the first of July, Five Dollars 
For the Medical News only, to be paid for tree of postage, and always in advance, - One Dollar 
10=" In no case can the News be sent without pay in advance.,/~[| 

Or, persons sending Ten Dollars, before next July, can have both the Journal and the News for 1847 and 
1848, together with nine numbers of the News for 1846, containing the first 228 pages of Todd and Bow- 
man's Physiology. 

Philadelphia, May y 1847 



32 



LEA & BLANCHARD'S PUBLICATIONS. 



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ONE GIVEN GRATIS. 
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AMERICAN JOURNAL OF THE MEDICAL SCIENCES. 

EDITED BY ISAAC HAYS, M. D., 

IS PUBLISHED QUARTERLY, ON THE FIRST OF JANUARY, APRIL, 
JULY AND OCTOBER. 

The number for January last contained over THREE HUNDRED large octavo pages, with two plates ; 
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ALSO, 

THE MEDICAL NEWS AND LIBRARY, 

A MONTHLY PERIODICAL OF THIRTY-TWO LARGE OCTAVO PAGES, 
WITH NUMEROUS WOOD-CUTS, 

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It will thus be seen that subscribers obtain about FIFTEEN HUNDRED large sized and solid octavo 
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The Medical Journal is now in the twenty-ninth year of its existence, during the whole of which time it 
has commanded the approbation of the profession at home and abroad. Appearing quarterly, its object is 
to furnish its readers with a full and accurate resum6 of all interesting investigations and discoveries made 
during the intervals, together with a choice selection of original papers. To this end, its pages are first 
devoted to 

ORIGINAL COMMUNICATIONS, 

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PHICAL NOTICES of all new works of interest ; and lastly, it presents a very full and extended QUAR- 
TERLY SUMMARY, consisting of a 

RETROSPECT A]\D ABSTRACT 

CF THE PROGRESS OF THE MEDICAL SCIENCES, 

CAREFULLY COLLECTED FROM ALL THE 
FORi:iG]V AND DOMESTIC JOlJRlVAIiS. 

This department is considered so practically useful, that no exertion is spared to render it as complete as 
possible, so that both in extent and variety it may compare with any publications of a similar kind. The 
shorter periods at which this journal appears, enables us to anticipate, by several months, from the original 
sources, a large portion of the intelligence contained in the semi-annual publications of BRAITHWAITE 
and RANKING, and the Annual Reports in the BRITISH AND FOREIGN MEDICAL REVIEW, DUB- 
LIN MEDICAL JOURNAL, &c., and whatever of value is found in them, of which the original accounts 
have not reached us, is at once taken and laid before our readers; besides much AMERICAN INTELLI- 
GENCE, which is not likely to find its way across the Atlantic. The arrangements of the publishers for the 
supply of this department, by purchase and exchange, are very extensive, embracing the principal Periodicals 
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ALL THE AMERICAN JOURNALS: 

And especial attention will be given to make it as complete a digest as possible, of all the 

IMPROVEMENTS AND DISCOVERIES IN MEDICAL SCIENCE. 
Besides this, subscribers have the advantage of 

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Which furnishes the lighter and floating information, and embraces important books for 

The Library Department. 

The work now passing through its columns is 

TODD AND BOWMAN'S 
PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN, 

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Each work in the Library is regularly paged, so as to be bound separately. 



>( it' J- * 




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